Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002

i Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 S.R. No. 79/2002 TABLE OF PROVISIONS Regulation Page PART 1—PRELIMINARY 1 1. Objective 1 2. Authorising provision 1 3. Commencement 2 4. Revocation 2 5. Definitions 2 PART 2—PRESCRIBED HEALTH SERVICES 4 6. Private hospitals 4 7. Day procedure centres 4 PART 3—FORMS OF APPLICATION AND FEES 6 8. Application for approval in principle 6 9. Application for variation or transfer of certificate of approval in principle 6 10. Application for registration 6 11. Application for renewal of registration 6 12. Application for variation of registration 6 13. Annual fee 7 PART 4—SENIOR APPOINTMENTS 8 Division 1—Director of Nursing 8 14. Director of Nursing to be appointed 8 15. Acting Director of Nursing 8 16. Secretary to be notified of termination or vacancy 9 Division 2—Other Appointments 9 17. Chief Executive Officer and Medical Director 9 18. Secretary to be notified of termination or vacancy 10 -- 1 of 50 -- Regulation Page ii PART 5—ADMISSION OF PATIENTS 11 Division 1—Unit Record Number 11 19. Unit record number to be allocated 11 Division 2—Information to be Given to Patients 11 20. Information about fees and services 11 Division 3—Clinical Records 13 21. Clinical record to be created 13 22. Information to be included in clinical record 13 Division 4—Identification of Patients 15 23. Means of identifying patients 15 24. Identification of infants 15 PART 6—CARE OF PATIENTS 17 Division 1—Management of Patient Care 17 25. Respect, dignity and privacy 17 Division 2—Nursing and Professional Care 17 26. Nurses to be registered and competent 17 27. Sufficient health care staff to be on duty 18 28. Needs of patients to be met 19 PART 7—COMPLAINTS 20 29. Nomination of complaints officer 20 30. Dealing with a complaint 20 31. Record of complaint 21 32. Person making complaint not to be adversely affected 21 PART 8—TRANSFER AND DISCHARGE OF PATIENTS 22 33. Transfer of patients 22 34. Discharge of patients 22 PART 9—REGISTERS AND RECORDS 23 Division 1—Patient Register 23 35. Patient Admission and Discharge Register 23 Division 2—Staff Register and Records 24 36. Staff register 24 -- 2 of 50 -- Regulation Page iii Division 3—Other Registers 24 37. Operation Theatre Register 24 38. Birth register 25 PART 10—PREMISES AND EQUIPMENT 27 39. Identification of rooms 27 40. Communications 27 41. Prevention of scalding 28 42. Repair and cleanliness of premises 28 43. Suitability and cleanliness of facilities, equipment etc. 28 PART 11—INFECTION CONTROL 29 44. Notification of infection control management plans 29 45. Infection Control Management Plan 29 PART 12—DISPLAY OF INFORMATION 31 46. Information to be prominently displayed 31 PART 13—STATISTICAL RETURNS 32 47. Information to be forwarded to the Secretary 32 PART 14—ENFORCEMENT 34 48. Form of notice of seizure 34 PART 15—TRANSITIONAL PROVISION 35 49. References to fertilisation procedure 35 __________________ SCHEDULES 36 SCHEDULE 1—Application for approval in principle of a private hospital or day procedure centre 36 SCHEDULE 2—Application for variation or transfer of certificate of approval in principle of a private hospital or day procedure centre 38 SCHEDULE 3—Application for the registration of a private hospital or day procedure centre 40 SCHEDULE 4—Application for the renewal of registration of a private hospital or day procedure centre 42 -- 3 of 50 -- Regulation Page iv SCHEDULE 5—Application for the variation of the registration of a private hospital or day procedure centre 43 SCHEDULE 6—Notice of seizure of document or thing from a private hospital or day procedure centre 45 ═══════════════ ENDNOTES 46 -- 4 of 50 -- 1 STATUTORY RULES 2002 S.R. No. 79/2002 Health Services Act 1988 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 The Governor in Council makes the following Regulations: Dated: 10 September 2002 Responsible Minister: JOHN THWAITES Minister for Health HELEN DOYE Clerk of the Executive Council PART 1—PRELIMINARY 1. Objective The objective of these Regulations is to— (a) provide for the safety and quality of care of patients receiving health services in private hospitals and day procedure centres; and (b) prescribe fees, forms and other matters required to be prescribed under the Health Services Act 1988 in relation to such health service establishments. 2. Authorising provision These Regulations are made under section 158 of the Health Services Act 1988. -- 5 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 2 3. Commencement (1) These Regulations, except regulations 30, 31 and 32, come into operation on the day on which they are made. (2) Regulations 30, 31 and 32 come into operation on 1 January 2003. 4. Revocation The Health Services (Private Hospitals and Day Procedure Centres) (Interim) Regulations 20011 are revoked. 5. Definitions In these Regulations— "Act" means the Health Services Act 1988; "infertility treatment" means a treatment procedure within the meaning of the Infertility Treatment Act 1995; "medical health services" means health services provided to a patient by a registered medical practitioner that— (a) involve diagnosis and non-operative treatment; and (b) require nursing supervision or care; "nurses register" means the register of nurses kept under Part 2 of the Nurses Act 1993; "registered dentist" has the same meaning as in the Dental Practice Act 1999; "speciality health services" means health services that are ordinarily undertaken only by, or under the supervision (whether direct or indirect) of, a specialist registered medical practitioner that require— (a) the admission of the patient; and r. 3 -- 6 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 3 (b) the use of specialist equipment; and (c) the area in which the services are provided to be fitted out specifically for those kinds of services; "surgical health services" means health services provided by a registered medical practitioner or a registered dentist that— (a) involve the use of— (i) surgical instruments; and (ii) an operating theatre, procedure room or treatment room; and (b) require either— (i) the attendance of one or more other registered health care practitioners; or (ii) post operative observation of the patient by nursing staff; "surgical instrument" includes— (a) a laser device that disrupts the integrity of epithelial tissue or stroma; and (b) cannulae used to penetrate subcutaneous tissue for the purpose of removing either tissue or fluid or both tissue and fluid containing body fat; "unit record number" means an identifying number unique to a patient. __________________ r. 5 -- 7 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 4 PART 2—PRESCRIBED HEALTH SERVICES 6. Private hospitals For the purposes of the definition of "private hospital" in section 3 of the Act, the following are health services of a prescribed kind or kinds— (a) medical health services; (b) surgical health services; (c) speciality health services for the provision of— (i) cardiac services; or (ii) emergency medicine; or (iii) endoscopy; or (iv) infertility treatment; or (v) intensive care; or (vi) mental health services; or (vii) neonatal services; or (viii) obstetrics; or (ix) oncology (chemotherapy); or (x) oncology (radiation therapy); or (xi) renal dialysis; or (xii) specialist rehabilitation services. 7. Day procedure centres For the purposes of the definition of "day procedure centre" in section 3 of the Act, the following are health services of a prescribed kind or kinds— (a) medical health services; (b) surgical health services; r. 6 -- 8 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 5 (c) speciality health services for the provision of— (i) cardiac services; or (ii) emergency medicine; or (iii) endoscopy; or (iv) infertility treatment; or (v) mental health services; or (vi) obstetrics; or (vii) oncology (chemotherapy); or (viii) oncology (radiation therapy); or (ix) renal dialysis; or (x) specialist rehabilitation services. __________________ r. 7 -- 9 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 6 PART 3—FORMS OF APPLICATION AND FEES 8. Application for approval in principle For the purposes of section 70(2) of the Act— (a) the prescribed form is the form in Schedule 1; and (b) the prescribed fee is $655. 9. Application for variation or transfer of certificate of approval in principle For the purposes of section 74 of the Act— (a) the prescribed form is the form in Schedule 2; and (b) the prescribed fee is $165. 10. Application for registration For the purposes of section 82(2) of the Act— (a) the prescribed form is the form in Schedule 3; and (b) the prescribed fee is $565. 11. Application for renewal of registration For the purposes of section 88(2) of the Act— (a) the prescribed form is the form in Schedule 4; and (b) the prescribed fee is $555. 12. Application for variation of registration For the purposes of section 92(2) of the Act— (a) the prescribed form is the form in Schedule 5; and r. 8 -- 10 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 7 (b) the prescribed fee— (i) in the case of an application for the transfer of the certificate to another person who intends to become the proprietor is $490; and (ii) in any other case is $165. 13. Annual fee For the purposes of section 87 of the Act, the prescribed annual fee for a private hospital or day procedure centre registered for the number of beds specified in column 1 of the Table below is the fee specified in column 2 of that Table opposite the relevant number of beds for that hospital or centre. TABLE Column 1 Number of beds for which the private hospital or day procedure centre is registered Column 2 Fee 1–26 $650 27–50 $750 51–75 $850 76–100 $950 101–150 $1100 151–200 $1300 201–300 $1500 301–400 $1800 401–500 $2200 501 or more $2700 __________________ r. 13 -- 11 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 8 PART 4—SENIOR APPOINTMENTS Division 1—Director of Nursing 14. Director of Nursing to be appointed (1) The proprietor of a private hospital or day procedure centre must appoint a suitably qualified person as the Director of Nursing. Penalty: 50 penalty units. (2) For the purposes of sub-regulation (1), a person is suitably qualified if he or she has a qualification or practical experience in nursing management and— (a) is registered in Division 1 of the Nurses Register; or (b) in the case of a private hospital or day procedure centre registered only for speciality health services for the provision of mental health services, is registered in either Division 1 or Division 3 of the Nurses Register. 15. Acting Director of Nursing If a Director of Nursing is absent, incapacitated or the position is vacant, the proprietor of a private hospital or day procedure centre must appoint a person to act as the Director of Nursing during the period of the absence, incapacity or vacancy. Penalty: 50 penalty units. r. 14 -- 12 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 9 16. Secretary to be notified of termination or vacancy The proprietor of a private hospital or day procedure centre must notify the Secretary in writing of the name, qualifications and experience of any person appointed by the proprietor— (a) as the Director of Nursing; or (b) to act as the Director of Nursing for a period of more than 28 days— within 28 days after the appointment has been made. Penalty: 20 penalty units. Division 2—Other Appointments 17. Chief Executive Officer and Medical Director If the proprietor of a private hospital or day procedure centre appoints a— (a) Chief Executive Officer; or (b) Medical Director— (however titled) the proprietor must notify the Secretary in writing of the name, qualifications and experience of the person appointed as Chief Executive Officer or Medical Director within 28 days of the appointment. Penalty: 20 penalty units. r. 16 -- 13 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 10 18. Secretary to be notified of termination or vacancy If the proprietor of a private hospital or day procedure centre terminates the appointment of a Chief Executive Officer or Medical Director (however titled) or the position otherwise becomes vacant the proprietor must notify the Secretary in writing within 28 days of the termination or vacancy. Penalty: 20 penalty units. __________________ r. 18 -- 14 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 11 PART 5—ADMISSION OF PATIENTS Division 1—Unit Record Number 19. Unit record number to be allocated The proprietor of a private hospital or day procedure centre must ensure that on or as soon as practicable after the admission of a patient to the hospital or centre a unit record number is allocated to that patient. Penalty: 30 penalty units. Division 2—Information to be Given to Patients 20. Information about fees and services (1) The proprietor of a private hospital or day procedure centre must ensure that on or before admission each patient of the hospital or centre is given— (a) a statement containing information in relation to the health care services provided at the hospital or centre that complies with sub-regulation (2); and (b) information about fees to be charged by the hospital or centre and any likely out of pocket expenses which may be incurred by the patient; and (c) a clear explanation of the treatment and services to be provided to the patient at the hospital or centre. Penalty: 50 penalty units. r. 19 -- 15 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 12 (2) A statement referred to in sub-regulation (1) must contain information about the following matters— (a) the quality or standard of health care and services provided in the private hospital or day procedure centre; (b) courteous treatment of patients; (c) consideration of a patient's beliefs and ethnic, cultural and religious practices; (d) consideration of a patient's special dietary needs, if any; (e) a patient's privacy; (f) that a patient may request the names and roles of the key health workers involved in the patient's care; (g) a patient's entitlement to ask for a referral if he or she wants to seek another medical opinion; (h) that any personal information or identifying material about a patient is dealt with in a confidential manner except— (i) where necessary to enable another health care worker to assist in the patient's care; or (ii) when authorised by or under a law; (i) a patient's consent to treatment; (j) that a patient may refuse the presence of health workers not directly involved in the patient's care; (k) that a patient may discharge himself or herself at any time despite the advice of the attending health care practitioner or staff of the hospital or centre; r. 20 -- 16 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 13 (l) that a patient may comment on or complain about the treatment or the quality of the health services or care being provided including to whom any complaint should be made. Division 3—Clinical Records 21. Clinical record to be created The proprietor of a private hospital or day procedure centre must ensure that a separate clinical record for each patient is— (a) created on or as soon as practicable after the admission of the patient to the hospital or centre; and (b) maintained during the patient's stay. Penalty: 30 penalty units. 22. Information to be included in clinical record The proprietor of a private hospital or day procedure centre must take reasonable steps to ensure that each clinical record contains the following information— (a) the patient's unit record number; (b) the patient's name, address, date of birth and sex; (c) the name and contact details of a relative or friend nominated by the patient; (d) relevant clinical details of the patient including— (i) clinical history on admission; (ii) progress notes during the patient's stay; r. 21 -- 17 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 14 (iii) any medication ordered or given; (iv) known allergies and drug sensitivities; (v) current medication; (vi) pre-procedure assessment; (vii) results of any relevant diagnostic tests; (e) if a procedure is carried out on a patient— (i) the consent form for the procedure and anaesthesia; (ii) the date of the procedure; (iii) the names and signatures of the practitioners carrying out the procedure; (iv) the type of procedure carried out; (v) the pre-procedure check list by the attending practitioner or by the assisting nurse; (vi) administered drugs and dosages; (vii) a record of any monitoring undertaken; (viii) a record of any intravenous fluids administered; (ix) a procedure room report including any procedure findings; (x) the final diagnosis of the patient on discharge. Penalty: 30 penalty units. Note: The Health Records Act 2001 contains provisions relating to the retention of records. See HPP4. r. 22 -- 18 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 15 Division 4—Identification of Patients 23. Means of identifying patients The proprietor of a private hospital or day procedure centre must ensure that a patient admitted to the hospital or centre can be readily identified at all times when the patient is receiving health care or other services at the hospital or centre by— (a) an identity band or other suitable device attached to the patient; or (b) a photograph, a copy of which must be attached to the clinical record of the patient. Penalty: 40 penalty units. 24. Identification of infants (1) The proprietor of a private hospital or day procedure centre must ensure that if an infant is born at the hospital or centre, at least 2 identity bands or other suitable devices which contain the information specified in sub-regulation (3) are attached to that infant— (a) as soon as practicable after the birth and before leaving the delivery room; and (b) as long as the infant remains in the hospital or centre. Penalty: 30 penalty units. (2) If immediately after giving birth to an infant, a mother is admitted as a patient of a private hospital or day procedure centre for— (a) the receipt of medical services in connection with the birth; or r. 23 -- 19 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 16 (b) the provision of nursing services by a suitably qualified nurse that are directly related to the birth— the proprietor of the hospital or centre must ensure that at least 2 identity bands or other suitable devices which contain the information specified in sub-regulation (3) are attached to the infant for as long as the infant remains in the hospital or centre. Penalty: 30 penalty units. (3) For the purposes of sub-regulations (1) and (2) the information is— (a) the surname of the infant; (b) the full name of the mother; (c) the unit record number of the mother. __________________ r. 24 -- 20 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 17 PART 6—CARE OF PATIENTS Division 1—Management of Patient Care 25. Respect, dignity and privacy The proprietor of a private hospital or day procedure centre must ensure that a patient admitted to the hospital or centre— (a) is treated with dignity and respect and with due regard to his or her religious beliefs, and ethnic and cultural practices; and (b) is entitled to privacy; and (c) is not subjected to unusual routines, particularly with respect to the timing of meals and hygiene procedures, unless the routines are for the benefit of the patient. Penalty: 50 penalty units. Division 2—Nursing and Professional Care 26. Nurses to be registered and competent The proprietor of a private hospital or day procedure centre must ensure that each nurse at the hospital or centre— (a) is registered in the Nurses Register; and (b) is professionally competent through education or experience to provide nursing care at the hospital or centre having regard to the kind or kinds of health service being provided. Penalty: 50 penalty units. r. 25 -- 21 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 18 27. Sufficient health care staff to be on duty (1) The proprietor of a private hospital or day procedure centre must ensure that whenever patients are receiving health services from the hospital or centre, a sufficient number of appropriately educated or experienced nursing and other health professional staff is on duty to provide care for those patients. Penalty: 50 penalty units. (2) For the purposes of sub-regulation (1), a sufficient number of appropriately educated or experienced nursing staff is on duty if— (a) in the case of a private hospital— (i) at least one nurse registered in Division 1 of the Nurses Register is on duty for each 10 patients or fraction of that number during day and evening shifts; and (ii) at least one nurse registered in Division 1 of the Nurses Register is on duty for each 15 patients or fraction of that number during night shifts; or (b) in the case of a day procedure centre, not less than one nurse registered in Division 1 of the Nurses Register is on duty for each 10 patients or fraction of that number. (3) Despite sub-regulation (2), in determining the number of nurses on duty— (a) if 3 or more nurses are on duty at a private hospital or a day procedure centre during a shift, one-third may be nurses registered in Division 2 of the Nurses Register; and r. 27 -- 22 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 19 (b) if the private hospital or day procedure centre is registered only for speciality health services for the provision of mental health services, a nurse may be registered in either Division 1 or Division 3 of the Nurses Register. 28. Needs of patients to be met The proprietor of a private hospital or day procedure centre must take reasonable steps to ensure that the needs of patients are met promptly and effectively by nursing and other health professional staff who are appropriately qualified or skilled to meet those needs. Penalty: 50 penalty units. __________________ r. 28 -- 23 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 20 PART 7—COMPLAINTS 29. Nomination of complaints officer (1) The proprietor of a private hospital or day procedure centre must nominate a person to receive and deal with any complaints that may be made by, or on behalf of, a patient of the hospital or centre. Penalty: 50 penalty units. (2) The proprietor of a private hospital or day procedure centre must take reasonable steps to ensure that every patient and member of the staff of the hospital or centre is informed of the name of the person nominated by the proprietor to receive and deal with complaints. Penalty: 50 penalty units. 30. Dealing with a complaint (1) The proprietor of a private hospital or day procedure centre must ensure that a complaint— (a) is responded to as soon as practicable after the complaint has been made; and (b) is dealt with as discreetly as possible in the particular circumstances. Penalty: 40 penalty units. (2) The proprietor of a private hospital or day procedure centre must ensure that the person who made the complaint is informed of the action taken in respect of the complaint. Penalty: 40 penalty units. r. 29 -- 24 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 21 31. Record of complaint (1) The proprietor of a private hospital or day procedure centre must ensure that a written record is kept of every complaint made by, or on behalf of, a patient of that hospital or centre that contains the following information— (a) the nature of the complaint; and (b) the date of the complaint; and (c) the action taken in respect of that complaint. Penalty: 30 penalty units. (2) The proprietor of a private hospital or day procedure centre must ensure that the written record referred to in sub-regulation (1) is kept in a secure place for a period of 7 years after the complaint has been made. Penalty: 30 penalty units. 32. Person making complaint not to be adversely affected The proprietor of a private hospital or day procedure centre must take reasonable steps to ensure that a patient of the hospital or centre or a person making a complaint on behalf of the patient is not adversely affected because a complaint has been made by the patient or on behalf of the patient. Penalty: 60 penalty units. __________________ r. 31 -- 25 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 22 PART 8—TRANSFER AND DISCHARGE OF PATIENTS 33. Transfer of patients If a patient is transferred from a private hospital or day procedure centre to another health service establishment or health care agency, the proprietor of the hospital or centre must ensure that all information and copies of any documents relating to the patient's medical condition and treatment necessary for the establishment or agency to which the patient is being transferred to provide appropriate ongoing treatment or care are sent with the patient. Penalty: 40 penalty units. 34. Discharge of patients The proprietor of a private hospital or day procedure centre must take reasonable steps to ensure that a patient being discharged from the hospital or centre is given a clear explanation of any recommendations or arrangements which have been made with respect to the future health care needs of the patient. Penalty: 60 penalty units. __________________ r. 33 -- 26 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 23 PART 9—REGISTERS AND RECORDS Division 1—Patient Register 35. Patient Admission and Discharge Register For the purposes of section 109(1) of the Act— (a) the prescribed particulars with respect to every patient who receives care in a private hospital or day procedure centre are— (i) the unit record number of the patient; (ii) the full name of the patient; (iii) the sex of the patient; (iv) the address and telephone number of the patient; (v) the patient's date of birth; (vi) the date of his or her admission and discharge; (vii) the status of the patient at discharge; (viii) if the patient is transferred to another health service establishment or health care agency, the name of that establishment or agency and the reason for the transfer; and (b) the prescribed manner in which the prescribed particulars are to be kept is in writing; and (c) the prescribed period for which the prescribed particulars are to be retained is 7 years. r. 35 -- 27 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 24 Division 2—Staff Register and Records 36. Staff register For the purposes of section 109(1) of the Act— (a) the prescribed particulars of staff employed in a private hospital or day procedure centre are— (i) the full name of every member of the nursing and other health professional staff responsible for the care and treatment of patients; (ii) the date of birth of every such member; (iii) the designation of every such member; (iv) the qualifications of every such member; (v) if applicable, the registration number of every such member; and (b) the prescribed manner in which the prescribed particulars are to be kept is in writing; and (c) the prescribed period for which the prescribed particulars are to be retained is 2 years. Division 3—Other Registers 37. Operation Theatre Register (1) The proprietor of a private hospital or day procedure centre at which surgical health services or speciality health services for the provision of endoscopy may be carried on must ensure that an Operation Theatre Register that complies with sub-regulation (2) is kept at the hospital or centre. Penalty: 30 penalty units. r. 36 -- 28 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 25 (2) An Operation Theatre Register must be in writing and contain the following information with respect to each procedure performed at the hospital or centre— (a) the date and time of the procedure; (b) the unit record number of the patient; (c) the full name of the patient, his or her sex and date of birth; (d) the nature of the procedure; (e) the name of the health practitioner undertaking the procedure and assistant (if any); (f) the name of the anaesthetist and assistant (if any); (g) the names of attending theatre staff; (h) any remarks concerning the outcome of the procedure; (i) the anaesthetic administered; (j) any anaesthetic or procedural complications encountered. Note: The Health Records Act 2001 contains provisions relating to the retention of records. See HPP4. 38. Birth register (1) The proprietor of a private hospital or day procedure centre in which speciality health services for the provision of obstetrics may be carried on must ensure that a Birth Register that complies with sub-regulation (2) is kept at the hospital or centre. Penalty: 30 penalty units. r. 38 -- 29 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 26 (2) A Birth Register must be in writing and contain the following information with respect to each birth at the hospital or centre— (a) the date and time of the birth; (b) the full name of the mother; (c) the unit record number of the mother; (d) the sex of the infant; (e) the names of all health care personnel in attendance at the birth. (3) The proprietor of a private hospital or day procedure centre must retain a Birth Register for at least 25 years after the date of the last entry. Penalty: 30 penalty units. __________________ r. 38 -- 30 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 27 PART 10—PREMISES AND EQUIPMENT 39. Identification of rooms The proprietor of a private hospital or day procedure centre must ensure that each room in which beds or recovery chairs are provided for the accommodation of patients is clearly identified at the entrance to that room by a sign stating— (a) the letter or number of that room; and (b) the number of beds and recovery chairs ordinarily in that room. Penalty: 10 penalty units. 40. Communications (1) The proprietor of a private hospital or day procedure centre must ensure that an effective electronic communication system that complies with sub-regulation (2) is provided and kept operational at the hospital or centre. Penalty: 60 penalty units. (2) An electronic communication system must— (a) enable patients and staff to summon assistance; and (b) enable calls to be made from— (i) each bed; (ii) any recovery chair in a recovery room; (iii) each toilet, shower or bath or other facility used for the bathing of patients; (iv) any common room, recreational or rest area or other place where patient care is provided. r. 39 -- 31 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 28 41. Prevention of scalding The proprietor of a private hospital or day procedure centre must ensure that a system or mechanism is installed to control the outlet temperature of hot water to every bath, shower or hand basin used by patients which avoids the risk of scalding. Penalty: 50 penalty units. 42. Repair and cleanliness of premises The proprietor of a private hospital or day procedure centre must ensure that the premises at which the hospital or centre is carried on are kept— (a) in a clean and hygienic condition; and (b) in a proper state of repair; and (c) free of hazards or the accumulation of materials which may become offensive, injurious to health or likely to facilitate the outbreak of fire. Penalty: 80 penalty units. 43. Suitability and cleanliness of facilities, equipment etc. The proprietor of a private hospital or day procedure centre must ensure that facilities, equipment, furnishings and fittings at the private hospital or day procedure centre are— (a) suitable for the kind or kinds of health services being provided by the hospital or centre; and (b) kept in a proper state of repair and maintained in good working order; and (c) kept in a clean and hygienic condition. Penalty: 80 penalty units. __________________ r. 41 -- 32 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 29 PART 11—INFECTION CONTROL 44. Notification of infection control management plans Until 1 July 2003, if the proprietor of a private hospital or day procedure centre implements a plan providing for the prevention and control of infection at the hospital or centre, the proprietor must, as soon as practicable after implementing the plan, notify the Secretary in writing— (a) that the proprietor has implemented such a plan; and (b) the name and telephone number of the person responsible for implementing the plan. 45. Infection Control Management Plan (1) After 1 July 2003, the proprietor of a private hospital or day procedure centre must develop and implement an Infection Control Management Plan that complies with sub-regulation (2). Penalty: 80 penalty units. (2) An Infection Control Management Plan must provide for the surveillance, prevention and control of infection at the hospital or centre and, without limiting the generality of this sub- regulation, must— (a) state its objectives; (b) identify and assess all the infection risks specific to the hospital or centre which the proprietor knows, or ought reasonably to know, exists or may exist and state how these risks are to be minimised; (c) provide for an on-going infection control education program for the staff of the hospital or centre; r. 44 -- 33 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 30 (d) state the particulars of training for persons who provide services at the hospital or centre that involve infection control risks; (e) set out how the proprietor will monitor and review the implementation and effectiveness of the plan. __________________ r. 45 -- 34 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 31 PART 12—DISPLAY OF INFORMATION 46. Information to be prominently displayed The proprietor of a private hospital or day procedure centre must display in a prominent position at the entrance foyer or reception area of the hospital or centre— (a) the certificate of registration of the premises as a private hospital or day procedure centre or a full size copy of the certificate; and (b) the name of the Director of Nursing and, if a Chief Executive Officer or Medical Director (however titled) has been appointed, the name of the Chief Executive Officer or Medical Director; and (c) the name and contact telephone number of the person nominated under regulation 29 to receive complaints. Penalty: 20 penalty units. __________________ r. 46 -- 35 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 32 PART 13—STATISTICAL RETURNS 47. Information to be forwarded to the Secretary (1) The proprietor of a private hospital or day procedure centre must forward to the Secretary for each month— (a) the following information relating to each patient— (i) unit record number; (ii) campus code; (iii) admission date, time and type of admission; (iv) admission source; (v) date of birth and country of birth; (vi) indigenous status; (vii) postcode and locality; (viii) marital status and sex; (ix) type of care received and procedures carried out; (x) health fund and level of insurance; (xi) Medicare number; (xii) account classification; (xiii) separation date, time and type; (xiv) transfer source; (xv) date of discharge or death; (xvi) discharge destination; (xvii) final diagnoses on discharge; and r. 47 -- 36 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 33 (b) the following information relating to occupancy rates— (i) the number of separations; (ii) the number of same day separations; (iii) the number of bed days; (iv) the average number of available beds. Penalty: 40 penalty units. (2) A proprietor must ensure that the information to be forwarded under sub-regulation (1) does not include the name and address of a patient. Penalty: 40 penalty units. (3) A proprietor must ensure that the information to be forwarded under sub-regulation (1) is forwarded to the Secretary— (a) if the Secretary has determined a time, being not less than 14 days after the end of the month to which the information relates, and has notified a proprietor in writing of that time, within that time; or (b) in any other case, not later than 17 days after the end of the month to which the information relates. Penalty: 40 penalty units. __________________ r. 47 -- 37 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 34 PART 14—ENFORCEMENT 48. Form of notice of seizure For the purposes of section 147(2)(a) of the Act, the prescribed form of a notice of seizure is the form of Schedule 6. __________________ r. 48 -- 38 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 35 PART 15—TRANSITIONAL PROVISION 49. References to fertilisation procedure On and from the commencement of regulation 3(1), a reference in a certificate of registration of a private hospital or day procedure centre to speciality health services for the provision of fertilisation procedures is to be read as a reference to speciality health services for the provision of infertility treatment. __________________ r. 49 -- 39 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 36 SCHEDULES SCHEDULE 1 Regulation 8 APPLICATION FOR APPROVAL IN PRINCIPLE OF A PRIVATE HOSPITAL OR DAY PROCEDURE CENTRE SECTION A 1. Full name of applicant: 2. Postal address of applicant: 3. The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application: 4. If the applicant is a body corporate, the name and address of a director or officer of the body corporate who may exercise control over the private hospital or day procedure centre: SECTION B 1. The kind of health service establishment to which the application relates is: *a private hospital *a day procedure centre 2. The name (or proposed name) of the hospital or centre, its street address and the municipal district in which the hospital or centre is, or is to be, located: 3. This application is for an approval in principle for: *the use of particular land or premises as a private hospital or a day procedure centre; *premises proposed to be constructed for use as a private hospital or day procedure centre; *alterations or extensions to premises used, or proposed to be used, as a private hospital or day procedure centre; *a variation of the registration of a private hospital or day procedure centre to alter the number of beds to which the registration relates; Sch. 1 -- 40 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 37 *a variation of the registration of a private hospital or day procedure centre to vary the kinds of health services that may be carried on on the premises; *a variation of the registration of a private hospital or day procedure centre to vary the number of beds that may be used for the specified kinds of prescribed health services. SECTION C In accordance with section 70(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee. Signature of applicant: Name of each signatory (in BLOCK LETTERS) Date: *(Strike out whichever does not apply) __________________ Sch. 1 -- 41 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 38 SCHEDULE 2 Regulation 9 APPLICATION FOR VARIATION OR TRANSFER OF CERTIFICATE OF APPROVAL IN PRINCIPLE OF A PRIVATE HOSPITAL OR DAY PROCEDURE CENTRE SECTION A 1. Full name of applicant: 2. Postal address of applicant: 3. The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application: SECTION B 1. The kind of health service establishment to which the application relates is: *a private hospital *a day procedure centre 2. The name (or proposed name) of the hospital or centre, its street address and the municipal district in which the hospital or centre is, or is to be, located: 3. This application is for approval in principle for: *variation of the certificate of approval in principle or any condition to which it is subject; or *transfer of the certificate of approval in principle to another person. 4. Reason for the proposed variation: 5. If the application relates to the transfer of the certificate to another person— (a) the name of that person; and (b) the postal address of that person; and (c) that person's, telephone and facsimile numbers and email address. 6. If the transferee is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the private hospital or day procedure centre: Sch. 2 -- 42 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 39 SECTION C In accordance with section 70(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee. Signature of applicant: Name of each signatory (in BLOCK LETTERS) Date: *(Strike out whichever does not apply) __________________ Sch. 2 -- 43 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 40 SCHEDULE 3 Regulation 10 APPLICATION FOR THE REGISTRATION OF A PRIVATE HOSPITAL OR DAY PROCEDURE CENTRE SECTION A 1. Full name of applicant: 2. Postal address of applicant: 3. The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application: 4. If the applicant is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the private hospital or day procedure centre: SECTION B 1. The kind of health service establishment for which registration is sought: *a private hospital *a day procedure centre 2. The proposed name of the hospital or centre, its street address and the municipal district in which the hospital or centre is located: 3. The proposed number of beds: 4. The kind or kinds of health service for which registration is being sought: *Medical health services *Surgical health services *Speciality health services for the provision of— *Cardiac Services *Emergency Medicine *Endoscopy *Infertility treatment *Intensive Care *Mental Health *Neonatal Services Sch. 3 -- 44 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 41 *Obstetrics *Oncology (Chemotherapy) *Oncology (Radiation Therapy) *Renal Dialysis *Specialist Rehabilitation 5. Is the applicant the owner or tenant of the premises? 6. If the applicant is not the owner, please state the name and address of the owner: Signature of applicant: Name of each signatory (in BLOCK LETTERS) Date: *(Strike out whichever does not apply) __________________ Sch. 3 -- 45 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 42 SCHEDULE 4 Regulation 11 APPLICATION FOR THE RENEWAL OF REGISTRATION OF A PRIVATE HOSPITAL OR DAY PROCEDURE CENTRE SECTION A 1. Full name of applicant: 2. Postal address of applicant: 3. The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application: 4. If the applicant is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the private hospital or day procedure centre: SECTION B 1. The name of the hospital or centre and its street address: 2. Date of expiry of current registration: SECTION C In accordance with section 88(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee. Signature of applicant: Name of each signatory (in BLOCK LETTERS) Date: __________________ Sch. 4 -- 46 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 43 SCHEDULE 5 Regulation 12 APPLICATION FOR THE VARIATION OF THE REGISTRATION OF A PRIVATE HOSPITAL OR DAY PROCEDURE CENTRE SECTION A 1. Full name of applicant: 2. Postal address of applicant: 3. The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application: SECTION B 1. The nature of the variation sought: *change of the kind of establishment to which the registration applies *transfer of the certificate of registration to another person who intends to become the proprietor of the establishment *variation of any condition to which the registration is subject *an alteration in the number of beds to which the registration relates *variation of the kinds of prescribed health services that may be carried on on the premises *variation of the number of beds that may be used for specified kinds of prescribed health services 2. Details of the variation sought: 3. If the application relates to the transfer of the certificate of registration to another person, the name, postal address, telephone and facsimile numbers and email address of the proposed transferee. Sch. 5 -- 47 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 44 SECTION C In accordance with section 92(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee. Signature of applicant: Name of each signatory (in BLOCK LETTERS) Date: *(Strike out whichever does not apply) __________________ Sch. 5 -- 48 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 45 SCHEDULE 6 Regulation 48 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 NOTICE OF SEIZURE OF DOCUMENT OR THING FROM A PRIVATE HOSPITAL OR DAY PROCEDURE CENTRE Name of private hospital or day procedure centre: Address of private hospital or day procedure centre: I, , being an authorised officer of the Department, am (print full name) seizing under section 147 of the Health Services Act 1988 the document or thing listed below. The seized document or thing will be returned to the place of seizure within 48 hours from the time of seizure. DOCUMENT OR THING SEIZED 1. 2. 3. Signed: Date: Time: (Authorised Officer) Signed: Date: Time: (Proprietor/staff member) DOCUMENT OR THING RETURNED Signed: Date: Time: (Authorised Officer) Signed: Date: Time: (Proprietor/staff member) ═══════════════ Sch. 6 -- 49 of 50 -- S.R. No. 79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002 46 ENDNOTES 1 Reg. 4: S.R. No. 170/2001. Endnotes -- 50 of 50 --