Document ID: chunk:federal_register_of_legislation:F2023C00396:reg:0:p1
Version: federal_register_of_legislation:F2023C00396
Segment Type: reg
Provision Reference: reg 0 (pt 1/4)
Character Range: 110278–113393

0       Major Non‑conformity                       The NDIS provider is unable to demonstrate appropriate processes systems or structures to meet the required outcome and indicators and/or the gaps in meeting the outcome present a high risk ‑ Three Minor Non‑Conformities within the same module may also constitute a Major Non‑Conformity ‑ A rating of 0 will preclude a recommendation for certification.

The audit report shall reflect findings and ratings as determined at the time of the audit, and in accordance with requirements at section 16 of this instrument.  This will ensure that appropriate outcomes and associated indicators will be further monitored at subsequent audits.

Annex C – Timeframe for correcting non‑conformities
Timeframe for correcting non‑conformities

    1. The approved quality auditor shall require a registered NDIS provider to present a corrective action plan to it within seven  calendar days of written notification of the non‑conformity.
    2. For a major non‑conformity, the approved quality auditor shall undertake a desktop review of the implemented corrective actions within three calendar months of receiving the corrective action plan and shall, if necessary, conduct an on‑site follow‑up.
    3. Critical risks or other serious matters would normally require an on‑site follow‑up or re‑audit within three  calendar months.
    4. Major non‑conformities shall be downgraded or closed within three calendar months of initial written notification of the non‑conformity.
    5. For major non‑conformities identified as part of a mid‑term or recertification audit, failure to downgrade or close a major non‑conformity within three calendar months shall result in automatic suspension of the certification decision made by the approved quality auditor.
    6. Minor non‑conformities shall be closed out within eighteen calendar months of initial written notification at the mid‑term or recertification audit (whichever comes first); otherwise the minor non‑conformity shall be escalated to a major non‑conformity.
    7. If a minor non‑conformity has been escalated to a major non‑conformity, failure to close out the major non‑conformity within three calendar months shall result in automatic suspension of certification decision made by the approved quality auditor (i.e. a non‑conformity that has been escalated to a major non‑conformity shall not be downgraded back to a non‑conformity).
    8. If a major non‑conformity has been downgraded to a minor non‑conformity, failure to close out the non‑conformity within twelve calendar months from the date of issue of the original finding shall result in automatic suspension of the certification decision of the approved quality auditor (i.e. a major non‑conformity downgraded to a minor non‑conformity shall be closed out within the remaining nine calendar months and not be escalated to a major non‑conformity again)
    9. The approved quality auditor shall conduct a follow‑up in the most cost‑effective manner that ensures that major non‑conformities have been properly downgraded or closed. This may entail a desktop