Existing facilities
The NHMSFAP awards accreditation to facilities for a period of up to five years.
Existing facilities must undergo a reaccreditation assessment at four years and correct any non-conformances to ensure compliance with standards before the award expires.
Duty to report changes in information and medical staff
The medical director must provide written notice to the CPSBC within 14 days of any change in information previously provided. This includes, without limitation, changes to the name of the facility, business contact information, and appointment of new medical staff.
Every facility must appoint a medical director who is a CPSBC licensee. A facility is not permitted to operate without a medical director.
The NHMSFAP must be informed of any change in medical director.
The medical director must provide written notice to CPSBC within 48 hours if a licensee or regulated health practitioner at the facility resigns or is terminated while under investigation, or has their privileges restricted, suspended or revoked by the facility.
Changes to program, procedure, or technology
The medical director must provide written notice to CPSBC prior to:
- adding a new program, procedure, or technology, or
- revising its authorized program, procedure, or technology.
This includes upgrading or downgrading the class of anesthesia procedures. This may result in an on-site assessment before being granted accreditation.
An accredited facility must obtain written authorization from the NHMSFAP Committee before making a proposed change.
Changes to ownership, closure, and location
The medical director must provide written notice to CPSBC:
- at least 90 days before any proposed change in the ownership of the facility,
- at least 30 days before the proposed closure of the facility and provide information outlining where the facility’s clinical records will be stored together with copies of agreements for access to the clinical records, and
- at least 90 days before any proposed change in location of the facility.
Changes in proposed construction or renovation
If major construction or renovation is planned for an accredited facility, the medical director must provide written notice to CPSBC:
- at least 180 days prior to the start of construction or renovation
- copies of the proposed construction or renovation plans, and
- other information and records the NHMSFAP Committee may request
Report a patient safety incident
The medical director must provide written notice of patient safety incidents to the CPSBC in accordance with the Patient Safety Incident Management standard.
Report safety risk and cease operations
If a facility experiences an event that is a risk to patients, staff or public safety such as, but not limited to, significant structural damage or risk of exposure of hazardous materials because of flood, fire, or accident, the medical director must provide written notice to CPSBC
- within 48 hours of the event, and
- immediately cease operations at the facility until:
- the risk has been abated,
- the facility has passed an inspection to the satisfaction of the registrar, and
- the registrar has provided written authorization to the medical director that the facility may resume operations, with or without limits or conditions.