Private Hospitals and Day Procedure Centres Act 1988 Private Hospitals Regulation 1990 (1990-435) [GG No 82 of 29.6.1990] (NSW)
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PRIVATE HOSPITALS AND DAY PROCEDURE CENTRES ACT
1988 - REGULATION
(Private Hospitals Regulation 1990)
NEW SOUTH WALES
[Published in Gazette No. 82 of 29 June 1990]
HIS Excellency the Governor, with the advice of the Executive Council, and in pursuance of the Private Hospitals and Day Procedure Centres Act 1982, has been pleased to make the Regulation set forth hereunder.
PETER COLLINS,
Minister for Health.
PART 1 - PRELIMINARY
Citation
1. This Regulation may be cited as the Private Hospitals Regulation
1990.
Commencement
2. This Regulation commences on 1 September 1990.
Application
3. This Regulation applies to and in respect of all private hospitals.
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Definitions
4. (1) In this Regulation:
"admission form" means an admission form referred to in clause 15;"approved" means approved for the time being by the Director-General, either generally or in any particular case or class of cases;
"child" means a person who is under the age of 10 years;
"clinical records" means clinical records referred to in Part 6 of
Schedule 1 or in Schedule 2;
"morbidity form" means a morbidity form referred to in clause 15; "nursing supervisor" means a person holding office or acting as a
nursing supervisor in the Department of Health;
"patient’s representative" means:
(a)
if the patient is under the age of 14 years - a parent having legal custody of the patient; or
(b)
if the patient is under guardianship - the patient’s guardian; or
(c)
if the patient has died - the executor or administrator of the patient’s estate;
"the Act" means the Private Hospitals and Day Procedure Centres
Act 1988.
(2) In this Regulation, a reference to a particular class of private hospital is a reference to a private hospital that is licensed as a private hospital of that class.
(3) In this Regulation, a reference to a form is a reference to a form set out in Schedule 3.
PART 2 - LICENSING OF PRIVATE HOSPITALS
Licensing standards
5. (1) For the purposes of section 7 of the Act, the following standards are prescribed:
(a)
with respect to all private hospitals - the standards specified in Schedule 1; and
(b)
with respect to surgical class private hospitals - the standards specified in Part 1 of Schedule 2; and
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| (c) | with respect to obstetric class private hospitals - the standards specified in Part 2 of Schedule 2; and |
| (d) | with respect to rehabilitation class private hospitals - the standards specified in Part 3 of Schedule 2; and |
| (e) | with respect to psychiatric class private hospitals - the standards specified in Part 4 of Schedule 2. |
(2) The licensee of a private hospital must not fail to conduct the private hospital in accordance with the provisions of Schedules 1 and 2 applicable to the private hospital.
Maximum penalty: 5 penalty units.
(3) The licensee of a private hospital is not guilty of an offence under
this clause if the licensee:
| (a) | was not aware of the circumstances giving rise to the alleged offence; and |
| (b) | could not reasonably be expected to have been aware of those circumstances. |
(4) A contravention of a provision of Schedule 1 or 2 by any person other than the licensee of a private hospital does not constitute an offence under this Regulation.
Applications for licences
6. For the purposes of section 8 of the Act:
(a) the prescribed form of application is Form 1; and
(b) the prescribed application fee is $450.
Development guidelines
7. (1) For the purposes of section 9 (3) (c) of the Act, the following development guidelines are prescribed:
| (a) | unless special circumstances are demonstrated by the applicant, a proposed private hospital: | |||
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| (b) | unless an applicant intends to provide a limited range of specialised hospital services, a proposed private hospital should |
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offer a comprehensive range of medical, surgical and diagnostic
services.
(2) Special circumstances referred to in subclause (1) (a) include:
(a) the geographical location; and(b) the specialist nature,
of the proposed private hospital.
Classes of private hospitals
8. (1) For the purposes of section 13 of the Act, the following classes of private hospitals are prescribed:
(a) general; (b) surgical; (c) obstetric;
(d) rehabilitation;
(e) psychiatric.(2) The licensee of a private hospital is not to admit a person to a
private hospital as a patient for surgery unless the private hospital is
a surgical class private hospital.
Maximum penalty: 5 penalty units.
(3) The licensee of a private hospital is not to permit a surgicaloperation or endoscopic procedure, other than one which would normally be carried out by a medical practitioner in his or her consulting room, to be performed in the private hospital unless the private hospital is a surgical class private hospital.
Maximum penalty: 5 penalty units.
(4) The licensee of a private hospital is not to admit a person to a
private hospital as a patient for the primary purpose of obstetric care
unless:
(a) the private hospital is an obstetric class private hospital; or
(b)
the licence for the private hospital is endorsed to authorise post-delivery care and the patient has given birth at a public hospital or obstetric class private hospital.
Maximum penalty: 5 penalty units.
(5) The licensee of a private hospital is not to admit a person to a
private hospital as a patient for the primary purpose of long-term or
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specialised physical rehabilitation unless the private hospital is a
rehabilitation class private hospital.
Maximum penalty: 5 penalty units.
(6) The licensee of a private hospital is not to admit a person to a
private hospital as a patient for the primary purpose of psychiatric care
unless the private hospital is a psychiatric class private hospital.
Maximum penalty: 5 penalty units.
Annual licence fees
9. For the purposes of section 17 of the Act, the prescribed annual licence fee for a private hospital licensed to accommodate a number of persons specified in Column 1 of the Table to this clause is the fee specified opposite that number in Column 2 of that Table.
TABLE
Column 1 Column 2
| Number of persons licensed to | Licence fee |
be accommodated
Less than 40 $840 40 - 49 $1,170 50 - 59 $1,510 60 - 69 $1,840 70 - 79 $2,190 80 - 89 $2,520 90 - 99 $2,850 100 or more $3,190
Transfer of licence
10. For the purposes of section 18 of the Act:
(a) the prescribed form of application is Form 2; and
(b) the prescribed application fee is $450.
Alterations or extensions
11. For the purposes of section 19 of the Act, the prescribed form of application is Form 3.
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Application for review of Director-General’s decision
12. For the purposes of section 28 of the Act, the prescribed form of application is Form 4.
Chief nurse of private hospital
13. (1) For the purposes of section 41 (1) of the Act, the prescribed qualifications to be held by a registered nurse who carries out the duties of chief nurse of a private hospital are:
(a) current registration in New South Wales as a nurse; and
(b) 5 years’ post-basic or post-graduate nursing experience; and
(c)
2 years’ administrative experience in a position of, or more senior than that of, nursing unit manager in a hospital,
or such other qualifications as may be approved.
(2) For the purposes of section 41 (2) of the Act, the prescribed number of days is 7.
(3) A notification under section 41 (3) of the Act must be in or to the effect of Form 5.
(4) For the purposes of section 41 (4) of the Act, the prescribed particulars in respect of a person who carries out the duties of chief nurse are those required to complete Form 5, together with the person’s curriculum vitae and a copy of the person’s current annual practising certificate.
Register of patients
14. (1) For the purposes of section 44 (1) of the Act, the prescribed form for a register of patients is a series of forms, each form being in or to the effect of Form 6, completed in respect of each patient and maintained in strict admission date order.
(2) For the purposes of section 44 (2) (e) of the Act, the prescribed particulars to be entered in the register of patients are the particulars required to complete Form 6.
(3) For the purposes of section 44 (3) of the Act, a particular required to be entered in the register of patients must be entered:
(a)
in the case of a particular required to complete Part A of Form 6, at the time of admission of the patient; and
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| (b) | in the case of a particular required to complete Part B of Form 6, at the time the person ceases to be a patient; and | |||
| (c) | in either case: | |||
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Records
15. (1) In addition to the register of patients, the licensee of a private hospital must keep, in respect of each patient:
(a) an admission form, in or to the effect of Form 7; and
(b) a morbidity form, in or to the effect of Form 8; and
(c) such other records as are referred to in Schedules 1 and 2.
Maximum penalty: 5 penalty units.
(2) Such records may be kept by hand or by use of an approved
electronic data processing system.
PART 3 - MISCELLANEOUS
Evidentiary certificates
16. For the purposes of section 51 of the Act, the following officers of the Department of Health are prescribed officers:
Deputy Director-General;
Executive Director, Service Development and Planning;
Chief Health Officer;
Deputy Chief Health Officer;Regional Director.
Display of licence
17. The licensee of a private hospital must, at all times while the private hospital is being conducted, cause to be displayed in a prominent place in the entrance foyer or other place readily visible to visitors the licence for the private hospital or a full-size copy of the licence.
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Maximum penalty: 5 penalty units.
Information to be furnished with annual licence fee
18. (1) The licensee of a private hospital must, when paying an annual licence fee referred to in section 17 of the Act, furnish to the Director-General:
(a) a certificate in or to the effect of Form 9; and (b) a copy of the chief nurse’s current annual practising certificate. Maximum penalty: 5 penalty units.
(2) If the licensee is a corporation, the licensee must at the same time furnish to the Director-General the following particulars:
(a) the full name of the corporation;
(b) the address of the registered office of the corporation;
(c) the full name, residential address and position of:
(i) each current director of the corporation; (ii) the principal executive officer of the corporation; (iii)
the secretary or, if there is more than one, each secretary of the corporation;
(d) in the case of a corporation limited by shares:
(i)
the types of shares and the number of shares of each type issued;
(ii)
in the case of a private corporation - the full name of, and the number of shares held by, each shareholder;
(iii)
in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings;
(e)
if the shares are held by another corporation, the name of the ultimate holding corporation.
Maximum penalty: 5 penalty units.
Information to be furnished periodically
19. (1) The licensee of a private hospital must, for each month, furnish to the Director-General a statistical statement in or to the effect of Form 10.
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Maximum penalty: 5 penalty units.
(2) Such a certificate is to contain the information required to
complete Form 10 and is to be furnished to the Director-General within 14 days after the end of the month to which the information relates.
SCHEDULE 1 - LICENSING STANDARDS FOR ALL PRIVATE HOSPITALS
(Cl. 5)
PART 1 - DESIGN AND CONSTRUCTION OF PREMISES
Ambulance access
1.1.1. A private hospital must have adequate access for the emergency transfer of patients by ambulance.
PART 2 - FACILITIES AND EQUIPMENT
Furnishing and equipping of wards
1.2.1. (1) All furniture, furnishings and bed linen provided by a private hospital are
to be: (a) of approved quality and quantity, and
(b) suitable for their intended use; and
(c) comfortable for patients and staff; and
(d) able to be readily cleaned.
(2) An approved hospital-type bed must be provided for each patient other than a cot patient.
(3) Each bed must be provided with at least 1 bedside locker, situated within easy reach of a patient in the bed and having a top surface which has rounded corners and is washable and impervious to liquids.
(4) Each bed must be provided with an overbed table which:
| (a) | must be of adjustable height; and |
| (b) | must be of safe design and robust construction; and |
| (c) | must have washable surfaces impervious to liquids. |
(5) At least 1 chair with arms must be provided for each bed and must be made of materials that facilitate the chair’s being kept clean and hygienic.
(6) At least 1 wardrobe (having hanging space of not less than 1 600 millimetres in height and 500 millimetres in depth or width) must be provided for each bed for the storage of the clothes of the patient occupying the bed.
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(7) Individual draw screens must be provided for patient privacy for each bed in each multiple bed ward and each such bed screen:
(a) must be of washable, fire-resistant materials; and (b) must be suspended from strong overhead tracking; and
(c)
must extend from not more than 450 millimetres above the floor to not less than 1 800 millimetres above the floor and 450 millimetres below the ceiling.
Furnishing and equipping of lounge areas
1.2.2. Patient lounge areas must be furnished with an adequate number of appropriate chairs.
Equipping of kitchen and serveries
1.2.3. (1) Adequate food storage containers and food preparation, cooking and serving utensils must be provided.
(2) Approved eating and drinking utensils of a sufficient number must be provided for the use of patients.
Medical, surgical and nursing equipment
1.2.4. (1) Medical, surgical and nursing equipment, appliances and materials that are necessary for the type and level of patient care in the private hospital must be provided from time to time as directed by the Director-General by notice in writing to the licensee of the private hospital.
(2) Without limiting subclause (1), the following equipment must be provided in a private hospital:
(a)
a resuscitation trolley containing a complete set of adult resuscitation and monitoring equipment in each of the following areas:
(i) each ward area supervised from a single nurse station; and (ii)
in a private hospital approved to provide intensive medical care - the intensive care area;
(b)
in a private hospital approved to admit paediatric patients - a resuscitation trolley containing a complete set of paediatric resuscitation and monitoring equipment in the children’s ward area;
(c) oxygen and suction facilities at appropriate locations.
(3) Without limiting subclause (1), an approved medication trolley must be provided in each clean utility room or other approved area.
Fire blankets
1.2.5. A fire blanket must be provided in each kitchen and each nurse station in a private hospital.
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Utility rooms
1.2.6. Unless otherwise approved, each dirty utility room in a private hospital must be provided with:
(a)
an approved flusher-sanitiser for emptying, rinsing and sanitising bed-pans, commode-pans and urinal vessels; and
(b)
an approved washer-sanitiser for washing and sanitising denture cups, tooth bowls, sputum cups and washing bowls; and
(c) mobile soiled linen containers; and (d) a garbage receptacle fitted with a lid.
Open fires and portable heaters prohibited
1.2.7. Open fires and portable heaters must not be provided in areas used by patients unless otherwise approved.
Maintenance of buildings, facilities and equipment
1.2.8. (1) The buildings, facilities and equipment of a private hospital must be maintained in good repair and operational order.
(2) Without limiting subclause (1), an approved maintenance programme must be current at all times for:
(a) all mixing valve systems installed in connection with ablution facilities; and (b)
all air-conditioning, heating, warming and cooling systems and appliances; and
(c) all lifts; and (d) all fire detection and extinguishing equipment and systems; and
(e) all sterilising equipment; and (f) nurse call systems.
(3) Gas cylinders must be stored in accordance with the distributor’s recommendations in cool, dry areas when not in immediate use.
(4) If a designated area is provided for the storage of medical gases, all medical gas cylinders must be stored in that area when not for immediate use.
PART 3 - CLINICAL STANDARDS
Practitioner services
1.3.1. (1) A medical advisory committee (consisting of at least 5 persons who are each either medical practitioners or dentists) is to be elected, in accordance with approved guidelines, for each private hospital.
(2) The medical advisory committee is to be responsible for:
(a)
advising the licensee on the accreditation of practitioners to provide services at the private hospital and the delineation of their clinical privileges; and
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(b) advising the licensee on matters concerning clinical practice at the private hospital; and (c) advising the licensee on matters concerning patient care and safety at the private hospital. (3) The medical advisory committee is to have power to co-opt other health care providers, who may include nominees or representatives of learned colleges or other relevant professional organisations.
(4) It is a function of the medical advisory committee to report to the Director-General any persistent failure by the licensee of the private hospital to act on the committee’s advice.
Medical procedures
1.3.2. (1) Each procedure performed at the private hospital is to be performed by an appropriately accredited practitioner.
(2) Where a procedure involves the administration of a general, spinal, epidural, major field block or large field infiltration anaesthetic or intravenous sedative, the patient is to be attended throughout the procedure by a second appropriately accredited practitioner.
(3) A practitioner is to be responsible for selecting patients suitable for treatment by the practitioner at the private hospital, subject to:
(a)
the class or classes of the private hospital and the limitations (if any) on the services that may be provided there; and
(b) the clinical privileges of the practitioner; and
(c) the maintenance of high professional standards.
Quality assurance
1.3.3. (1) The licensee is to cause procedures to be established for evaluating the quality of clinical service and care provided at the private hospital and for correcting identified problems.
(2) Such procedures are to take account of relevant external standards and programmes recommended by learned colleges and other relevant professional organisations.
Experimental treatment
1.3.4. (1) Experimental treatment must not be carried out otherwise than in accordance with the Statement on Human Experimentation issued by the National Health and Medical Research Council.
(2) The licensee must refer any proposed new or experimental treatment to an institutional ethics committee, constituted in accordance with that Statement, and the treatment must not be carried out otherwise than in accordance with the recommendations of the committee.
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PART 4 - STAFFING
Staffing
1.4.1. (1) The nursing staff of a private hospital must be sufficient in number, and must have appropriate experience, to fully perform the nursing duties necessary for the proper care of patients at all times.
(2) The nursing staff of a private hospital must include persons having qualifications and experience appropriate for each class of private hospital specified in the licence for the private hospital.
(3) The chief nurse must cause a register to be kept in which are recorded the following particulars:
(a) the name of each person employed in nursing duties in the private hospital; (b) the residential address of each such person;
| (c) | in respect of each such person who is a registered or enrolled nurse: | |||||
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(4) Sufficient staff with appropriate qualifications must be provided in a private hospital to provide allied health services necessary for good patient care.
(5) Sufficient domestic and maintenance staff or services must be provided in a private hospital to carry out the cooking, cleaning, laundering, maintenance and other duties necessary for the proper conduct of the private hospital.
PART 5 - OPERATIONAL MATTERS
Child patients
1.5.1. (1) A child must not be admitted to a private hospital as a patient unless:
| (a) | the private hospital is approved to admit child patients and the licence is endorsed accordingly, or |
(b) the admission is otherwise approved.
(2) The licensee of a private hospital who applies for an endorsement of the
licence in respect of that hospital for the purposes of subclause (1) must indicate:
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(a) the age range of children to be admitted; and (b) the types of investigation and treatment to be performed on children; and (c) the maximum duration of stay of children; and (d) the maximum number of children to be accommodated at any one time; and (e) the facilities to be provided for the treatment and care of children, for consideration in determining the conditions (if any) to be endorsed on the
licence.(3) If a child whose age, general state, condition from which the child is suffering, proposed duration of stay or proposed investigation or treatment requires special paediatric facilities or services, the private hospital admitting the child:
(a)
must arrange for a paediatric physician to be readily available for consultation at all times;
(b)
unless otherwise approved - must have a registered nurse with post-basic or post-graduate paediatric experience on duty at all times while the child is a patient in the private hospital; and
(c)
must arrange for microchemistry to be readily available for analysis of capillary blood specimens from the child.
(4) If a child has been admitted to a private hospital as a patient:
(a) the parents of the child must have easy access to the child at all times except while the child is undergoing surgery, and (b) facilities must be made available for a parent of the patient to remain with their child throughout the period of hospitalisation. (5) If a child who is less than 2 years of age is admitted to a private hospital as a patient, the child must be accommodated in a cot.
Specialised hospital services
1.5.2. (1) The following specialised services must only be performed at a private hospital where approved facilities and appropriate personnel are available and the licence is endorsed to authorise the provision of that service:
(a) accident and emergency service; (b) cardiac catheterisation; (c) intensive medical care, other than high dependency care; (d) lithotripsy, (e) open heart surgery; (f) radiotherapy, (g) renal dialysis. (2) For the purposes of this clause, an accident and emergency service does not include pre-arranged emergency admissions.
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Patient programmes
1.5.3. The licensee of a private hospital must ensure that the pursuit of cultural and religious interests of patients is not unnecessarily obstructed by staff of the private hospital.
Admission and separation of patients
1.5.4. (1) On the admission of a patient to a private hospital:
| (a) | a record of the patient’s personal particulars and reason for admission must be made; and | |||
| (b) | the patient or a person responsible for the patient must be informed in writing of: | |||
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(2) On a person ceasing to be a patient of a private hospital (whether by discharge home, transfer to another institution or death), a record of further personal and clinical particulars is to be made in relation to the person.
(3) The records referred to in this clause are to be made:
| (a) | in the register of patients; and |
| (b) | in the admission form for the patient concerned; and |
| (c) | in the morbidity form for the patient concerned. |
(4) On completion of the admission details, and again on completion of the separation details, the records are to be signed by the chief nurse (or by some other person authorised by the chief nurse for that purpose) and are to be dealt with as follows:
| (a) | the register of patients form is to be retained in a loose-leaf file with all other completed register of patients forms; |
| (b) | the admission form is to be retained as the front sheet of the patient’s clinical record; |
| (c) | the morbidity form is, unless otherwise approved, to be submitted to the Health Statistics Unit of the Department of Health within 6 weeks after the discharge of the person to whom the record relates. |
Quality assurance
1.5.5. The licensee of a private hospital must cause procedures to be established for evaluating the quality of non-clinical services provided at the private hospital and for correcting identified problems.
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Identification of patients
1.5.6. Each patient in a private hospital who is unable to clearly establish his or her identity to other persons must have the name and telephone number of the private hospital:
(a) marked indelibly and legibly on each change of clothing; or (b)
engraved or written legibly on a bracelet, anklet or necklace worn by the patient.
Notification of missing patients
1.5.7. If a patient is known to be missing from a private hospital, the senior nurse
on duty
(a)
must forthwith notify the patient’s representative or next of kin, the patient’s medical practitioner and the police verbally of the fact; and
(b)
must, as soon as practicable, notily a nursing supervisor verbally and in writing of the fact and of the details of the incident.
Patient cleanliness and comfort
1.5.8. (1) All practicable measures (including the prompt removal and replacement of soiled clothing and linen) must be taken to keep each patient clean and comfortable at all times.
(2) Heating and cooling facilities must be used as necessary to maintain the comfort of each patient.
Pharmacist’s shops and dispensaries
1.5.9. (1) If, pursuant to section 39 (1) (b) of the Act, the conduct of a pharmacist’s shop is permitted by a condition of a licence:
(a)
the pharmacist’s shop must be conducted as the business of a pharmacist in open shop in accordance with the Pharmacy Act 1964 and the regulations thereunder; and
(b)
the pharmacist in charge of the business must, in addition to providing a pharmacy service to members of the public, provide a comprehensive pharmacy service to the private hospital and its patients, including the following services:
(i)
the provision of all medication for patients, whether on prescription or otherwise, in a form that is suitable, as far as practicable, for direct administration or utilisation;
(ii)
the provision of advice on drug compatibility, possible adverse drug reactions, appropriate doses for different classes of patients and medication policy
(iii)
regular inspection of drug stocks and records to ensure proper storage of medication, proper stock rotation, withdrawal of stock that is outdated or no longer required and proper recording of drug use; and
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(iv) the establishment of written policies and procedures on the procurement, preparation, distribution and administration of medication and other therapeutic goods; and
| (c) | the pharmacist in charge of the business must make adequate provision for emergency drugs to be available in a room or cupboard accessible to staff of the private hospital outside the normal hours of business. |
(2) If, pursuant to section 39 (1) (b) of the Act, the conduct of a dispensary is permitted by a condition of a licence:
| (a) | the dispensary must be under the control of a pharmacist at all times; and |
| (b) | all dispensing must be personally supervised by a pharmacist; and |
| (c) | in the absence of a pharmacist, persons must not be permitted to have access to the dispensary, and |
| (d) | the dispensary must comply with the requirements of the regulations under the Pharmacy Act 1964 in relation to equipment, appliances and reference books; and |
| (e) | the functions of the dispensary are to be limited to the provision of a service to the private hospital and its patients; and |
| (f) | the services provided by the pharmacist in charge of the dispensary must |
include:
(i) the provision of all medication for patients, whether on prescription or otherwise, in a form that is suitable, as far as practicable, for direct administration or utilisation; and (ii) the provision of advice on drug compatibility, possible adverse drug reactions, appropriate doses for different classes of patients and medication policy, and (iii) regular inspection of drug stocks and records to ensure proper storage of medication, proper stock rotation, withdrawal of stock that is outdated or no longer required and proper recording of drug use; and (iv) the establishment of written policies and procedures on the Procurement, Preparation, distribution and administration of medication and other therapeutic goods; and (g) the pharmacist in charge of the dispensary must make adequate provision for emergency drugs to be available in a room or cupboard accessible to staff of the private hospital outside the normal hours of operation of the dispensary.
Storage and administration of medicines
1.5.10. (1) In this clause:
"drug of addiction" means a substance specified in Schedule Eight of the Poisons
List under the Poisons Act 1966;
"prescribed restricted substance" means a restricted substance prescribed for the
purposes of section 16 of the Poisons Act 1966;
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"qualified person" means a medical practitioner, pharmacist, dentist or registered
nurse;
"restricted substance" means a substance specified in Schedule Four of the
Poisons List under the Poisons Act 1966.
(2) Except for medication stored in a dispensary under the control of a pharmacist, the chief nurse of a private hospital:
(a)
must store any drug of addiction or prescribed restricted substance in a cupboard that:
(i)
is securely affixed to the premises in a clean utility room or other approved area;
(ii) is constructed in an approved manner with approved materials; (iii)
is fitted with a 5-lever keylock or locking mechanism providing at least equivalent security and
(iv)
contains no other goods except drugs of addiction and prescribed restricted substances; and
(b)
must store any other medication in a secure glace in a clean utility room or other approved area.
(3) The chief nurse of a private hospital must ensure that:
(a) medication stocks and records are regularly inspected by a qualified and responsible person to ensure the proper storage of medication, proper stock rotation, withdrawal of stock that is outdated or no longer required and proper recording of medication use; and (b) written policies and procedures are established for the procurement, preparation, distribution and administration of medication. (4) Medication must not be transferred from the container in which it was supplied by the manufacturer or a pharmacist to another container, except where transfer to a syringe, infusion bottle or other container is necessary for the purpose of administration of the medication.
(5) A person must not administer a medication to a patient unless the person is a qualified person or the patient.
(6) If a patient administers a medication to himself or herself, a qualified person must check each item of medication before administration.
(7) Except in an emergency, a medical practitioner or dentist must, when authorising the administration of any medication to a patient, record on an approved medication sheet kept in respect of the patient;
(a) the name and, where applicable, the strength of the medication; and (b) the dosage to be administered; and (c) the route of administration; and (d) the times of day or frequency of administration; and (e)
the number of doses or period of time for which administration is authorised; and
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(f) the date on which the entry is made; and (g) his or her signature.
(8) If in an emergency the administration of any medication to a patient has been authorised verbally by a medical practitioner or dentist, the nurse to whom the verbal authorisation was given must record on an approved medication sheet kept in respect of the patient:
(a) the name and, where applicable, the strength of the medication; and
(b) the dosage to be administered; and
(c) the route of administration; and(d) the times of day or frequency of administration; and
(e)
the number of doses or period of time for which administration is authorised; and
(f) the date on which the entry is made; and
(g) the name of the medical practitioner or dentist; and
(h) his or her signature.
(9) The records referred to in this clause:
(a)
must be handwritten in ink by the medical practitioner, dentist or nurse, as the case may be; or
(b) must be recorded in such other manner as may be approved,
and must be signed in ink by the medical practitioner, dentist or nurse next to or
immediately below the name of each item of medication.
(10) A medical practitioner or dentist who, in an emergency, has verbally authorised the administration of any medication to a patient must confirm the authorisation within 24 hours of giving that verbal authority by signing the entry made pursuant to subclause (8).
(11) A person must not administer a restricted substance or drug of addiction to a patient except on the authorisation of a medical practitioner or dentist given in accordance with subclause (7) or (8).
(12) The person administering a medication to a patient:
(a)
must refer directly to the authorisation in respect of that medication on the approved medication sheet; and
(b)
must, when the medication is given, initial the appropriate place on the approved medication sheet to indicate that the medication has been given.
(13) Each completed medication sheet must be retained in the patient’s clinical
record.
1990 - No. 435
Notifiable diseases
1.511. (1) In this clause:
"notifiable disease" means any of the following diseases:
acquired immune deficiency syndrome (AIDS);
acquired immune deficiency syndrome-related complex (AIDS-related
complex);
bacterial or amoebic dysentery,
cholera;
diphtheria;
food poisoning;
hepatitis (Type A, Type B or other);
legionnaire’s disease;
leprosy,
lymphadenopathy syndrome;
meningococcal meningitis;
methicillin-resistant staphylococcal infections;
plague;
poliomyelitis;
rabies;
scabies;
staphylococcal infections in new-born infants;
tuberculosis (all forms);
typhoid and paratyphoid;
typhus (all forms);
viral haemorrhagic fever;
yellow fever.
(2) If a patient in a private hospital is suffering or is reasonably suspected to be suffering from a notifiable disease, the chief nurse:
(a)
must cause such measures to be taken as are necessary to prevent the spread of infection; and
(b)
must, within 24 hours, notify a nursing supervisor by telephone of the fact; and
(c)
must, within 24 hours, send to the Director-General notice in writing, in or to the effect of Form 11, of the fact, ensuring that no personal identification of the patient is included in the notice; and
(d) must take such further measures as the Director-General may require. Hygiene
1.5.12. (1) Adequate facilities, equipment and stores must be maintained in a private hospital for the effective cleaning and disinfection of the buildings and their fixtures and fittings.
(2) Buildings of a private hospital, together with their fixtures and fittings, must be maintained in a clean and sanitary condition.
1990 - No. 435
(3) Without limiting subclause (2):
| (a) | all furniture, furnishings, fittings, bedsteads and bedding must be kept in a clean and sanitary condition; and |
| (b) | eating, drinking or cooking utensils or food storage containers which are cracked, chipped, scored, stained or defective must not be used; and |
| (c) | each bed-pan, commode-pan, urinal vessel, wash basin and vomit bowl must be sanitised after each use; and |
| (d) | each tooth mug, denture container and sputum mug must, while in use, be sanitised at least once every 24 hours. |
(4) All necessary measures must be taken:
| (a) | to exclude flies and other vermin from a private hospital; and |
| (b) | to destroy any flies or other vermin that are within a private hospital. |
(5) A pan sluice or flusher-sanitiser (but not a toilet facility) must be used for disposal of the contents of bed-pans, commode-pans and urinal vessels.
(6) Receptacles with close-fitting lids must be provided for the collection of household refuse.
(7) Household refuse must be disposed of by the use of a service provided by the local authority or in some other approved manner.
(8) Contaminated wastes must be disposed of in an approved manner.
(9) The grounds of a private hospital must be maintained in a clean, tidy and safe condition.
Smoking
1.5.13. (1) There must be a written policy on smoking in the private hospital by patients and staff.
(2) The policy on smoking must provide:
| (a) | that neither patients nor staff are allowed to smoke in wards or dining areas; and |
| (b) | that, if patients or staff are allowed to smoke within the private hospital, smoking is confined to designated areas that allow other patients to avoid exposure to smoke without unduly restricting their activities; and |
| (c) | that frail patients are to be kept under direct supervision of a member of staff while smoking. |
Animals
1.5.14. (1) Birds and animals are not, except at the discretion of the licensee and with the approval of the Director-General, to be permitted in any area of a private hospital occupied by patients.
(2) Birds and animals are not to be permitted in any area of a private hospital where food is stored, prepared or cooked.
1990 - No. 435
Telephones
1.5.15. (1) A telephone (not being coin-operated and not fitted with any locking device) must be available at all times in a. private hospital for use by staff in order to deal with emergencies.
(2) At least one other telephone must be provided on each floor in a private
hospital for use by patients and their next of kin for both incoming and outgoing calls.(3) The location of telephones provided for use by patients must take account of the need for access and privacy by patients and their next of kin when making telephone calls.
Visiting hours
1.5.16. (1) Subject to subclause (2), patients in a private hospital must be allowed to receive visitors at any reasonable time.
(2) A medical practitioner or the senior nurse on duty may, if necessary for the care of a patient:
(a)
restrict the hours €or visiting the patient and, if necessary, other patients in the same ward; and
(b) restrict the number of persons who may visit the patient at any one time. Meal times
1.5.17. (1) Meals must be served to patients at the following times:
(a) Breakfast - not earlier than 6.30 a.m.; (b) Mid-day meal - not earlier than noon; (c) Evening meal - not earlier than 5.00 p.m. (2) Morning and afternoon tea and supper must be provided for patients at the
appropriate times.
Storage, preparation and serving of food
1.5.18. (1) A kitchen in a private hospital must be used solely for the purposes of:
(a) storing, preparing, cooking and distributing food; and (b) washing dishes and utensils used in connection with the storage, preparation, cooking or serving of food. (2) An area of a private hospital, other than a kitchen, must not be used for the purposes specified in subclause (1), except that:
(a) a servery may be used for the preparation of beverages and light snacks; and (b) a scullery may be used for washing dishes and utensils. (3) Laundry and waste (other than kitchen waste) must not be taken through a
kitchen.
1990 - No. 435
(4) Meals at a private hospital must be prepared and served:
(a) in accordance with a planned menu of not less than 1 week; and (b) in sufficient variety, quality and quantity
(i) as to be attractive and palatable to and edible by patients; and (ii) as to provide the dietary allowances recommended from time to time by the National Health and Medical Research Council.
(5) Any special diet prescribed or requested for a patient by the medical practitioner in charge of the patient’s care must be provided.
Overcrowding etc.
1.5.19. (1) Unless otherwise approved, a patient must not be lodged in any part of a private hospital other than a ward.
(2) If in an emergency the number of patients in a ward exceeds the number of patients specified in the licence in relation to that ward, the licensee of the private hospital:
(a)
must, as soon as practicable, cause the excess patient or patients to be removed from that ward; and
(b)
must, as soon as practicable, notify a nursing supervisor by telephone of the fact; and
(c)
must, as soon as practicable, send to the Director-General notice in writing of the fact and of all the relevant details of the circumstances in which it occurred.
Removal of bodies
1.5.20. The body of a dead person must not be left for more than 1 hour in any ward or other room occupied by other patients.
Accidents etc.
1.5.21. (1) If, as a result of an incident occurring in a private hospital, a patient sustains an injury which requires medical attention, the senior nurse on duty must enter the details of the incident in Part A of Form 12 and must report the incident to the chief nurse and to the patient’s medical practitioner.
(2) As soon as practicable after receiving such a report, the chief nurse:
(a)
must cause the incident to be investigated and enter the results of the investigation in Part B of Form 12; and
(b)
if the patient was transferred to another hospital, must enter the details of the transfer in Part C of Form 12; and
(c)
if the incident vas lire-threatening or fatal, must notify the patient’s representative or next of kin and a nursing supervisor verbally of the incident; and
1990 - No. 435
(d) must forward to the Director-General a copy of the completed form; and
(e) must retain the completed form in the patient’s clinical record.
Fire safety
1.5.22. (1) The licensee of a private hospital must have an emergency procedures policy (including contingency arrangements for the transfer of patients where necessary) and must ensure that all staff are familiar with the procedures.
(2) The licensee of a private hospital must appoint a member of the staff to be the fire safety officer for the private hospital and must ensure that the fire safety officer is provided with appropriate training.
(3) Each means of escape from a private hospital must be kept clear of obstacles at all times.
(4) Doors and other required fire exits must be kept in good working order and are at all times to be capable of being opened from the inside by a single-handed action.
(5) Fire detection and extinguishing equipment and systems in a private hospital are to be kept in good order and are to be serviced annually.
(6) Approved fire safety notices are to be displayed in each nurse station and in other conspicuous positions in a private hospital and are to be maintained in legible condition.
(7) All of the staff of a private hospital must attend approved fire safety training at least once every year.
(8) A record of each such fire safety training, showing the name of each person attending and signed by the training officer, must be maintained.
(9) All of the staff of a private hospital must participate in an evacuation exercise at least once every 6 months.
(10) If a fire occurs in a private hospital, the licensee, as soon as practicable after the fire and regardless of whether or not the fire brigade has been called to extinguish the fire:
(a) must notify a nursing supervisor verbally of the fact; and (b)
must send to the Director-General notice in writing of the fact and of all the relevant details of the circumstances in which the fire occurred.
PART 6 - CLINICAL RECORDS
Clinical records
1.6.1. (1) A record of the medical condition of each patient in a private hospital and all medical, nursing and other care provided to the patient must be maintained by an entry in a patient clinical record system by the appropriate medical, nursing or other health care provider.
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(2) Without limiting subclause (1), the clinical record of a patient must include the following:
| (a) | the patient’s admission form; | |||
| (b) | the patient’s medical history, and results of any physical examination, which may be contained in any referral document; | |||
| (c) | medical consultation reports; | |||
| (d) | the patient’s medication sheet; | |||
| (e) | a record of planned nursing management, including all other treatment and diet orders; | |||
| (f) | a record of allergies and other factors requiring special consideration; | |||
| (g) | progress notes including: | |||
| ||||
| (h) | reports of all laboratory tests performed; |
reports of all X-ray and other medical imaging examinations performed;
| (j) | consent or request forms, where applicable; |
| (k) | a discharge statement, completed by the medical practitioner or dentist attending the patient, that gives any major procedures performed, the final diagnosis, the patient’s condition and recommendations and arrangements for the patient’s future care. |
(3) A discharge statement referred to in subclause (2) (k) must be completed prior to the patient’s discharge unless verbal discharge instructions are given, in which case the statement must be completed within 48 hours after the patient’s discharge.
Retention of records
1.6.2. (1) The register of patients, together with the patients’ clinical records, must be retained as follows:
| (a) | the register of patients must be kept indefinitely, |
| (b) | clinical records relating to patients (other than obstetric patients) aged 18 years or over at the date of last separation must be kept for 7 years from the date of last separation; |
| (c) | clinical records relating to patients (other than obstetric patients) aged under 18 years at the date of last separation must be kept until the patient to whom the record relates attains, or would have attained, the age of 25 years. |
(2) If the licence of a private hospital is transferred to another person, the transferee must continue to retain the register of patients and the patients’ clinical records in accordance with this clause.
1990 - No. 435
(3) If the licence of a private hospital is surrendered or cancelled, the licensee must deal with the register and records in accordance with the instructions of the Director-General.
Patient access to clinical records
1.6.3. (1) A patient of a private hospital or the patient’s representative may, by written application to the licensee, request access to the patient’s clinical record.
(2) Except as provided by subclause (3), the licensee of a private hospital must, as soon as practicable after receipt of such an application, make the clinical record available for inspection at the private hospital:
(a) by the patient or by the patient’s representative; or
(b) by a person nominated by the patient or representative and approved by the licensee. (3) The licensee of a private hospital may refuse a request by a patient or by the patient’s representative for access to the patient’s clinical record:
(a)
if the medical practitioner in charge of the patient’s care advises that the request should be refused; and
(b)
if the licensee is satisfied that access by the patient or representative to the patient’s clinical record would be prejudicial to the patient’s physical or mental health.
(4) An application under this clause is to be retained in the patient’s clinical
record. (5) If the licensee of a private hospital refuses a request by a patient or by the
patient’s representative for access to the patient’s clinical record, the licensee:
(a) must inform the patient or representative of the reason for the refusal; and (b) must include in the patient’s clinical record a written note of the refusal and the reason given for the refusal. (6) If the licensee of a private hospital makes clinical records available for inspection under this clause, the patient or representative is (on payment of a fee, not exceeding the approved maximum fee, determined by the licensee) to be given. assistance in the interpretation of test results, findings and comments by a person qualified to do so.
(7) If a patient or the patient’s representative disagrees with the information contained in the patient’s clinical record, the licensee must, on request by the patient or representative, attach the patient’s or representative’s own comments in the form of an addendum to the record.
(8) If a patient or the patient’s representative requests particular clinical information (such as test results or details of past treatment) rather than access to the patient’s clinical record, the information may be provided by the medical practitioner in charge of the patient’s care or, subject to the advice of that medical practitioner, by a medical practitioner or registered nurse on the staff of the private hospital.
1990 - No. 435
(9) A patient or the patient’s representative may appeal in writing to the Director-General against a decision of the licensee of a private hospital to refuse access to the patient’s clinical record.
(10) The Director-General may, in determining such an appeal:
| (a) | confirm the decision of the licensee; or |
| (b) | direct that the licensee grant the patient or the patient’s representative access to the patient’s clinical record under such conditions as the Director-General may direct. |
(11) A determination made by the Director-General must be conveyed in writing to the licensee and must be retained in the clinical record of the patient to whom it relates.
Confidentiality of records
1.6.4. (1) The licensee of a private hospital must ensure that, except as provided
by this clause, personal information concerning a patient is not released from the
private hospital without the consent of the patient or the patient’s representative.
(2) Personal information concerning a patient may be released from the private hospital without consent:
| (a) | if the release of that information is required or authorised by law - in the manner so required or authorised; or |
| (b) | if the private hospital is a defendant in a case involving the patient and the release of that information is required for the defence - to the legal representative of the licensee of the private hospital; or |
| (c) | to the medical practitioner in charge of the patient’s care and, where applicable, the patient’s anaesthetist and any medical practitioner or dentist consulted on the patient’s care; or |
| (d) | if the patient is transferred to another health establishment - to that health establishment; or |
| (e) | if the patient is discharged into the care of a medical practitioner - to that medical practitioner; or |
| (f) | if the information is limited to a general statement about the patient’s condition and if the patient has not instructed otherwise - to a relative or friend of the patient. |
(3) Access to personal information concerning a patient may be granted for bona fide research purposes without consent:
| (a) | if a comprehensive code detailing the aims, methods and reasons for the study has been approved by an institutional ethics committee referred to in clause 1.3.4; and |
| (b) | if the person carrying out the research does not remove the records concerned from the private hospital; and |
| (c) | if the information recorded by the person carrying out the research does not identify the patient directly; and |
1990 - No. 435
(d) if the patient is not contacted directly by the person carrying out the research. (4) Nothing in subclause (2) or (3) permits the release of personal information concerning a patient where the information consists of a confidential communication between the patient and a medical practitioner.
(5) All clinical records must be stored in a secure place to which unauthorised persons are not to be permitted to have access.
SCHEDULE 2 - ADDITIONAL LICENSING STANDARDS FOR
PARTICULAR CLASSES OF PRIVATE HOSPITAL
(Cl. 5)
PART 1 - SURGICAL HOSPITALS
Support services
2.1.1. A surgical class prime hospital must have access to basic pathology and radiography services within a period of time appropriate to clinical need.
Clinical records
2.1.2. The clinical record of a patient in a surgical class private hospital is, if a surgical procedure has been performed, to include:
(a)
the anaesthetic record, which must comply with the recommendations of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "The Anaesthetic Record"; and
(b)
the operative report, including pre-operative and post-operative diagnosis, description of findings, technique used and tissue removed or altered; and
(c) if tissue or body fluid was removed, the pathological report; and (d) a record of the swab, sponge and instrument count. Staffing
2.1.3. Without limiting clause 1.4.1, staff are to be provided to assist an anaesthetist in accordance with the recommendations of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Minimum Assistance Required for the Safe Conduct of Anaesthesia".
Child patients
2.1.4. If a child is undergoing surgery, the parents of the child must have easy access to the child in the pre-anaesthetic and recovery areas unless, in the opinion of the attending practitioner, the presence of the parents in those areas is detrimental to patient welfare.
1990 - No. 435
Identification of patients
2.1.5. Each surgical patient must have fitted around a wrist or ankle an
identification band on which is indelibly and legibly written the name of the patient.
Medical, surgical and nursing equipment
2.1.6. Without limiting clause 1.2.4, the following equipment must be provided in a surgical class private hospital in the operating suite:
| (a) | an electrosurgical unit for each operating room; |
| (b) | adequate instrument sets for elective use; |
| (c) | sterile instrument sets available for emergency procedures; |
| (d) | anaesthetic equipment recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Recommended Minimum Facilities for Safe Anaesthetic Practice in Operating Suites"; |
| (e) | monitoring equipment recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Monitoring During Anaesthesia”; |
| (f) | recovery equipment and drugs recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication “Guidelines for the Care of Patients Recovering from Anaesthesia in the Recovery Area". |
PART 2 - OBSTETRIC HOSPITALS
Clinical records
2.2.1. (1) The clinical record of a patient in an obstetric class private hospital must, if an obstetric delivery has been performed, include the labour record.
(2) An obstetric patient’s clinical records must be retained for at least 25 years from the date of separation.
Record of births
2.2.2. (1) On the birth of a baby (whether live or stillborn) in a private hospital
or the admission of a newborn baby otherwise than by transfer from another hospital:
| (a) | a record of the particulars of the birth must be made; and | |||
| (b) | the record must be signed: | |||
|
(2) Three copies of the record, in or to the effect of Form 13, must be made.
(3) The particulars referred to in subclause (1) are the particulars required to complete Form 13.
1990 - No. 435
(4) On completion of the particulars of a birth, the copies of Form 13 are to be dealt with as follows:
(a) the first copy is to be retained with the mother’s clinical record; (b)
the second copy is, unless otherwise approved, to be submitted to the Health Statistics Unit of the Department of Health within 6 weeks after the separation of the mother or baby, whichever first occurs;
(c)
the third copy is, subject to the mother’s consent, to be submitted to the appropriate health care nurse forthwith after separation of the mother or the baby, whichever occurs first.
Identification of patients
2.2.3. Each obstetric patient and baby must have fitted around a wrist or an ankle an identification band on which is indelibly and legibly written the name of the patient or baby.
Furnishing of wards
2.2.4. In addition to the bed referred to in clause 1.2.1, each maternity ward must be provided with 1 bassinet for each maternity bed and 1 reserve bassinet for every 10 maternity beds or part thereof.
Medical, surgical and nursing equipment
2.2.5. Without limiting clause 1.2.1, the delivery suite of an obstetric class private hospital must be equipped in accordance with the recommendations of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication
"Recommended Minimum Facilities for Safe Anaesthetic Practice in Delivery
Suites”.
PART 3 - REHABILITATION HOSPITALS
Furnishing and equipping of dining and therapy areas
2.3.1. (1) Patient dining areas in a rehabilitation class private hospital must be furnished with adequate numbers of suitable tables and chairs.
(2) Activities areas in a rehabilitation class private hospital must be adequately equipped for therapy and other activities.
PART 4 - PSYCHIATRIC HOSPITALS
Furnishing of wards
2.4.1. Subclauses (2) and (5) of clause 1.2.1 do not apply to a psychiatric ward if a suitable domestic-type bed is provided for each patient.
1990 - No. 435
Furnishing and equipping of dining and therapy areas
2.4.2. (1) Patient dining areas in a psychiatric class private hospital must be furnished with adequate numbers of suitable tables and chairs.
(2) Activities areas in a psychiatric class private hospital must be adequately equipped for therapy and other activities.
ECT equipment
2.4.3. Without limiting clause 1.2.1, the equipment and drugs provided in areas in which electro-convulsive therapy is administered must comply with the recommendations of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Recommended Minimum Facilities for Safe Anaesthetic Practice for Electro Convulsive Therapy".
1990 - No. 435
SCHEDULE 3 - FORMS
Form 1
(Cl. 6)
APPLICATION FOR LICENCE
FOR A PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
I/We, .........................................................................................................................................
(full name of applicant[s])
...................................................................................................................................................... of
(address of applicant[s])
hereby apply for a licence for a private hospital of the
following class[es] ...................................................................................................................
The private hospital will be known as
......................................................................................................................................................
(proposed name)
and will be situated at
......................................................................................................................................................
( proposed location)
and will accommodate ........................ patients. The applicant[s] is/are/will be * owner[s] * lessee[s]
of the private hospital.
I/We attach hereto the following information:
(1) In the case of an application by a corporation: (a) a copy of the certificate of incorporation; (b) the address of the registered office of the corporation;
(c) the full name, residential address and position of:
(i) each current director of the corporation; (ii) the principal executive officer of the corporation; (iii)
the secretary or, if there is more than one, each secretary of the corporation;
1990 - No. 435
(d) in the case of a corporation limited by shares:
(i)
the types of shares and the number of shares of each type issued;
(ii)
in the case of a private corporation - the full name of, and the number of shares of each type held by, each shareholder;
(iii)
in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings;
(e)
if the shares are held by another corporation, the name of the ultimate holding corporation.
| (2) | If the private hospital is leased, a copy of the lease. |
| (3) | If the private hospital is proposed to be leased, a description of the proposed lease arrangements. |
I/We also forward herewith the prescribed application fee.
.................................................. ..............................................
(Print name) (Signature)
.................................................. ..............................................
(Position) (Date)
* Delete whichever is not applicable
1990 - No. 435
Form 2
(Cl. 10)
APPLICATION FOR TRANSFER OF LICENCE
FOR A PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
I/We, ......................................................................................................................................
(full name of applicant[s])
of ...........................................................................................................................................
(address of applicant[s])
hereby apply for a transfer to me/us of the licence for the private hospital known as
...............................................................................................................................................
(name of private hospital)
at ...........................................................................................................................................
(address of private hospital)
The applicant[s] is/are/will be
* owner[s] * lessee[s]
of the private hospital.
I/We attach hereto the following information:(1) In the case of an application by a corporation: (a) a copy of the certificate of incorporation; (b) the address of the registered office of the corporation;
(c) the full name, residential address and position of:
(i) each current director of the corporation; (ii) the principal executive officer of the corporation; (iii)
the secretary or, if there is more than one, each secretary of the corporation;
(d) in the case of a corporation limited by shares:
(i)
the types of shares and the number of shares of each type issued;
(ii)
in the case of a private corporation - the full name of, and the number of shares of each type held by, each shareholder;
(iii)
in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings;
1990 - No. 435
(e)
if the shares are held by another corporation, the name of the ultimate holding corporation.
| (2) | If the private hospital is leased, a copy of the lease. |
| (3) | If the private hospital is proposed to be leased, a description of the proposed lease arrangements. |
I/We also forward herewith the prescribed application fee.
.................................................. ...................................................
(Print name) (Signature)
.................................................. ....................................................
( Position) (Date)
TO BE COMPLETED BY CURRENT LICENSEE
I/We agree to the transfer of the license to the abovenamed applicant(s).
.................................................. ...................................................
(Print name) (Signature)
..................................................... ....................................................
(Position) (Date)
* Delete whichever is not applicable
1990 - No. 435
Form 3
(Cl. 11)
APPLICATION FOR APPROVAL TO ALTER OR EXTEND
A LICENSED PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
I/We, ....................................................................................................................................
(name of licensee)
of .........................................................................................................................................
(address of licensee)
being the holder of the licence (No. ..............) for the private hospital known as
..............................................................................................................................................
(name of private hospital)
at ............................................................................................................................................
(address of private hospital)
hereby apply for approval to alter or extend the private hospital.
I/We attach hereto the following documents:
(1)
Two copies of a site plan of the private hospital, drawn to scale and showing the lot number and deposited plan number or other relevant particulars which identify the site.
(2)
Two copies of sketch plans of the private hospital, drawn to a scale of 1:100 and showing the dimensions of each part of the private hospital and the use to which each part is to be put (the proposed alterations or extensions to the private hospital are shown by distinctive colouring or cross-hatching).
.................................................. ...................................................
(Print name) (Signature)
.................................................. ....................................................
(Position) (Date)
1990 - No. 435
Form 4
(Cl. 12)
APPLICATION FOR REVIEW
OF DIRECTOR-GENERAL’S DECISION
(Private Hospitals and Day Procedure Centres Act 1988)
I/We, ......................................................................................................................................
(name of applicant)
of ...........................................................................................................................................
(address of applicant)
hereby apply for a review of the decision of the Director-General to:
.................................................................................................................................................
(nature of decision)
I/We enclose a copy of the Director-General’s letter notifying the decision.
The grounds for my/our request for review are as follows:
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
I/We understand that this application will be referred to a Committee of Review, which may make such investigation as ia considers necessary in relation to this application before reporting to you. I/We agree, for this purpose, to allow any member of the Committee access to documentation, staff and patients, as judged necessary by the Committee. I/We also agree to relevant documentation held by the Department of Health being made available to members of the Committee for the purposes of its investigation.
.................................................. ...................................................
(Print name) (Signature)
.................................................. ....................................................
(Position) (Date)
1990 - No. 435
Form 5
(Cl. 13)
NOTIFICATION OF PARTICULARS OF PERSON
TO BE APPOINTED AS CHIEF NURSE OF A PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
I/We, ........................................................................................................................................
(name of licensee)
of ............................................................................................................................................
(address of licensee)
hereby notify the Director-General that ..............................................................................
...................................................................................................................................................
(name of appointee)
................................................................................................................................................... of (residential address of appointee)
who is registered as a ...............................................................................................................
(nature of registered qualification)
registered number .....................................................................................................................
(number of registration certificate issued
by the Nurses Registration Board of N.S. W.)
with ................................ years of post-basic or post-graduate nursing experience (number of years)
has been appointed to carry out the duties of chief nurse
at ..........................................................................................................................................
(name of private hospital)
of ..............................................................................................................................................
(address of private hospital)
from ..........................................................................................................................................
(date of commencement of duty)
I attach hereto:
(1) The appointee’s curriculum vitae. (2) A copy of the appointee’s current annual practising certificate.
1990 - No. 435
.................................................. ...................................................
(Print name) (Signature)
.................................................. ....................................................
(Position) (Date)
....................................................
(Signature of appointee)
1990 - No. 435
Form 6
(Cl. 14)
REGISTER OF PATIENTS AT A PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
1990 - No. 435
Form 7
(Cl. 15)
PRIVATE HOSPITAL ADMISSION FORM
(Private Hospitals and Day Procedure Centres Act 1988)
1990 - No. 435
Form 8
(C1. 15)
PRIVATE HOSPITAL MORBIDITY FORM
(Private Hospitals and Day Procedure Centres Act 1988)
1990 - No. 435
Form 9
(Cl. 18)
LICENSEE’S ANNUAL CERTIFICATE
FOR A PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
Name of licensee: .................................................................................................................
Address of licensee: ............................................................................................................
Name of private hospital: ..................................................................................................
Address of private hospital: ................................................................................................
Class(es) of private hospital: ..............................................................................................
Name of chief nurse: ...........................................................................................................
Registration No. of chief nurse: ........................................................................................
The private hospital is
* owned by the licensee
* leased from ....................................................................................................................
(name of lessor)
I/We forward herewith:
(1) The prescribed annual licence fee.
| (2) | A copy of the chief nurse’s current annual practising certificate. |
(3) If the licensee is a corporation:
(a) the full name of the corporation;
(b) the address of the registered office of the corporation;
1990 - No. 435
(c) the full name, residential address and position of:
(i) each current director of the corporation; (ii) the principal executive officer of the corporation; (iii) the secretary or, if there is more than one, each secretary of the corporation; (d) in the case of a corporation limited by shares:
(i) the types of shares and the number of shares of each type issued; (ii) in the case of a private corporation - the full name of, and the number of shares of each type held by, each shareholder; (iii) in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings; (e) if the shares are held by another corporation, the name of the ultimate holding corporation.
.................................................. ............................................
(Print name) (Signature)
.................................................. .............................................
(Position) (Date)
* Delete whichever is not applicable
1990 - No. 435
Form 10
(Cl. 19)
PRIVATE HOSPITAL STATISTICAL STATEMENT
(Private Hospitals and Day Procedure Centres Act 1988)
HOSPITAL:
CODE No: ..........
STATEMENT FOR MONTH OF ...................... 19 ........
ALE PATIENTS ADMITTED DURING MONTH
Day only Overnight Total &
longer
Private patients .......... .......... ............ Nursing home type patients .......... .......... ............ Compensable and ineligible patients .......... .......... ............
Total patients .......... ........... ............
BED DAYS FOR PERIOD
(Midnight bed count plus day only patients)
Private patients ............ Nursing home type patients ............ Compensable and ineligible patients ............ Total patient bed days ............
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Form 11
(Sch. 1.5.11)
NOTIFICATION OF ILLNESS DUE TO NOTIFIABLE DISEASE
AT A PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
Name of private hospital: .....................................................................................................
Address of private hospital: .............................................................................................
Patient reference No.: ............................................................................................................
Date of admission of patient: .........................................................................................
Disease: .................................................................................................................................
Time and date of apparent onset: ........................................................................................
Name of attending practitioner: ..........................................................................................I hereby give notice that the patient to whom the above reference number relates is, or is reasonably suspected to be, suffering from the notifiable disease specified above.
.................................................. .................................................. (Signature of chief nurse) (Date)
1990 - No. 435
Form 12
(Sch. 1.5.21)
PRIVATE HOSPITAL INCIDENT REPORT FORM
(Private Hospitals and Day Procedure Centres Act 1988)
1990 - No. 435
Form 13
(Sch. 2.2.2)
RECORD OF BIRTH
AT A PRIVATE HOSPITAL
(Private Hospitals and Day Procedure Centres Act 1988)
1990 - No. 435
NOTE
TABLE OF PROVISIONS
PART 1 - PRELIMINARY
1. Citation
2. Commencement
3. Application
4. Definitions
PART 2 - LICENSING OF PRIVATE HOSPITALS
5. Licensing standards
6. Applications for licences
7. Development guidelines
8. Classes of private hospitals
9. Annual licence fees
10. Transfer of licence
11. Alterations or extensions
12. Application for review of Director-General’s decision
13. Chief nurse of private hospital
14. Register of patients
15. Records
PART 3 - MISCELLANEOUS
16. Evidentiary certificates
17. Display of licence
18. Information to be furnished with annual licence fee
19. Information to be furnished periodically
SCHEDULE 1 - LICENSING STANDARDS FOR ALL PRIVATE HOSPITALS SCHEDULE 2 - ADDITIONAL LICENSING STANDARDS FOR
PARTICULAR CLASSES OF PRIVATE HOSPITAL
SCHEDULE 3 - FORMS
EXPLANATORY NOTE
The objects of this Regulation are to make provisions necessary or convenient for carrying out or giving effect to the Private Hospitals and Drug Procedure Centres Act 1988 in so far as that Act relates to private hospitals. Apart from machinery provisions, the Regulation deals with licensing standards. These standards include provisions concerning design and construction of premises, facilities and equipment, clinical standards, staffing, operational matters and clinical records.
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