Health Services (Health Service Establishments) Regulations 2024 (Vic)

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Version No. 001

Health Services (Health Service Establishments) Regulations 2024

S.R. No. 77/2024

Version as at


31 August 2024

TABLE OF PROVISIONS

Regulation  Page

Part 1—Preliminary

1Objectives

2Authorising provision

3Commencement

4Revocations

5Definitions

Part 2—Prescribed health services

6Day procedure centres

7Private hospitals

Part 3—Health service establishment protocols for quality and safety

8Health service establishment protocols for quality and safety

9Determination of quality and safety guidelines

10Review of health service establishment protocols for quality and safety

Part 4—Forms of application and fees

11Application for approval in principle

12Application for transfer or variation of certificate of approval in principle

13Application for registration of a health service establishment

14Annual fees for health service establishments

15Application for renewal of registration of a health service establishment

16Application for variation of registration of a health service establishment

17Application for approval of alterations to clinical area within a health service establishment

Part 5—Senior appointments

Division 1—Director of Nursing

18Director of Nursing must be appointed

19Appointment of acting Director of Nursing

20Secretary must be notified of appointment

Division 2—Other appointments

21Chief Executive Officer and Medical Director

22Secretary to be notified of termination or vacancy

Part 6—Admission of patients

Division 1—Unit record number

23Unit record number must be allocated

Division 2—Information to be given to patients

24Information about fees and services

Division 3—Clinical risk assessments

25Pre-admission assessment

26Pre-presentation assessment

Division 4—Clinical records

27Clinical record must be created and updated

28Information to be included in clinical record

Division 5—Identification of patients

29Means of identifying patients

30Identification of infants

Part 7—Care of patients

Division 1—Management of patient care

31Respect, dignity and privacy

Division 2—Nursing and professional care

32Nurses must be registered and competent

33Post-operative care of surgery patients

34Care of maternity, obstetric and neonatal patients

35Sufficient nursing staff must be on duty

36Needs of patients must be met

37Reversal agents must be available

Part 8—Complaints

38Nomination of complaints officer

39Dealing with a complaint

40Record of complaint

41Person making complaint must not be adversely affected

Part 9—Transfer and discharge of patients

42Documentation required for transferred patients

43Information provided to patient transport

44Discharge information

Part 10—Registers, records and permits

Division 1—Patient admission and discharge records

45Patient admission and discharge records

Division 2—Staff records

46Staff records

Division 3—Registers

47Surgical Procedure Register

48Birth Register

Division 4—Permits

49Permit issued under section 19 of the Drugs, Poisons and Controlled Substances Act 1981

Part 11—Premises and equipment

50Identification of rooms

51Communications

52Repair and cleanliness of premises

53Suitability and cleanliness of facilities, equipment, furnishings and fittings

54Premises, staff and equipment outside health service establishment premises

55Evacuation plan

Part 12—Infection control

56Infection Control Management Plan

Part 13—Display of information

57Information to be prominently displayed

Part 14—Enforcement

58Form of notice of seizure

59Infringement offences and infringement penalties

Part 15—Returns and reports to be given to the Secretary

60Returns and reports to be given to the Secretary

61Reporting of compliance with the duty of candour

Part 16—Quality and safety review data

62Open disclosure policy

63Review of quality and safety of health services provided

64Patient experience survey data

65Staff safety culture survey data

Part 17—Sentinel events

66Reporting of sentinel events

67Review of sentinel events

Schedule 1—Revocations

Schedule 2—Application for approval in principle in relation to a health service establishment

Schedule 3—Application for transfer or variation of certificate of approval in principle of a health service establishment

Schedule 4—Application for registration of a health service establishment

Schedule 5—Application for renewal of registration of a health service establishment

Schedule 6—Application for variation of the registration of a health service establishment

Schedule 7—Application for approval of alterations to a clinical area within a health service establishment

Schedule 8—Notice of seizure of document or thing from a health service establishment

Schedule 9—Infringements

═════════════

Endnotes

1      General information

2      Table of Amendments

3      Explanatory details

Version No. 001

Health Services (Health Service Establishments) Regulations 2024

S.R. No. 77/2024

Version as at


31 August 2024

PART 1—PRELIMINARY

1Objectives

The objectives of these Regulations are—

(a)to provide for the quality and safety of care of patients receiving health services in or from health service establishments by prescribing—

(i)requirements for staffing; and

(ii)procedures for the handling of complaints; and

(iii)records to be kept; and

(iv)reporting requirements; and

(v)requirements for health service establishment protocols for quality and safety; and

(vi)other requirements to ensure the welfare of patients; and

(b)to prescribe fees, forms and other matters required to be prescribed under the Health Services Act 1988 in relation to health service establishments.

2Authorising provision

These Regulations are made under section 158 of the Health Services Act 1988.

3Commencement

These Regulations come into operation on 31 August 2024.

4Revocations

The Regulations listed in Schedule 1 are revoked.

5Definitions

In these Regulations—

Aboriginal person means a person who—

(a)is descended from an Aboriginal or Torres Strait Islander; and

(b)identifies as an Aboriginal or Torres Strait Islander; and

(c)is accepted as an Aboriginal or Torres Strait Islander by an Aboriginal or Torres Strait Island community;

admission means the recording in writing of a person's admission as a patient to a health service establishment under the care of—

(a)a registered medical practitioner; or

(b)a registered dental practitioner; or

(c)a registered medical radiation practitioner; or

(d)a registered podiatrist;

anaesthesia—

(a)means any of the following—

(i)general anaesthesia;

(ii)a major regional anaesthetic block;

(iii)intravenous sedation;

(iv)a high dose of local anaesthetic that has the potential to cause systemic toxicity; and

(b)does not include a dental nerve block;

bed includes any of the following—

(a)an emergency bed;

(b)an intensive care unit bed;

(c)an in-patient overnight or day bed;

(d)an in-patient overnight or day cot;

(e)a stage 1 recovery bed;

(f)a stage 2 recovery bed;

(g)an oncology chair;

(h)a renal treatment chair;

emergency medicine means the medical or surgical treatment of patients as a matter of urgency for the purpose of—

(a)saving life; or

(b)preventing further serious damage to health; or

(c)preventing suffering or the continuation of suffering of significant pain or distress;

emergency stabilisation treatment means treatment of a patient to stabilise and manage a serious or life-threatening condition or to manage significant pain while waiting to transport the patient to an appropriate health service establishment;

enrolled nurse means a person registered in Division 2 of the Register of Nurses under the Health Practitioner Regulation National Law to practise in the nursing and midwifery profession (other than as a student);

medical health service means a health service (other than emergency stabilisation treatment) that—

(a)is provided to a patient by a registered medical practitioner; and

(b)involves diagnosis and treatment that requires—

(i)nursing supervision and care; or

(ii)the use of anaesthesia;

registered dental practitioner means a person registered under the Health Practitioner Regulation National Law to practise in the dental profession (other than as a student);

registered health practitioner means a person registered under the Health Practitioner Regulation National Law to practise in a health profession (other than as a student);

registered medical radiation practitioner means a person registered under the Health Practitioner Regulation National Law to practise in the medical radiation profession (other than as a student); and

registered midwife means a person registered in the Register of Midwives under the Health Practitioner Regulation National Law to practise in the nursing and midwifery profession (other than as a nurse or student);

registered nurse means a person registered in Division 1 of the Register of Nurses under the Health Practitioner Regulation National Law to practise in the nursing and midwifery profession (other than as a midwife or student);

registered podiatrist means a person registered under the Health Practitioner Regulation National Law to practise in the podiatry profession (other than as a student);

renal dialysis means (haemodialysis) treatment that uses a dialyzer machine to remove waste and excess water from the blood;

sentinel event means an unexpected and adverse event that occurs infrequently in a health service establishment and results in the death of, or serious physical or psychological injury to, a patient as a result of system and process deficiencies at the health service establishment;

speciality health service means a health service (other than emergency stabilisation treatment) that—

(a)is ordinarily undertaken by, or under the supervision of, a registered medical practitioner, a registered dental practitioner, a registered medical radiation practitioner or a registered podiatrist; and

(b)requires one or both of the following—

(i)specialist equipment;

(ii)an area that is specifically fitted out for the kind of service provided;

surgical health service means a health service (other than emergency stabilisation treatment) that—

(a)is ordinarily provided by a registered medical practitioner, a registered dental practitioner, a registered medical radiation practitioner or a registered podiatrist; and

(b)involves the use of surgical instruments and an operating theatre, procedure room or treatment room; and

(c)uses or requires one or more of the following—

(i)anaesthesia;

(ii)the attendance of at least one other registered health practitioner;

(iii)post-operative observation of the patient by nursing staff;

the Act means the Health Services Act 1988;

unit record number means an identifying number unique to a patient that is allocated under regulation 23.

PART 2—PRESCRIBED HEALTH SERVICES

6Day procedure centres

For the purposes of paragraph (a) of the definition of day procedure centre in section 3(1) 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 one or more of the following—

(i)anaesthesia;

(ii)bariatric procedures;

(iii)cataract surgery;

(iv)endoscopy;

(v)liposuction (removing in total at least 200 ml of lipoaspirate);

(vi)mental health services;

(vii)oncology (chemotherapy);

(viii)oncology (radiation therapy);

(ix)oocyte retrieval;

(x)paediatric services (provided to patients aged at least 28 days and under 18 years when admitted);

(xi)renal dialysis;

(xii)specialist rehabilitation services.

7Private hospitals

For the purposes of the definition of private hospital in section 3(1) 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 one or more of the following—

(i)alcohol or drug withdrawal (detoxification—acute phase);

(ii)anaesthesia;

(iii)bariatric procedures;

(iv)cardiac catheterisation;

(v)cardiac surgery;

(vi)cataract surgery;

(vii)emergency medicine;

(viii)endoscopy;

(ix)intensive care;

(x)liposuction (removing in total at least 200 ml of lipoaspirate);

(xi)mental health services;

(xii)neonatal services (provided to patients aged 28 days and under when admitted);

(xiii)neurosurgery;

(xiv)obstetrics;

(xv)oncology (chemotherapy);

(xvi)oncology (radiation therapy);

(xvii)oocyte retrieval;

(xviii)paediatric services (provided to patients aged at least 28 days and under 18 years when admitted);

(xix)renal dialysis;

(xx)specialist rehabilitation services.

PART 3—HEALTH SERVICE ESTABLISHMENT PROTOCOLS FOR QUALITY AND SAFETY

8Health service establishment protocols for quality and safety

(1)For the purpose of ensuring the quality and safety of health services provided at a health service establishment, the proprietor of a health service establishment must prepare health service establishment protocols in accordance with this regulation.

(2)The health service establishment protocols must be—

(a)documented in writing; and

(b)made available to the public—

(i)on the health service establishment's website; or

(ii)in the manner and form determined by the Secretary; and

(c)made available to the Secretary on request.

(3)The health service establishment protocols must include the following—

(a)processes for assessing every 3 years the credentials of each health professional practising at the health service establishment;

(b)processes for setting the scope of practice for each health professional practising at the health service establishment;

(c)processes for continually assessing the competence and performance of each health professional practising at the health service establishment;

(d)processes for continually assessing and reviewing health services provided by each health professional practising at the health service establishment;

(e)processes for continually assessing the capacity of the health service establishment to provide safe, patient‑centred and appropriate health services to patients at each of its premises;

(f)setting the frequency of, and procedures for, meetings of any committees of the health service establishment with responsibility for the quality and safety of health services provided at, or from, the health service establishment;

Note

Relevant committees may include, but are not limited to, a medical advisory committee, a quality and safety committee and the board of the health service establishment.

(g)processes for ensuring that appropriate arrangements have been made for evaluating, monitoring and improving the quality and safety of health services provided at each premises of the health service establishment;

(h)on and from 31 August 2025, the description and allocation of quality and safety roles in relation to the health service establishment;

(i)on and from 31 August 2025, having regard to the kind or kinds of health services being provided at, or from, the health service establishment, processes and procedures for the following—

(i)the availability of appropriate adjunct diagnostic services;

(ii)review of adverse patient safety events, including participation of all relevant personnel in the review (whether employees or not);

(iii)addressing the specific needs of Aboriginal persons;

(iv)recognising and responding to deteriorations in the condition of patients.

(4)The proprietor of a health service establishment must ensure that the health service establishment's quality and safety protocols are implemented and complied with.

(5)In this regulation—

health professional means a registered medical practitioner, a registered dental practitioner, a registered medical radiation practitioner or a registered podiatrist.

9Determination of quality and safety guidelines

(1)The Secretary may determine approved quality and safety guidelines in relation to the health service establishment protocols for quality and safety set out in regulation 8.

(2)The Secretary must cause a notice of a determination under subregulation (1) to be published—

(a)in the Government Gazette; and

(b)on the Department's Internet site.

(3)A notice of a determination of approved quality and safety guidelines must state—

(a)where a copy of the approved quality and safety guidelines may be obtained; and

(b)the date on which the approved quality and safety guidelines take effect.

10Review of health service establishment protocols for quality and safety

(1)On and from 28 February 2026, the Secretary may determine to conduct a review of the health service establishment protocols for quality and safety prepared by a health service establishment under regulation 8(1).

(2)The Secretary may, after conducting a review of a health service establishment's protocols for quality and safety, determine to issue a written direction to the proprietor of that health service establishment to update the protocols for quality and safety in the manner directed by the Secretary.

(3)The Secretary may determine to issue a written direction to the proprietor of a health service establishment if the Secretary considers that the protocols for quality and safety of that health service establishment—

(a)are inconsistent with the Act or these Regulations; or

(b)are otherwise inadequate for ensuring the quality and safety of health services provided at, or from, the health service establishment.

(4)In conducting a review of health service establishment protocols for quality and safety, the Secretary may have regard to an approved quality and safety guideline referred to in regulation 9(1).

(5)The proprietor of a health service establishment must ensure that a written direction of the Secretary to update the health service establishment's protocols for quality and safety is complied with.

PART 4—FORMS OF APPLICATION AND FEES

11Application for approval in principle

(1)For the purposes of section 70(2)(a) of the Act, the prescribed form is the form in Schedule 2.

(2)For the purposes of section 70(2)(b) of the Act, the following fees are prescribed—

(a)for an application for approval in principle to use particular land or premises as a private hospital or day procedure centre—325 fee units;

(b)for an application for approval in principle to construct premises for use as a private hospital—325 fee units;

(c)for an application for approval in principle to make alterations or extensions to premises used or proposed to be used as a private hospital—290 fee units;

(d)for an application for approval in principle to construct premises for use as a day procedure centre—285 fee units;

(e)for an application for approval in principle to make alterations or extensions to premises used or proposed to be used as a day procedure centre—276 fee units;

(f)for an application for approval in principle to use particular land or premises as a health service establishment from which health services are to be provided at premises other than the first-mentioned premises—91 fee units;

(g)for an application for approval in principle to vary the registration of a health service establishment—16×1 fee units.

12Application for transfer or variation of certificate of approval in principle

For the purposes of section 74(2) of the Act—

(a)the prescribed form is the form in Schedule 3; and

(b)the prescribed fee is 16×1 fee units.

13Application for registration of a health service establishment

(1)For the purposes of section 82(2)(a) of the Act, the prescribed form is the form in Schedule 4.

(2)For the purposes of section 82(2)(b) of the Act, the following fees are prescribed—

(a)for an application for registration of a health service establishment with 0 to 26 beds—366 fee units;

(b)for an application for registration of a health service establishment with 27 to 50 beds—405 fee units;

(c)for an application for registration of a health service establishment with 51 to 75 beds—445 fee units;

(d)for an application for registration of a health service establishment with 76 to 100 beds—484 fee units;

(e)for an application for registration of a health service establishment with 101 to 150 beds—543 fee units;

(f)for an application for registration of a health service establishment with 151 to 200 beds—623 fee units;

(g)for an application for registration of a health service establishment with 201 to 300 beds—701 fee units;

(h)for an application for registration of a health service establishment with 301 to 400 beds—820 fee units;

(i)for an application for registration of a health service establishment with 401 to 500 beds—978 fee units;

(j)for an application for registration of a health service establishment with 501 or more beds—1175 fee units.

14Annual fees for health service establishments

For the purposes of section 87(1) and (2)(a) of the Act, the prescribed annual fee is nil fee units.

15Application for renewal of registration of a health service establishment

(1)For the purposes of section 88(2)(a) of the Act, the prescribed form is the form in Schedule 5.

(2)For the purposes of section 88(2)(b) of the Act, the following fees are prescribed—

(a)for an application for renewal of the registration of a health service establishment with 0 to 26 beds—366 fee units;

(b)for an application for renewal of the registration of a health service establishment with 27 to 50 beds—405 fee units;

(c)for an application for renewal of the registration of a health service establishment with 51 to 75 beds—445 fee units;

(d)for an application for renewal of the registration of a health service establishment with 76 to 100 beds—484 fee units;

(e)for an application for renewal of the registration of a health service establishment with 101 to 150 beds—543 fee units;

(f)for an application for renewal of the registration of a health service establishment with 151 to 200 beds—623 fee units;

(g)for an application for renewal of the registration of a health service establishment with 201 to 300 beds—701 fee units;

(h)for an application for renewal of the registration of a health service establishment with 301 to 400 beds—820 fee units;

(i)for an application for renewal of the registration of a health service establishment with 401 to 500 beds—978 fee units;

(j)for an application for renewal of the registration of a health service establishment with 501 or more beds—1175 fee units.

16Application for variation of registration of a health service establishment

(1)For the purposes of section 92(2)(a) of the Act, the prescribed form is the form in Schedule 6.

(2)For the purposes of section 92(2)(b) of the Act, the prescribed fee—

(a)in the case of an application for the transfer of a certificate of registration or certificate of renewal of registration to another person who intends to become the proprietor is 47×8 fee units; and

(b)in any other case is 16×1 fee units.

17Application for approval of alterations to clinical area within a health service establishment

(1)For the purposes of section 108(2)(a) of the Act, the prescribed form is the form in Schedule 7.

(2)For the purposes of section 108(2)(b) of the Act, the prescribed fee is nil fee units.

PART 5—SENIOR APPOINTMENTS

Division 1—Director of Nursing

18Director of Nursing must be appointed

(1)The proprietor of a health service establishment that provides one or more of its health services at the premises for which it is registered must appoint a suitably qualified person as the Director of Nursing.

Penalty:50 penalty units.

(2)For the purposes of subregulation (1), a person is suitably qualified if the person—

(a)is a registered nurse; and

(b)has at least 12 months' practical experience in nursing management; and

(c)has at least 5 years' clinical experience as a registered nurse.

19Appointment of acting Director of Nursing

If the Director of Nursing is absent or incapacitated, or the position is vacant, the proprietor of a health service establishment must appoint a person to act as the Director of Nursing during the period of the absence, incapacity or vacancy.

Penalty:50 penalty units.

20Secretary must be notified of appointment

(1)The proprietor of a health service establishment must notify the Secretary in writing of the name, qualifications and experience of any person appointed under this Division as the Director of Nursing within 28 days after making the appointment.

Penalty:20 penalty units.

(2)The proprietor of a health service establishment must notify the Secretary in writing of the name, qualifications and experience of any person appointed under this Division to act as the Director of Nursing for a period of more than 28 days within 28 days after making the appointment.

Penalty:20 penalty units.

Division 2—Other appointments

21Chief Executive Officer and Medical Director

If the proprietor of a health service establishment appoints a Chief Executive Officer or Medical Director (however titled), the proprietor must notify the Secretary in writing of the name, qualifications and experience of the person appointed within 28 days of the appointment.

Penalty:20 penalty units.

22Secretary to be notified of termination or vacancy

If the proprietor of a health service establishment 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.


PART 6—ADMISSION OF PATIENTS

Division 1—Unit record number

23Unit record number must be allocated

The proprietor of a health service establishment that provides one or more of its health services at the premises for which it is registered must ensure that a unit record number is allocated to a patient on or as soon as practicable after the admission of the patient to the health service establishment.

Penalty:30 penalty units.

Division 2—Information to be given to patients

24Information about fees and services

(1)The proprietor of a health service establishment 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 services provided at the health service establishment that complies with subregulation (2); and

(b)information about health service establishment fees and likely out of pocket expenses to be charged by the health service establishment, and any likely third party fees and out of pocket expenses in relation to the health services to be provided to the patient at the health service establishment; and

(c)a clear explanation of the treatment and other health services to be provided to the patient at the health service establishment.

Penalty:50 penalty units.

(2)A statement referred to in subregulation (1) must contain information about the following matters—

(a)the quality or standard of health care and services provided at the health service establishment;

(b)courteous treatment of patients;

(c)consideration of a patient's gender identity, 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 they want 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)if necessary to enable another health care worker to assist in the patient's care; or

(ii)if 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 themselves at any time despite the advice of the attending registered health practitioner or staff of the health service establishment;

(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 risk assessments

25Pre-admission assessment

The proprietor of a health service establishment must ensure that for a non-emergency patient admitted to the health service establishment—

(a)a pre-admission clinical risk assessment is carried out by a registered health practitioner for that patient before admission; and

(b)the following matters are recorded in writing, not less than 24 hours before admission—

(i)the matters considered and assessed by the registered health practitioner as part of the pre-admission clinical risk assessment;

(ii)the results of the pre-admission clinical risk assessment;

(iii)the name and signature of the registered health practitioner carrying out the pre‑admission clinical risk assessment; and

(c)the health service for which the patient is admitted is assessed in relation to the scope of practice of the registered health practitioner who will provide the health service to that patient.

26Pre-presentation assessment

The proprietor of a health service establishment must ensure that for each non-emergency patient that is provided with a health service by the health service establishment but is not admitted to the health service establishment—

(a)a pre-presentation clinical risk assessment is carried out by a registered health practitioner; and

(b)the following matters are recorded in writing, not less than 24 hours before the health service is provided—

(i)the matters considered and assessed by the registered health practitioner as part of the pre-presentation clinical risk assessment;

(ii)the results of the pre-presentation clinical risk assessment;

(iii)the name and signature of the registered health practitioner carrying out the pre‑presentation clinical risk assessment; and

(c)the health service for which the patient presents is assessed in relation to the scope of practice of the registered health practitioner who will provide the health service to that patient.

Division 4—Clinical records

27Clinical record must be created and updated

(1)The proprietor of a health service establishment must ensure that a separate clinical record for each patient is created on or as soon as practicable after the admission of the patient to the health service establishment.

Penalty:30 penalty units.

(2)The proprietor of a health service establishment must ensure that, whenever a patient receives a health service from the health service establishment, any clinical record for the patient is updated.

Penalty:30 penalty units.

28Information to be included in clinical record

The proprietor of a health service establishment 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 the following—

(i)clinical history on admission;

(ii)progress notes whenever the patient is receiving health services from the health service establishment, including notes of any incidents that are clinically relevant;

(iii)any medication ordered or given;

(iv)known allergies and drug sensitivities;

(v)current medication;

(vi)clinical risk assessments conducted before the patient receives a health service, including a pre-admission assessment conducted in accordance with regulation 25;

(vii)results of any relevant diagnostic tests;

(e)if a procedure is carried out on the patient, the following information—

(i)the consent form for the procedure and anaesthesia;

(ii)the date of the procedure;

(iii)the name and signature of each registered health practitioner 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 HPP 4 of the Health Privacy Principles in that Act.

Division 5—Identification of patients

29Means of identifying patients

The proprietor of a health service establishment must ensure that a patient can be readily identified at all times when the patient is receiving a health service at the health service establishment 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.

30Identification of infants

(1)The proprietor of a health service establishment must ensure that if an infant is born at the health service establishment, at least 2 identity bands or other suitable devices which contain the birth information are attached to that infant—

(a)as soon as practicable after the birth and before leaving the delivery room; and

(b)while the infant remains in the health service establishment.

Penalty:30 penalty units.

(2)The proprietor of a health service establishment must ensure that at least 2 identity bands or other suitable devices which contain the birth information are attached to an infant for as long as the infant remains in the health service establishment if, immediately after giving birth to the infant, the mother is admitted as a patient of a health service establishment for—

(a)the receipt of medical services in connection with the birth; or

(b)the provision of nursing services by a suitably qualified nurse that are directly related to the birth.

Penalty:30 penalty units.

(3)In this regulation, birth information means—

(a)the surname of the infant; and

(b)the full name of the mother; and

(c)the unit record number of the mother.

PART 7—CARE OF PATIENTS

Division 1—Management of patient care

31Respect, dignity and privacy

The proprietor of a health service establishment must ensure that a patient—

(a)is treated with dignity and respect, and with due regard to their gender identity, religious beliefs and ethnic and cultural practices; and

(b)is given 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.

Examples

1Facilities are provided to allow patients to undertake personal activities, including bathing, toileting and dressing in private.

2Facilities are designed to ensure auditory and visual privacy for patients whenever patients are receiving health services from the health service establishment.

3If facilities are shared, provision is made to ensure patient privacy.

4Patients are provided with meals in accordance with their religious beliefs and ethnic and cultural practices.

Division 2—Nursing and professional care

32Nurses must be registered and competent

The proprietor of a health service establishment must ensure that each nurse at the health service establishment—

(a)is an enrolled nurse or a registered nurse; and

(b)is professionally competent through education or experience to provide nursing care at the health service establishment, having regard to the kind or kinds of health services being provided.

Penalty:50 penalty units.

33Post-operative care of surgery patients

If the Director of Nursing is not present at a health service establishment on a day on which a surgical health service is provided at the health service establishment, the proprietor of the health service establishment must ensure that a registered nurse with at least 3 years' relevant clinical experience is present to supervise the provision of the surgical health service to, and the post-operative care of, any patient receiving that surgical health service.

34Care of maternity, obstetric and neonatal patients

If maternity services, obstetric services or neonatal services are provided at a health service establishment, the proprietor of the health service establishment must ensure that a registered midwife with at least 3 years' relevant clinical experience is present to provide clinical oversight of those health services.

35Sufficient nursing staff must be on duty

(1)The proprietor of a health service establishment must ensure that whenever patients are receiving health services from the health service establishment, a sufficient number of nursing staff are on duty to provide care for those patients.

Penalty:50 penalty units.

(2)For the purposes of subregulation (1), a sufficient number of nursing staff is—

(a)in the case of a private hospital—

(i)at least one registered nurse for every 10 patients or fraction of that number during day and evening shifts; and

(ii)at least one registered nurse for every 15 patients or fraction of that number during night shifts; or

(b)in the case of a day procedure centre, at least one registered nurse for every 10 patients or fraction of that number.

(3)Despite subregulation (2), in determining the number of nurses on duty, if 3 or more nurses are on duty at a health service establishment during a shift, up to one-third may be enrolled nurses.

36Needs of patients must be met

The proprietor of a health service establishment must take reasonable steps to ensure that the needs of patients are met promptly and effectively by nursing staff and other professionally competent registered health practitioners.

Penalty:50 penalty units.

37Reversal agents must be available

If health services are provided at a health service establishment involving the use of anaesthesia or other sedation for which there are reversal agents, the proprietor of the health service establishment must ensure that these reversal agents are available for immediate access at the premises of the health service establishment.

PART 8—COMPLAINTS

38Nomination of complaints officer

(1)The proprietor of a health service establishment must nominate in writing a person to receive and deal with any complaints that may be made against the health service establishment by, or on behalf of, a patient of the health service establishment.

Penalty:50 penalty units.

(2)The proprietor of a health service establishment must take reasonable steps to ensure that every patient and member of the staff of the health service establishment is informed of the name of the person nominated under subregulation (1) by the proprietor to receive and deal with complaints.

Penalty:50 penalty units.

39Dealing with a complaint

(1)The proprietor of a health service establishment must ensure that a complaint made against the health service establishment is responded to as soon as practicable after the complaint has been made.

Penalty:40 penalty units.

(2)The proprietor of a health service establishment must ensure that a complaint made against the health service establishment is dealt with as discreetly as possible in the particular circumstances.

Penalty:40 penalty units.

(3)The proprietor of a health service establishment must ensure that a person who makes a complaint against the health service establishment is informed of the action taken in respect of the complaint.

Penalty:40 penalty units.

40Record of complaint

(1)The proprietor of a health service establishment must ensure that a written record is kept of every complaint made against the health service establishment by, or on behalf of, a patient of the health service establishment.

Penalty:30 penalty units.

(2)For the purposes of subregulation (1), the written record must contain the following information—

(a)the nature of the complaint;

(b)the date of the complaint;

(c)the action taken in respect of that complaint.

(3)The proprietor of a health service establishment must ensure that a written record of a complaint referred to in subregulation (1) is kept in a secure place for a period of 7 years after the complaint was made.

Penalty:30 penalty units.

41Person making complaint must not be adversely affected

The proprietor of a health service establishment must take reasonable steps to ensure that, if a complaint has been made against the health service establishment by a patient or a person on behalf of the patient, the patient or the person is not adversely affected because the complaint has been made.

Penalty:60 penalty units.

PART 9—TRANSFER AND DISCHARGE OF PATIENTS

42Documentation required for transferred patients

If a patient is transferred from a health service establishment to another health service establishment or health care agency, the proprietor of the health service establishment from which the patient is transferred 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 provide appropriate ongoing treatment or care are sent with the patient.

Penalty:40 penalty units.

43Information provided to patient transport

(1)The proprietor of a health service establishment must ensure that the crew of a vehicle used by a non-emergency patient transport service or by an ambulance service to transport a patient from the health service establishment is provided with—

(a)handover notes in writing in relation to the patient's clinical condition; and

(b)a copy of any advance care directive given by the patient in accordance with the Medical Treatment Planning and Decisions Act 2016.

(2)In this regulation—

non-emergency patient transport service has the same meaning as in the Non‑Emergency Patient Transport and First Aid Services Act 2003;

ambulance service has the same meaning as in the Ambulance Services Act 1986.

44Discharge information

(1)The proprietor of a health service establishment must ensure that, at the time of the discharge of an admitted patient from the health service establishment, the following is given to the patient—

(a)the name and contact details in writing of whom to contact for post-procedure medical advice;

(b)a copy of the patient's discharge summary that complies with subregulation (3).

(2)The proprietor of a health service establishment must ensure that a copy of the patient's discharge summary that complies with subregulation (3)—

(a)is provided to the patient's registered medical practitioner as soon as practicable after the discharge of the patient; or

(b)has been given to the patient at discharge for the patient to provide to the patient's registered medical practitioner.

(3)A patient's discharge summary must include the following information—

(a)the full name of the patient;

(b)the date of birth of the patient;

(c)a description of the health service that the patient received at the health service establishment;

(d)the post-discharge instructions for patient care;

(e)an itemised list of any new medication prescribed for the patient in relation to the health services received at the health service establishment and any cessations of, or variations to, any regular prescribed medication of the patient;

(f)in the case of a patient of a private hospital who was admitted overnight—a list, summary or statement regarding the unchanged, regular prescribed medication of the patient.

(4)The proprietor of the health service establishment must have regard to the clinical profile of a patient in deciding the nature and detail of information to be included in a list, summary or statement of unchanged, regular prescribed medication prepared in accordance with subregulation (3)(f).

PART 10—REGISTERS, RECORDS AND PERMITS

Division 1—Patient admission and discharge records

45Patient admission and discharge records

For the purposes of section 109(1) of the Act, with respect to persons who receive care in the health service establishment—

(a)the prescribed manner is in writing; and

(b)the prescribed period is 7 years; and

(c)the prescribed particulars are the following—

(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 the patient's admission and discharge;

(vii)a description of care received and 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.

Division 2—Staff records

46Staff records

For the purposes of section 109(1) of the Act, with respect to staff employed in the health service establishment—

(a)the prescribed manner is in writing; and

(b)the prescribed period is 2 years; and

(c)the prescribed particulars are the following—

(i)the full name of every member of the nursing staff and other registered health practitioners;

(ii)the date of birth of every member;

(iii)the designation of every member;

(iv)the qualifications of every member;

(v)if applicable, the registration number or code of every member.

Division 3—Registers

47Surgical Procedure Register

(1)The proprietor of a health service establishment at which surgical health services or speciality health services for the provision of endoscopy may be provided must ensure that a Surgical Procedure Register that complies with subregulation (2) is kept at the health service establishment.

Penalty:30 penalty units.

(2)For the purposes of subregulation (1), a Surgical Procedure Register must be in writing and contain the following records with respect to each procedure performed at the health service establishment—

(a)the date and time of the procedure;

(b)the unit record number of the patient;

(c)the patient's full name, sex and date of birth;

(d)the nature of the procedure;

(e)the names of the registered health practitioner undertaking the procedure and assistant (if any);

(f)the names of the anaesthetist and assistant (if any);

(g)the names of attending clinical staff;

(h)any remarks concerning the outcome of the procedure;

(i)any anaesthetic or procedural complications encountered.

Note

The Health Records Act 2001 contains provisions relating to the retention of records. See HPP 4 of the Health Privacy Principles in that Act.

48Birth Register

(1)The proprietor of a health service establishment in which speciality health services for the provision of obstetrics may be provided must ensure that a Birth Register that complies with subregulation (2) is kept at the health service establishment.

Penalty:30 penalty units.

(2)For the purposes of subregulation (1), a Birth Register must be in writing and contain the following records with respect to each birth at the health service establishment—

(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 health service establishment must retain a Birth Register for at least 25 years after the date of the last entry.

Penalty:30 penalty units.

Division 4—Permits

49Permit issued under section 19 of the Drugs, Poisons and Controlled Substances Act 1981

(1)The proprietor of a health service establishment must hold a permit issued under section 19 of the Drugs, Poisons and Controlled Substances Act 1981 by which the proprietor is authorised under section 20(3) of that Act to purchase or otherwise obtain certain poisons or controlled substances for the provision of health services.

(2)Subregulation (1) does not apply to the following—

(a)a proprietor of a health service establishment at or from which the health services provided do not usually require the purchase or otherwise obtaining of any poisons or controlled substances, other than a patient's own medicine, for the provision of those health services;

Example

Drug and alcohol withdrawal treatment services and dialysis services.

(b)a proprietor of a health service establishment—

(i)that provides health services solely at premises other than the premises for which it is registered; and

Note

An example of a health service establishment that provides health services solely at premises other than the premises for which it is registered is the provider of mobile anaesthetic services at a dental clinic.

(ii)where at those other premises only one registered health practitioner (other than the additional nursing staff required under regulation 35 or one or more additional registered midwives) provides the health services.

(3)In this regulation, patient's own medicine means a poison or controlled substance that has been supplied to a patient by a registered health practitioner other than—

(a)the proprietor of the health service establishment; or

(b)a registered health practitioner employed by or contracted to provide health services prescribed under Part 2 for or at the health service establishment.

PART 11—PREMISES AND EQUIPMENT

50Identification of rooms

The proprietor of a health service establishment 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.

51Communications

(1)The proprietor of a health service establishment that provides one or more of its health services at the premises for which it is registered must ensure that an effective electronic communication system that complies with subregulation (2) is provided and kept operational at the health service establishment.

Penalty:60 penalty units.

(2)For the purposes of subregulation (1), an electronic communication system must—

(a)enable patients and staff to summon assistance; and

(b)enable calls to be made from the following—

(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.

52Repair and cleanliness of premises

The proprietor of a health service establishment must ensure that the premises 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.

53Suitability and cleanliness of facilities, equipment, furnishings and fittings

(1)The proprietor of a health service establishment must ensure that facilities, equipment, furnishings and fittings at the health service establishment are suitable for the kind or kinds of health services being provided by the health service establishment.

(2)The proprietor of a health service establishment must ensure that facilities, equipment, furnishings and fittings at the health service establishment are—

(a)kept in a proper state of repair and maintained in good working order; and

(b)kept in a clean and hygienic condition.

Penalty:80 penalty units.

54Premises, staff and equipment outside health service establishment premises

For the purpose of ensuring the quality and safety of health services provided by a health service establishment at premises other than the premises for which it is registered, the proprietor of the health service establishment must ensure that—

(a)those other premises are suitable for the provision of safe patient care; and

(b)persons with appropriate training and experience provide those health services; and

(c)the equipment used to provide those health services is suitable for the type of health services provided.

55Evacuation plan

The proprietor of a health service establishment must ensure that—

(a)an evacuation plan for all patients and members of staff at the health service establishment is prepared; and

(b)the evacuation plan is displayed in a prominent position at the entrance foyer or reception area of the health service establishment and in any common room, recreational or rest area or other place where patient care is provided; and

(c)all staff are trained in the implementation of the evacuation plan.

PART 12—INFECTION CONTROL

56Infection Control Management Plan

(1)The proprietor of a health service establishment must implement and maintain an Infection Control Management Plan that complies with subregulations (2) and (3).

Penalty:80 penalty units.

(2)For the purposes of subregulation (1), an Infection Control Management Plan must provide for the surveillance, prevention and control of infection at the health service establishment.

(3)Without limiting subregulation (2), an Infection Control Management Plan must—

(a)state its objectives; and

(b)identify and assess all the infection risks specific to the health service establishment which the proprietor knows, or can reasonably be expected to know, exists or may exist, and state how these risks are to be minimised; and

(c)provide for an ongoing infection control education program for the staff of the health service establishment; and

(d)state the particulars of training for persons who provide services at the health service establishment that involve infection control risks; and

(e)set out how the proprietor will monitor and review the implementation and effectiveness of the Plan.

PART 13—DISPLAY OF INFORMATION

57Information to be prominently displayed

The proprietor of a health service establishment must display in a prominent position at the entrance foyer or reception area of the health service establishment the following information—

(a)the certificate of registration of the premises as a health service establishment or a full size copy of the certificate;

(b)the certificate of accreditation for any accreditation scheme applicable to the health service establishment and approved by the Secretary under section 107(1) of the Act;

(c)the name of the Director of Nursing (if required to be appointed) and the name of any appointed Chief Executive Officer or Medical Director (however titled);

(d)the name and telephone number of the person nominated under regulation 38 to receive and deal with complaints.

Penalty:20 penalty units.

PART 14—ENFORCEMENT

58Form of notice of seizure

For the purposes of section 147(2)(a) of the Act, the prescribed form is the form in Schedule 8.

59Infringement offences and infringement penalties

(1)For the purposes of section 155(1) of the Act, an offence specified in Column 1 of the Table in Schedule 9 is prescribed as an infringement offence.

(2)For the purposes of section 155(1) of the Act, the prescribed infringement penalty for an infringement offence referred to in subregulation (1) is the penalty specified in Column 2 of the Table in Schedule 9 in respect of that infringement offence.

PART 15—RETURNS AND REPORTS TO BE GIVEN TO THE SECRETARY

60Returns and reports to be given to the Secretary

(1)The proprietor of a health service establishment must prepare a return for each month containing data in relation to each patient admitted to the health service establishment during that month as determined by the Secretary.

(2)The proprietor of a health service establishment must ensure that a return prepared under subregulation (1) is given to the Secretary—

(a)in the case of admission and discharge data, within 17 days after the end of the month to which the return relates; and

(b)in the case of clinical care data, within 47 days after the end of the month to which the return relates.

(3)The proprietor of a private hospital must prepare a return for each month containing the following—

(a)data about infections acquired by patients and staff at the private hospital and infection prevention and surveillance activities implemented at the private hospital;

(b)data in relation to any electroconvulsive treatment (within the meaning of the Mental Health and Wellbeing Act 2022) provided at the private hospital;

(c)data as determined by the Secretary about patients who presented at the private hospital's emergency department.

(4)The proprietor of a private hospital must ensure that a return prepared under subregulation (3) is given to the Secretary within 17 days after the end of the month to which the return relates.

(5)The Secretary may determine to direct the proprietor of a health service establishment that provides health services solely at premises other than the premises for which it is registered to prepare a return in the manner and form determined by the Secretary.

(6)The proprietor of a health service establishment must ensure that a return prepared under subregulation (5) is given to the Secretary within the time determined by the Secretary.

(7)The proprietor of a health service establishment must ensure that a return prepared under this regulation does not include the name or address of a patient.

(8)The proprietor of a health service establishment must provide a copy of each report received from the accreditation scheme applicable to the health service establishment and approved by the Secretary under section 107(1) of the Act, to the Secretary within 14 days of the receipt of the report.

61Reporting of compliance with the duty of candour

(1)The proprietor of a private hospital or day procedure centre must submit a report that complies with subregulation (2) to the Secretary concerning compliance by that private hospital or day procedure centre with the requirements of its duty of candour under section 128ZC(1) of the Act for each reporting period within 14 days after the end of a reporting period.

(2)A report submitted to the Secretary under subregulation (1) must include the following information—

(a)data specifying the number of serious adverse patient safety events suffered by patients in the course of receiving health services from that private hospital or day procedure centre that were identified in the first 3 months of the reporting period;

(b)in relation to the serious adverse patient safety events specified for the purposes of paragraph (a), the following data for the reporting period—

(i)the number of serious adverse patient safety events if the requirements of the duty of candour under section 128ZC(1) of the Act were commenced in the reporting period;

(ii)the number of serious adverse patient safety events that occurred where the patient has been provided with the information specified in section 128ZC(1)(a) of the Act in the reporting period;

(iii)the number of serious adverse patient safety events that occurred where the patient chose under section 128ZC(2) of the Act not to receive the information specified in section 128ZC(1)(a) of the Act.

(3)The proprietor of a private hospital or day procedure centre must ensure that the report prepared for the purposes of this regulation is submitted to the Secretary in the manner and form determined by the Secretary.

(4)In this regulation, reporting period means each of the following periods—

(a)the period beginning on 1 October and ending on 31 March;

(b)the period beginning on 1 January and ending on 30 June;

(c)the period beginning on 1 April and ending on 30 September;

(d)the period beginning on 1 July and ending on 31 December.

PART 16—QUALITY AND SAFETY REVIEW DATA

62Open disclosure policy

(1)For the purpose of ensuring the quality and safety of health services provided at a health service establishment, the proprietor of a health service establishment must prepare an open disclosure policy in accordance with this regulation.

(2)The open disclosure policy must be—

(a)documented in writing; and

(b)published on the health service establishment's website.

(3)The open disclosure policy must include processes by which open discussion between the health service establishment and a patient and the patient's family and carers are to occur following any adverse event that results in harm to the patient.

(4)The proprietor of a health service establishment must ensure that the open disclosure policy is implemented.

63Review of quality and safety of health services provided

(1)The proprietor of a health service establishment must ensure the following information is recorded in writing and reviewed at least every 3 months—

(a)information in relation to the decisions and actions taken for the purposes of improving the quality and safety of health services provided;

(b)if applicable, information in relation to—

(i)all adverse events occurring at the health service establishment; and

(ii)all sentinel events occurring at the health service establishment; and

(iii)mortality and morbidity occurring at the health service establishment; and

(iv)all transfers of patients from the health service establishment to another health service establishment or health care agency for the escalation of patient care; and

(v)compliance with the health service establishment's protocols; and

(vi)results from surveys about patient experience and about staff safety culture.

(2)The proprietor of a health service establishment must make information recorded under this regulation available to the Secretary on request.

64Patient experience survey data

The proprietor of a health service establishment must ensure that at each premises of the health service establishment—

(a)patient experience survey data is collected; and

(b)the patient experience survey data is reviewed; and

(c)the patient experience survey data is made available to the Secretary on request.

65Staff safety culture survey data

The proprietor of a health service establishment must ensure that at each premises of the health service establishment—

(a)staff safety culture survey data is collected; and

(b)the staff safety culture survey data is reviewed; and

(c)the staff safety culture survey data is made available to the Secretary on request.

PART 17—SENTINEL EVENTS

66Reporting of sentinel events

The proprietor of a health service establishment must report in writing each sentinel event that occurs at the health service establishment to the Secretary—

(a)within the time determined by the Secretary; and

(b)in the form and manner determined by the Secretary.

Penalty:40 penalty units.

67Review of sentinel events

(1)For the purpose of ensuring the quality and safety of health services provided by a health service establishment, the proprietor of a health service establishment must ensure that a review is conducted of each sentinel event that occurs at the health service establishment.

(2)A review conducted under subregulation (1) must be conducted in the manner and within the time determined by the Secretary.

(3)The proprietor of a health service establishment must record the outcome of a review conducted under subregulation (1) in writing and submit it to the Secretary within the time and in the form determined by the Secretary.

SCHEDULE 1—REVOCATIONS

Regulation 4

S.R. No. Name
113/2013 Health Services (Health Service Establishments) Regulations 2013
83/2018 Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018
99/2019 Health Services (Health Service Establishments) Amendment Regulations 2019
57/2023 Health Services (Health Service Establishments) Amendment Regulations 2023

SCHEDULE 2—APPLICATION FOR APPROVAL IN PRINCIPLE IN RELATION TO A HEALTH SERVICE ESTABLISHMENT

Section 70(2)(a) of the Health Services Act 1988

Regulation 11(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone number and email address of a contact person for the purposes of the application:

4.   If the applicant is a body corporate, the *ABN/*ACN of the applicant and the name and address of any director or officer of the body corporate who may exercise control over the health service establishment:

SECTION B

1.   The kind of health service establishment to which the application relates is:

*a private hospital

*a day procedure centre

2.   Are any or all of the health services to be provided by the health service establishment at premises other than the premises for which it is or is to be registered?

*yes / *no

3.   The name (or proposed name) of the health service establishment, its street address and the municipal district in which the health service establishment is, or is to be, located or, if all the health services are to be provided by the health service establishment at premises other than the premises for which it is or is to be registered, the business address of the health service establishment.

4.   This application is for an approval in principle for:

*the use of particular land or premises as a health service establishment;

*premises proposed to be constructed for use as a health service establishment;

*alterations or extensions to premises used, or proposed to be used, as a health service establishment;

*a variation of the registration of a health service establishment to alter the number of beds to which the registration relates;

*a variation of the registration of a health service establishment to vary the kinds of prescribed health services that may be carried on at the premises;

*a variation of the registration of a health service establishment to vary the number of beds that may be used for the specified kinds of prescribed health services;

*use of a premises as a health service establishment from which health services are to be provided at premises other than the first-mentioned premises;

*a variation of the registration of a health service establishment to vary the kinds of prescribed health services that may be carried on at premises other than the premises for which the health service establishment is registered.

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:

*Delete if not applicable

SCHEDULE 3—APPLICATION FOR TRANSFER OR VARIATION OF CERTIFICATE OF APPROVAL IN PRINCIPLE OF A HEALTH SERVICE ESTABLISHMENT

Section 74(2) of the Health Services Act 1988

Regulation 12(a)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone number 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.   Are any or all of the health services to be provided by the health service establishment at premises other than the premises for which it is or is to be registered?

*yes / *no

3.   The name (or proposed name) of the health service establishment, its street address and the municipal district in which the health service establishment is, or is to be, located or, if all the health services are to be provided by the health service establishment at premises other than the premises for which it is or is to be registered, the business address of the health service establishment.

4.   This application is for approval in principle for:

*variation of the certificate of approval in principle or any condition to which it is subject;

*transfer of the certificate of approval in principle to another person.

5.   Reason for the proposed variation:

6.   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 number and email address.

7.   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 health service establishment:

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:

*Delete if not applicable

SCHEDULE 4—APPLICATION FOR REGISTRATION OF A HEALTH SERVICE ESTABLISHMENT

Section 82(2)(a) of the Health Services Act 1988

Regulation 13(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone number and email address of a contact person for the purposes of the application:

4.   If the applicant is a body corporate, the *ABN/*ACN of the applicant and the name and address of any director or officer of the body corporate who may exercise control over the health service establishment:

SECTION B

1.   The kind of health service establishment for which registration is sought:

*a private hospital

*a day procedure centre

2.   Are any or all of the health services to be provided by the health service establishment at premises other than the premises for which it is to be registered?

*yes / *no

3.   The name (or proposed name) of the health service establishment, its street address and the municipal district in which the health service establishment is, or is to be, located or, if all the health services are to be provided by the health service establishment at premises other than the premises for which it is to be registered, the business address of the health service establishment.

4.   The proposed number of beds:

5.   The kind or kinds of health services for which registration is sought:

*Medical health services

*Surgical health services

*Speciality health services for the provision of—

*alcohol or drug withdrawal (detoxification—acute phase)

*anaesthesia

*bariatric procedures

*cardiac catheterisation

*cardiac surgery

*cataract surgery

*emergency medicine

*endoscopy

*intensive care

*liposuction (removing in total at least 200 ml of lipoaspirate)

*mental health services

*neonatal services (provided to patients aged under 28 days when admitted)

*neurosurgery

*obstetrics

*oncology (chemotherapy)

*oncology (radiation therapy)

*oocyte retrieval

*orthopaedic surgery

*paediatric services (provided to patients aged at least 28 days and less than 18 years when admitted)

*renal dialysis

*specialist rehabilitation services

6.   Is the applicant the owner or tenant of the premises?

*yes / *no

7.   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:

*Delete if not applicable

SCHEDULE 5—APPLICATION FOR RENEWAL OF REGISTRATION OF A HEALTH SERVICE ESTABLISHMENT

Section 88(2)(a) of the Health Services Act 1988

Regulation 15(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone number and email address of a contact person for the purposes of the application:

4.   If the applicant is a body corporate, the *ABN/*ACN of the applicant and the name and address of any director or officer of the body corporate who may exercise control over the health service establishment:

SECTION B

1.   The name of the health service establishment and its street address or, if all the health services are to be provided by the health service establishment at premises other than the premises for which it is registered, the business address of the health service establishment:

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:

SCHEDULE 6—APPLICATION FOR VARIATION OF THE REGISTRATION OF A HEALTH SERVICE ESTABLISHMENT

Section 92(2)(a) of the Health Services Act 1988

Regulation 16(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone number 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 or certificate of renewal to another person who intends to become the proprietor of the establishment

*a variation of any condition to which the registration is subject

*an alteration in the number of beds to which the registration relates

*a variation of the kinds of prescribed health services that may be carried on at the premises

*a variation of the number of beds that may be used for specified kinds of prescribed health services

*a variation of registration of a health service establishment to vary the kinds of prescribed health services that may be carried on at premises other than the premises for which the health service establishment is registered.

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 number and email address of the proposed transferee.

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:

*Delete if not applicable.

SCHEDULE 7—APPLICATION FOR APPROVAL OF ALTERATIONS TO A CLINICAL AREA WITHIN A HEALTH SERVICE ESTABLISHMENT

Section 108(2)(a) of the Health Services Act 1988

Regulation 17(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone number and email address of a contact person for the purposes of the application:

SECTION B

1.   Name of registered health service establishment:

2.   Address of registered health service establishment:

SECTION C

1.   The nature of the alterations to a clinical area sought:

2.   Details of the alterations to a clinical area sought:

3.   Certificate of approval in principle number:

SECTION D

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

SCHEDULE 8—NOTICE OF SEIZURE OF DOCUMENT OR THING FROM A HEALTH SERVICE ESTABLISHMENT

Section 147(2)(a) of the Health Services Act 1988

Regulation 58

Health Services (Health Service Establishments) Regulations 2024

Name of health service establishment:

Address of health service establishment:

I, being an authorised officer of the Department, am


[print full name]

seizing under section 147(1) 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 after 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]

SCHEDULE 9—INFRINGEMENTS

Section 155 of the Health Services Act 1988

Regulation 59

Table

Item Column 1
Infringement offence 		Column 2
Infringement penalty
1 Regulation 18(1) 10 penalty units
2 Regulation 19 10 penalty units
3 Regulation 20(1) 4 penalty units
4 Regulation 20(2) 4 penalty units
5 Regulation 21 4 penalty units
6 Regulation 22 4 penalty units
7 Regulation 23 6 penalty units
8 Regulation 24(1) 10 penalty units
9 Regulation 27(1) 6 penalty units
10 Regulation 27(2) 6 penalty units
11 Regulation 29 8 penalty units
12 Regulation 30(1) 6 penalty units
13 Regulation 30(2) 6 penalty units
14 Regulation 32 10 penalty units
15 Regulation 35(1) 10 penalty units
16 Regulation 38(1) 10 penalty units
17 Regulation 38(2) 10 penalty units
18 Regulation 39(3) 8 penalty units
19 Regulation 40(1) 6 penalty units
20 Regulation 40(3) 6 penalty units
21 Regulation 42 8 penalty units
22 Regulation 47(1) 6 penalty units
23 Regulation 48(1) 6 penalty units
24 Regulation 48(3) 6 penalty units
25 Regulation 50 2 penalty units
26 Regulation 51(1) 12 penalty units
27 Regulation 56(1) 12 penalty units
28 Regulation 57 4 penalty units
29 Regulation 66 8 penalty units

═════════════


ENDNOTES

1   General information

See for Victorian Bills, Acts and current Versions of legislation and up-to-date legislative information.

The Health Services (Health Service Establishments) Regulations 2024, S.R. No. 77/2024 were made on 20 August 2024 by the Governor in Council under section 158 of the Health Services Act 1988, No. 49/1988 and came into operation on 31 August 2024: regulation 3.

The Health Services (Health Service Establishments) Regulations 2024 will sunset 10 years after the day of making on 20 August 2034 (see section 5 of the Subordinate Legislation Act 1994).

INTERPRETATION OF LEGISLATION ACT 1984 (ILA)

Style changes

Section 54A of the ILA authorises the making of the style changes set out in Schedule 1 to that Act.

References to ILA s. 39B

Sidenotes which cite ILA s. 39B refer to section 39B of the ILA which provides that where an undivided regulation, rule or clause of a Schedule is amended by the insertion of one or more subregulations, subrules or subclauses the original regulation, rule or clause becomes subregulation, subrule or subclause (1) and is amended by the insertion of the expression "(1)" at the beginning of the original regulation, rule or clause.

Interpretation

As from 1 January 2001, amendments to section 36 of the ILA have the following effects:

•     Headings

All headings included in a Statutory Rule which is made on or after
1 January 2001 form part of that Statutory Rule.  Any heading inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.
This includes headings to Parts, Divisions or Subdivisions in a Schedule; Orders; Parts into which an Order is divided; clauses; regulations; rules; items; tables; columns; examples; diagrams; notes or forms. 
See section 36(1A)(2A)(2B).

•     Examples, diagrams or notes

All examples, diagrams or notes included in a Statutory Rule which is made on or after 1 January 2001 form part of that Statutory Rule.  Any examples, diagrams or notes inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, form part of that Statutory Rule.  See section 36(3A).

•     Punctuation

All punctuation included in a Statutory Rule which is made on or after
1 January 2001 forms part of that Statutory Rule.  Any punctuation inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.
See section 36(3B).

•     Provision numbers

All provision numbers included in a Statutory Rule form part of that Statutory Rule, whether inserted in the Statutory Rule before, on or after
1 January 2001.  Provision numbers include regulation numbers, rule numbers, subregulation numbers, subrule numbers, paragraphs and subparagraphs.  See section 36(3C).

•     Location of "legislative items"

A "legislative item" is a penalty, an example or a note.  As from 13 October 2004, a legislative item relating to a provision of a Statutory Rule is taken to be at the foot of that provision even if it is preceded or followed by another legislative item that relates to that provision.  For example, if a penalty at the foot of a provision is followed by a note, both of these legislative items will be regarded as being at the foot of that provision.  See section 36B.

•     Other material

Any explanatory memorandum, table of provisions, endnotes, index and other material printed after the Endnotes does not form part of a Statutory Rule.  See section 36(3)(3D)(3E).

2   Table of Amendments

There are no amendments made to the Health Services (Health Service Establishments) Regulations 2024 by statutory rules, subordinate instruments and Acts.

3   Explanatory details

Fee Units

These Regulations provide for fees by reference to fee units within the meaning of the Monetary Units Act 2004. The amount of the fee is to be calculated, in accordance with section 7 of that Act, by multiplying the number of fee units applicable by the value of a fee unit.

The value of a fee unit for the financial year commencing 1 July 2024 is $16.33. The amount of the calculated fee may be rounded to the nearest 10 cents.

The value of a fee unit for future financial years is to be fixed by the Treasurer under section 5 of the Monetary Units Act 2004. The value of a fee unit for a financial year must be published in the Government Gazette and a Victorian newspaper before 1 June in the preceding financial year.

Penalty Units

These Regulations provide for penalties by reference to penalty units within the meaning of section 110 of the Sentencing Act 1991. The amount of the penalty is to be calculated, in accordance with section 7 of the Monetary Units Act 2004, by multiplying the number of penalty units applicable by the value of a penalty unit.

The value of a penalty unit for the financial year commencing 1 July 2024 is $197.59. The amount of the calculated penalty may be rounded to the nearest dollar.

The value of a penalty unit for future financial years is to be fixed by the Treasurer under section 5 of the Monetary Units Act 2004. The value of a penalty unit for a financial year must be published in the Government Gazette and a Victorian newspaper before 1 June in the preceding financial year.

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