AI and Automated Decision-Making Policy Template

Establishes governance for the use of artificial intelligence tools in care planning, compliance monitoring, and administrative processes, including transparency, human oversight, bias prevention, and resident rights.

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AI and Automated Decision-Making Policy Template

As AI tools become embedded in aged care operations, this policy establishes the governance framework to ensure they are used transparently, ethically, and with meaningful human oversight.

Overview

Artificial intelligence is increasingly used in residential aged care for functions including care planning support, risk stratification, compliance monitoring, medication management, and workforce scheduling. While AI tools offer significant efficiency and safety benefits, their use also introduces risks including algorithmic bias, lack of transparency, and the erosion of human judgement in care decisions. This policy template — the first of its kind for the aged care sector — establishes governance principles for responsible AI use, with specific application to tools like Governa's Norma compliance assistant.

What This Policy Covers

Definition of AI and automated decision-making in the aged care context
Approved use cases for AI tools within the facility
Mandatory human oversight requirements for AI-generated recommendations
Transparency obligations: residents' right to know when AI is used in their care
Algorithmic bias assessment and monitoring
Data governance for AI training and input data (resident privacy)
Vendor due diligence for AI tools and platforms
Staff training on responsible AI use
Incident reporting for AI errors or unexpected outputs
Governance escalation for high-risk automated decisions

Compliance Alignment

Privacy Act 1988 – Australian Privacy Principles (automated processing)
Aged Care Quality Standard 8 – Organisational Governance
Australian Government – Responsible AI Framework
OECD AI Principles
Aged Care Act 1997 – Provider duties of care
Charter of Aged Care Rights – Right to be informed

Why This Policy Matters

Governa AI is uniquely positioned to address this gap — as a provider of AI-powered compliance tools, having an AI governance policy demonstrates that Governa practices what it preaches. For facility clients, the absence of AI governance creates regulatory exposure as the ACQSC and federal government move toward mandatory AI accountability frameworks in healthcare. This is the most forward-looking policy gap in the sector.

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Resident Trust Accounts and Liquid Assets Policy Template

Governs the management of resident trust accounts and liquid assets held by the facility, including transaction records, reconciliation, annual reporting, and resident financial rights.

Mandatory Reporting Policy (Non-SIRS) Template

Covers mandatory reporting obligations beyond the SIRS scheme, including reporting to police, the NDIS Quality and Safeguards Commission, state ombudsmen, and other regulatory and law enforcement bodies.

Financial Hardship and Accommodation Assistance Policy Template

Outlines how the facility supports residents experiencing financial hardship, covering means-tested care fees, hardship supplement applications, accommodation assistance, and coordination with Services Australia.

Food Safety and HACCP Policy Template

Establishes food handling, storage, preparation, and temperature monitoring procedures in compliance with Food Standards Australia New Zealand (FSANZ) and HACCP principles, beyond the Nutrition Policy.

Working with Vulnerable People (WWVP) Policy Template

Mandates pre-employment and ongoing screening checks for all staff, contractors, and volunteers including police checks and state-based WWVP/WWCC clearances, ensuring the facility meets child and vulnerable person protection obligations.

Onboarding and Orientation Policy Template

Defines the structured process for inducting new staff into the facility, including mandatory orientation content, buddy system arrangements, probationary review, and role-specific competency checks.

Mandatory Staffing Levels and Rostering Policy Template

Addresses compliance with legislated 24/7 Registered Nurse requirements and minimum 200 direct care minutes per resident per day, including rostering systems, reporting obligations, and contingency staffing plans.

My Aged Care and Referral Management Policy Template

Covers the end-to-end process of managing referrals through the My Aged Care portal, including ACAT assessments, waitlist management, intake coordination, and care type transitions.

Star Ratings Management Policy Template

Governs how the facility monitors, manages, and responds to its Australian Aged Care Star Rating across all four sub-categories to protect consumer trust, reputation, and funding.

Accreditation and Regulatory Audit Management Policy Template

Defines how the facility prepares for, manages during, and responds after ACQSC site audits and performance assessments, including documentation readiness, staff briefings, and corrective action planning.

Interpreter and Language Services Policy Template

Establishes when and how professional interpreter services are arranged for residents and families with limited English proficiency, covering booking processes, consent obligations, and staff guidance.

Veteran and Specific Population Care Policy Template

Addresses the distinctive care needs of veteran residents including trauma-informed approaches, DVA entitlements, PTSD-informed care, and coordination with veteran-specific services.

Photography, Recording and Social Media Policy Template

Governs consent for photographing or recording residents, staff social media conduct regarding residents and the facility, and the use of surveillance or monitoring technology.

Personal Property and Valuables Policy Template

Establishes procedures for identifying, recording, safeguarding, and managing residents' personal belongings and valuables during their stay, including at entry, during care, and at exit.

Aboriginal and Torres Strait Islander Peoples Care Policy Template

Provides a dedicated framework for culturally safe, responsive, and affirming care for Aboriginal and Torres Strait Islander residents, going beyond the general Cultural Diversity Policy.

Visitor and Support Person Policy Template

Manages visitor access to the facility including visiting hours, identification requirements, secure unit access protocols, and provisions for essential visitors and designated support persons.

Alcohol, Smoking and Substance Use Policy Template

Balances residents' right to use alcohol, tobacco, and other substances with the facility's safety obligations and health risk management duties.

Coroner and Reportable Deaths Policy Template

Defines which resident deaths must be reported to the coroner under applicable state and territory legislation and outlines the step-by-step notification, documentation, and family communication process.

AN-ACC Assessment and Funding Policy Template

Outlines the Australian National Aged Care Classification assessment process, including timeframes, responsibilities, and how funding is calculated and reviewed under the new funding model.

Pathology and Diagnostic Services Policy Template

Establishes processes for requesting, collecting, transporting, and communicating pathology and diagnostic test results for residents in residential aged care.

Assistive Technology and Equipment Management Policy Template

Governs the procurement, maintenance, and safe use of clinical and assistive equipment including mobility aids, pressure care devices, monitoring technology, and loan equipment.

Manual Handling and Assisted Mobility Policy Template

Covers safe manual handling of residents including use of assistive equipment, transfer techniques, and staff training to prevent workplace injuries and maintain resident dignity.

Outbreak Management Policy Template

Defines protocols for managing infectious disease outbreaks including COVID-19, influenza, and gastroenteritis within the facility, covering cohorting, visitor restrictions, and mandatory reporting.

Dignity of Risk and Positive Risk-Taking Policy Template

Supports residents' right to make informed decisions about risk, balancing personal autonomy with duty of care, in line with Royal Commission recommendations and the Charter of Aged Care Rights.

Clinical Handover and Escalation Policy Template

Standardises clinical handover communication between shifts and escalation pathways for deteriorating residents, using structured tools such as ISBAR.

Telehealth and Digital Health Policy

This policy covers how aged care providers plan, deliver, and govern telehealth and digital health consultations, including remote GP visits, specialist reviews, and allied health sessions. Australian providers need it to meet Strengthened Aged Care Quality Standards and Medicare Benefits Schedule telehealth requirements while protecting resident safety and privacy.

Cybersecurity and Data Governance Policy

This policy covers how aged care providers protect resident and organisational data from cyber threats, unauthorised access, and data breaches, while meeting obligations under the Privacy Act 1988 and Aged Care Act 2024. Australian providers need it to demonstrate accountability under the Strengthened Aged Care Quality Standards and reduce the risk of costly security incidents.

Staff Wellbeing and Mental Health Policy

This policy sets out how Australian aged care providers support staff mental health and psychological safety in the workplace, addressing burnout, psychosocial hazards, and workforce wellness obligations. Providers need it to meet Strengthened Aged Care Quality Standard 2 and Work Health and Safety Act 2011 requirements.

Workplace Bullying and Harassment Policy

This policy sets out how Australian aged care providers must prevent, identify, and respond to workplace bullying and harassment to protect staff, residents, and volunteers. It supports compliance with the Strengthened Aged Care Quality Standards, the Work Health and Safety Act 2011, and the Fair Work Act 2009.

Volunteer Management Policy

This policy covers how aged care providers recruit, screen, orient, and supervise volunteers working within their service. Australian providers need it to meet Strengthened Aged Care Quality Standards and to protect the safety of residents and staff.

Performance Management Policy

A performance management policy sets out how an aged care provider identifies, supports, and addresses staff performance to maintain safe, high-quality care. Australian providers need this policy to meet obligations under the Strengthened Aged Care Quality Standards and the Fair Work Act 2009.

Pets and Companion Animals Policy

This policy sets out how Australian aged care providers manage resident access to pets and companion animals, covering resident-owned animals, visiting animals, and pet therapy programs. Providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and to support resident wellbeing while managing infection control and safety risks.

Family and Carer Engagement Policy

This policy sets out how Australian aged care providers engage with residents' families and carers, covering communication, involvement in care planning, and rights under the Aged Care Act 2024. Providers need it to meet Strengthened Aged Care Quality Standard 1 and demonstrate that residents' support networks are treated as genuine partners in care.

Consumer Entry, Transition and Exit Policy

This policy covers the processes for admitting, transitioning, and discharging consumers in residential aged care, including rights, documentation, and care continuity obligations. Australian aged care providers need it to meet their duties under the Aged Care Act 2024 and Strengthened Aged Care Quality Standards.

Social Connectedness and Isolation Prevention Policy

This policy sets out how aged care providers identify, prevent, and respond to social isolation among residents, supporting their right to meaningful connection and participation. Australian providers need it to meet the Strengthened Aged Care Quality Standards and demonstrate a genuine commitment to resident wellbeing beyond physical care.

Lifestyle and Recreational Activities Policy

This policy covers how aged care providers plan, deliver, and review lifestyle and recreational activities for residents, supporting their wellbeing, identity, and right to participate in meaningful daily life. Australian providers need it to meet the Strengthened Aged Care Quality Standards and demonstrate a genuine commitment to person-centred care.

LGBTQI+ Inclusive Care Policy

This policy guides Australian aged care providers in delivering respectful, affirming care to LGBTQI+ residents, covering anti-discrimination obligations, identity-affirming practices, and staff training requirements. Providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and federal anti-discrimination law.

Sexuality and Intimacy Policy

This policy covers the rights of aged care residents to express their sexuality and experience intimacy, providing guidance for staff on how to support these rights respectfully and safely. Australian aged care providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and the Aged Care Act 2024.

Sensory Aids and Communication Support Policy

This policy sets out how aged care providers identify, supply, and maintain sensory aids and communication supports for residents, covering hearing devices, vision aids, and augmentative communication tools. Australian providers need it to meet the Strengthened Aged Care Quality Standards and the Charter of Aged Care Rights, which require care to reflect each person's communication needs and preferences.

Sleep and Rest Policy

This policy covers how aged care providers support residents to sleep and rest according to their individual preferences, routines, and clinical needs. Australian providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and the Charter of Aged Care Rights.

Mental Health and Wellbeing Policy (Residents)

This policy covers the identification, assessment, and management of mental health and emotional wellbeing needs for residents in aged care settings, including approaches to depression, anxiety, grief, and social isolation. Australian aged care providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and the Aged Care Act 2024, and to demonstrate person-centred, clinically sound care practices.

Rehabilitation and Restorative Care Policy

This policy covers the planning, delivery, and review of rehabilitation and restorative care services for residents in Australian aged care settings, including the roles of allied health professionals. Providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and the Aged Care Act 2024.

Dysphagia and Swallowing Management Policy

This policy covers the identification, assessment, and safe management of dysphagia (swallowing difficulties) in aged care residents, including IDDSI-aligned texture modification and mealtime supervision. Australian aged care providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and to reduce the risk of choking, aspiration, and malnutrition.

Pain Assessment and Management Policy

This policy covers the systematic assessment, monitoring, and management of pain in residential aged care settings, including both acute and chronic pain. Australian aged care providers need it to meet obligations under the Strengthened Aged Care Quality Standards and the Aged Care Act 2024, and to protect residents from unnecessary suffering.

Oral Health Care Policy

This policy sets out how aged care providers assess, plan, and deliver oral health care to residents, supporting compliance with the Strengthened Aged Care Quality Standards and reducing the risk of preventable oral disease. Australian providers need it to demonstrate person-centred care, meet regulatory obligations, and protect the dignity and wellbeing of every resident.

Continence Management Policy

This policy covers the assessment, planning, and delivery of continence care for residents in aged care settings, including bowel and bladder management protocols. Australian aged care providers need it to meet their obligations under the Strengthened Aged Care Quality Standards and to protect resident dignity and clinical outcomes.

Fee Transparency and Financial Governance Policy

This policy covers how aged care providers must disclose fees, pricing structures, and financial arrangements to consumers under the Aged Care Act 2024 and Support at Home program reforms. Australian providers need it to meet pricing disclosure obligations, protect consumer rights, and demonstrate accountable financial governance to the Aged Care Quality and Safety Commission.

Third-Party and Subcontractor Management Policy

This policy sets out how Australian aged care providers select, engage, oversee, and review third-party providers and subcontractors to protect residents and meet their obligations under the Aged Care Act 2024 and the Strengthened Aged Care Quality Standards. It gives facility managers and compliance teams a practical framework for contractor governance that holds up under audit.

Conflict of Interest Policy

This policy helps Australian aged care providers identify, disclose, and manage conflicts of interest across their workforce and governance structures. It supports compliance with the Strengthened Aged Care Quality Standards and the Aged Care Act 2024, protecting residents and the integrity of care decisions.

Governance and Board Accountability Policy

This policy sets out how Australian aged care providers structure board oversight, define accountability obligations, and meet governance requirements under the Aged Care Act 2024 and Strengthened Aged Care Quality Standard 2. Providers need it to demonstrate that their governing body actively directs, monitors, and takes responsibility for safe, high-quality care.

Elopement and Missing Person Policy

This policy covers the prevention, detection, and response procedures for elopement and missing person incidents in residential aged care settings. Australian providers need it to meet their obligations under the Serious Incident Response Scheme, the Aged Care Act 2024, and the Strengthened Aged Care Quality Standards.

Staff Rostering and Workforce Planning Policy

This policy sets out how Australian aged care providers must plan, schedule, and maintain a compliant workforce, including meeting the 24/7 registered nurse mandate under the Aged Care Act 2024. Facility managers and directors of nursing can use this template to build rostering practices that align with Strengthened Aged Care Quality Standard 2 and the needs of residents.

Clinical Governance Framework Policy

Access a free Clinical Governance Framework Policy template designed for aged care providers to meet Strengthened Aged Care Quality Standards. This resource provides a structured framework for defining accountability, monitoring clinical performance, and ensuring regulatory compliance for boards and clinical leaders.

Business Continuity Policy

Access a free Business Continuity Policy template designed to help Australian aged care providers maintain operational resilience and meet Strengthened Quality Standard 8 requirements. This resource provides a comprehensive framework for managing IT outages, staffing shortages, and supply chain disruptions to ensure continuous care delivery.

Wound Care Pressure Injury Prevention Policy

Access a free Wound Care and Pressure Injury Prevention Policy template designed to help aged care providers align with Standard 5 of the Strengthened Quality Standards. This resource provides a comprehensive framework for risk assessment, prevention strategies, and clinical documentation to ensure regulatory compliance and improved resident outcomes.

Cultural Diversity Inclusion Policy

Access a free, editable Cultural Diversity and Inclusion Policy template designed to help aged care providers meet the Strengthened Aged Care Quality Standards. This resource provides a comprehensive framework for delivering culturally safe care, covering assessment procedures, staff training, and inclusive care planning.

Consumer Rights Dignity Choice Policy

Access a free Consumer Rights, Dignity and Choice Policy template designed to help Australian aged care providers align with Standard 1 of the Strengthened Quality Standards. This resource provides a comprehensive framework for upholding the Charter of Aged Care Rights and supporting informed resident decision-making.

Work Health And Safety Policy

Access a free, editable WHS policy template for aged care facilities designed to manage high-risk hazards and ensure compliance with the Work Health and Safety Act 2011. This resource provides a comprehensive framework to protect staff and residents while meeting the latest aged care quality standards.

Abuse Neglect Prevention Policy

Access a free, audit-ready Abuse and Neglect Prevention Policy template for aged care providers. This comprehensive resource covers all forms of abuse, reporting pathways, and prevention strategies to ensure compliance with the Strengthened Aged Care Quality Standards and SIRS requirements.

Serious Incident Response Scheme Policy

Access a free SIRS policy template designed for residential aged care providers to meet mandatory reporting obligations under the Aged Care Act 1997. This resource covers all eight reportable incident categories, notification timeframes, and investigation requirements to ensure compliance with ACQSC standards.

Palliative End Of Life Care Policy

Access a free Palliative and End-of-Life Care Policy Template designed to help aged care providers meet the Strengthened Quality Standards. This customizable resource provides a comprehensive framework for advance care planning, symptom management, and bereavement support to ensure residents die with dignity and comfort.

Dementia Care Policy Template

Access a free dementia care policy template designed to help aged care providers align with Standards 1 and 5 of the Strengthened Quality Standards. This customizable resource ensures consistent, person-centred care delivery and compliance with the Aged Care Act across Australian residential facilities.

Advance Care Planning Policy Template

Access a free Advance Care Planning policy template designed to help aged care providers align with Standard 5 of the Strengthened Quality Standards. This resource provides a comprehensive framework for documenting resident preferences and ensuring compliance with the Aged Care Act 2024 across all Australian jurisdictions.

Environmental Health and Waste Management Policy Template

Get your free Environmental Health and Waste Management Policy Template. Meet standards and manage waste safely in your facility.

Quality Improvement Policy Template

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Code of Conduct and Ethics Policy Template

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Behaviour Support Policy Template

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Nutrition and Hydration Policy Template

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Emergency and Disaster Management Policy Template

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Infection Prevention and Control Policy Template

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Workforce Training and Competency Policy Template

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Staff Recruitment and Selection Policy Template

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Privacy and Confidentiality Policy Template

Get your free Privacy and Confidentiality Policy Template. Protect sensitive information and meet legal duties with our easy-to-use policy.

Feedback and Complaints Management Policy Template

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Incident Management and Reporting Policy Template

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Risk Management Policy Template

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Falls Prevention and Management Policy Template

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Medication Management Policy Template

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Whistleblower Policy Template

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Trauma-Informed Care Policy Template

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Restrictive Practices Policy

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Advocacy and Access Policy

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Consent for Medication Policy

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