Reporting

Reporting

The following information should be provided under the Act as appropriate. Please note it is your responsibility to update any information held by the Department in relation your facility, to ensure currency.

New Licence Applications (including applications to transfer and alter/extend)

 

Documentation / Information

Form for Use / example of acceptable evidentiary item

When

Ref:

Director of Nursing details

Authority to Practice

On application

Reg. 11(a)

Annual Report

Last Annual Report published by the licensee for HSE

On application

Reg. 11(b)

Insurance Details

Copy of Insurance Policy/Certificate

On application

Reg. 13

Accreditation Details

Copy of most recent Accreditation report

On application

Schedule 1, Pt 2

Company Details (where applicable)

Certificate of incorporation and company extract, listing details of the directors

On application

Section 9(f)

Trustee Details (where applicable)

Trust Deed

On application

Section 9(f)

Procedure Details

Form 1, 2, or 3 as appropriate. List the procedures to be carried out at the facility, providing Medicare item numbers. If anaesthetic is to be used, provide a signed letter from an anaesthetist endorsing the procedures and anaesthetics proposed.

On application

Section 9(f); s23

Medical Advisory Committee and credentialling details

(see also Medical Advisory Committees)

Refer to Schedule 1, Pt 2 and Schedule 5 of the HSE Regulations.

On application

Schedule 1, Part 2; Schedule 5

HSE Regs.

Suitability of HSE Premises

Please refer to application form.

On application

Section 9(f); s.10(2)

Fitness and Probity Information

Form 4

On application

Section 9(f); s.10(3)

Existing Licences - Change in Circumstances

Documentation / Information  

Form for Use / example of acceptable evidentiary item

When

Ref:

Particulars of change in directors and/or major shareholders (i.e. shareholding exceeds 20%).

Details of changes (names, positions/shareholdings).

As soon as practicable following change.

Reg. 19

Particulars of change in insurance

Copy of amended/current insurance policy

As soon as practicable.

Reg. 13

Particulars of change in director of nursing

Authority to Practice

As soon as practicable.

s.39(5);

Reg. 15

Particulars of renewal of Accreditation

Current Certificate of Accreditation; copy of most recent accreditation report.

As soon as practicable.

Schedule 1, Pt 2,

Clause 2 - HSE Regs

Medical Advisory Committee, membership changes

(see also Medical Advisory Committees)

The name, contact details and qualifications of each member, and the date on which each person becomes a member/ceases to be a member of the Medical Advisory Committee.

As soon as practicable following change.

Schedule 1, Part 2, Clause 4(5),

HSE Regs.

Routine Reporting

 

Documentation / Information

Form for Use / example of acceptable evidentiary item

When

Ref:

Mandatory Reporting of iatrogenic conditions resulting in hospital transfer and/or life-threatening or fatal incidents (includes sentinel events).

Form 18, or alternative form approved by Secretary.

As soon as practicable following incident

Schedule 1, Part 4, Clause 10 - HSE Regs

Routine reporting, where requested

In accordance with National Minimum Data Set Requirements

Within 30 days of the end of each calendar month

Reg. 12

Any information for the purposes of the HSE Act requested by the Secretary

[Information as requested]

As soon as practicable following request.

s54

Note: Under sections 9(f) and 23 of the Act, the Secretary may request any particulars in relation to the establishment and its function to determine an application. An application may be refused where an applicant fails to provide the required information.

Section 54 of the Act specifies that a person who conducts an establishment must provide the Secretary with any information that in the opinion of the Secretary is required for the purposes of this Act. Failure to do so is an offence under the Act (penalties may apply).


References:

Health Service Establishments Act 2006, as above.

Health Service Establishments Regulations 2011, as above.