Draft Rules for the
Bombay Nursing Home Registration Act (Amendment) 2005

Submitted To
Dr. Prakash Doke
Director General of Health Services
Government of Maharashtra

Submitted By
CEHAT, Mumbai
On 5th June 2006

1. Short title, extent and commencement
i. These Rules may be called the Bombay Nursing Home Registration Rules 2006.
ii. They shall come into force from the date of their publication in the Official Gazette.
iii. These rules shall apply to the entire state of Maharashtra.

2. Definitions
In these rules, unless there is anything repugnant in the subject or context,-
i. "The Act" means the Bombay Nursing Home Registration (Amendment)Act, 1949
ii. "Appendix" means appendix to these rules;
iii. "Local Supervisory Authority" means,-
a. In the areas falling within the jurisdiction of the Municipal Corporation - the Health Officer of the concerned Municipal Corporation;
b. In the areas falling within the jurisdiction of the Municipal Council - the Civil Surgeon of the District in which such council is situated
c. In the areas falling within the jurisdiction of the Cantonment - the Health Officer of the Cantonment;
d. In the areas not falling in sub-clauses (i), (ii) and (iii) above, the District Health Officer of the concerned Zilla Parishad,
iv. "The District Nursing Home Registration Board" means a multi-stake holder board, chaired ex-officio by the Collector at district level to guide the Local Supervisory Authority in discharging the functions under this Act.
v. "The State Nursing Home Registration Board" means a multi-stake holder board at the State level to guide the Local Supervisory Authority in discharging the functions under the Rules. The Director General of Health Services will be the ex-officio Chairperson of this board.
vi. "Maternity Homes" means any premise used or intended to be used for the reception of pregnant women or of women in or immediately after childbirth.
vii. "R.M.O or DMO" means the Residential or Duty Medical Officer, with requisite qualifications and registration under Government recognized council.
viii. A Consultant means an expert who has at least one the following post-graduate degrees in the relevant subjects, recognized by the MCI - M.D./ MS/ DM/ MCH degree from a university or equivalent from recognized body OR post-graduate degree from the Diplomate of National Board or equivalent from a recognized body.
ix. "Medical Laboratory means" a laboratory based within a nursing home, where bio-medical, biological, clinical, pathological, biopsy, bacteriological, radiological, microscopic, chemical, genetic investigations or any other diagnostic tests, examinations or analysis or the preparation of cultures, vaccines, serums or other biological or bacteriological products, in connection with the diagnosis or treatment of diseases, are or is usually carried on.
x. "Disease means" a notifiable disease which a Qualified Medical Practitioner is required to notify to the Medical and Health Officer of his area under the law for the time being in force.

3. Functions of Local Supervisory Authority
The Local Supervisory Board shall perform the following functions-
i. To grant, suspend or cancel registration of a nursing home,
ii. To enforce standards prescribed for the nursing home,
iii. To investigate complaints of breach of the provisions of this Act or the Rules made there under and take immediate action,
iv. To supervise the implementation of the provision of the Act and its Rules,
v. To seek and consider the advice of the District Nursing Home Registration Board constituted under the Rule 5 to the Act on complaints for suspension or cancellation of a registration.
vi. To file a report of all decisions taken such as number of registrations, registration renewals, inspections, cancellations and any other matter pertaining to the implementation of the Act, in the District Nursing Home Registration Board meeting.

4. Powers of Local Supervisory Authority
The Local Supervisory Board shall have the following powers-
i. To conduct regular and emergency visits/inspections of the nursing homes.
ii. To summon any individual or organization who is or may be in possession of information relating to the violation of the Act or the Rules. Look into the records of a Nursing home, for the purpose of compliance of the Act.
iii. Issue an inspection warrant in consultation with Chairperson of the District Nursing Home Registration Board for any Nursing Home on receipt of complaints against nursing home.
iv. Any other matter which may be prescribed.

5. District Nursing Home Registration Board composition
The District Nursing Home Registration Board will have 12 members nominated by the State Government out of which not more than 50% will be government officers.
i. Collector of the District or Municipal Commissioner in case of Municipal Corporation will be the ex-officio Chairperson,
ii. Local Supervisory Authority will be the Member Secretary,
iii. A member of local chapter of Indian Medical Association running a Nursing Home
iv. The professor or senior faculty, from Community Medicine Department, preferably from a government medical college
v. One representative from the hospital owners association,
vi. One qualified practitioner running a Nursing Home and registered under the homeopathy council
vii. One qualified practitioner running a Nursing Home and registered under the council of Indian System Of Medicine
viii. One representative from a government Nursing home,
ix. One local representative from the Nurses' Association
x. One representative from the local consumer organization,
xi. One representative from a non governmental organization/network working in the area of health,
xii. One representative from a women's group in the district

6. Functions of the District Nursing Home Registration Board
The District Nursing Home Registration Board will carry out the following functions-
i. To review and monitor the implementation of the Act
ii. To conduct regular meetings of the District Nursing Home Registration Board
iii. The board shall also act as a grievance redressal forum regarding provisions stipulated under this act where it would entertain complaints from patients, Nursing Home owners, consumers, and public.
iv. To communicate to the State Nursing Home Registration Board any modifications required in the rules, especially with reference to minimum requirements (standards) and revision of fees charged.
v. The board shall act as an appellate body for any order passed by the Local Supervisory Authority.
vi. The board can appoint a smaller committee or committees from its members for the performance of various tasks.

7. Functioning of the District Nursing Home Registration Board
i. The meeting of the District Nursing Home Registration Board will be called by the Chairperson with a minimum notice of 15 days and will need a minimum quorum of 50% of members
ii. The intervening period between two meetings shall not exceed 90 days
iii. Emergency meetings could be called by the Chairperson or Local Supervisory Authority or any of the members of the District Nursing Home Registration Board with the sanction of the Chairperson, with a three clear days notice. Emergency meetings can be called on receipt of serious complaints made to the District Nursing Home Registration Board
iv. The constitution of the board should be valid for the period of five years
v. In event of the Chairperson not being available and looking at the urgency of the matter or to adhere to the time limit the Local Supervisory Authority can call for the meeting with 7 clear days notice to all members
vi. The decisions of the District Nursing Home Registration Board will be taken by consensus or by majority vote and in case of equal vote the Chairperson will have the casting vote
vii. All the members appointed to the District Nursing Home Registration Board will be entitled to traveling allowance and daily allowance according to the traveling allowance rules of the State Government, for attending the meeting
viii. All orders and decisions of the board shall be authenticated by the signature of the Chairperson or any member authorized by the Board

8. Temporary association of the person with the District Nursing Home Registration Board(DNHRB) for particular purpose
i. A person, who is not the member of the District Nursing Home Registration Board, whose assistance or advice may be required for the functioning of the board, may be appointed to do so by the District Nursing Home Registration Board.
ii. The person will have right to take part in the discussion relevant for the purpose but shall have no right to vote at a meeting of the board.

9. Disqualification for appointment as members to District Nursing Home Registration Board.
A person shall be disqualified as member of the board if he/she
i. Has been convicted by the court of law for offence of moral turpitude.
ii. Vacates or is dismissed from the position by virtue of which he/she was appointed.
iii. Incase of medical practitioners if they are found guilty by court or the respective medical council of medical negligence and malpractice.

10. Composition of the State Nursing Home Registration Board (SNHRB)
State Nursing Home Registration Board shall constitute no more than 12 members nominated by the Government, with not more than 50% being Government representatives.
i. Director General Health Services, Maharashtra (Ex-officio Chairperson),
ii. Joint Director (Medical) Health Services, (Member Secretary),
iii. 1 representative from the State Indian Medical Association, running a Nursing Home
iv. Secretary or Commissioner in charge of Indian Systems of Medicines and Homeopathy
v. One representative from the Hospital Owners Association,
vi. One qualified practitioner running a Nursing Home and registered under the Homeopathy Council,
vii. One qualified practitioner running a Nursing Home and registered under the council of Indian System Of Medicine,
viii. One representative from Nurses' Association
ix. The professor or senior faculty, from Community Medicine Department, preferably from a government medical college or one representative from a government Nursing home,
x. One representative from a registered state level consumer organization
xi. One representative from a state level NGO or coalition/network of non-government organizations working in the area of health rights
xii. One representative from a state level women's group.

11. Functions of State Nursing Home Registration Board
i. Lay down minimum requirements (standards) or upgrade existing requirements periodically (every 5 years) for different types of nursing homes
ii. If on the day when the meeting is called, quorum is not present, the meeting will be adjourned for 30 minutes and after that if the quorum is still not present the meeting will proceed as if the quorum is present
iii. Suggest revision of fees charged periodically,
iv. To review and monitor the implementation of the Act and recommend changes in the Act and Rules.
v. To act as supervisory body for monitoring the Local Supervisory Authority. This would involve receiving quarterly reports from the District Nursing Home Registration Board and the Local Supervisory Authority, giving directives to the Local Supervisory Authority, acting as apex body at state level and supporting the District Nursing Home Registration Board.
vi The board shall also act as a grievance redressal forum regarding provisions stipulated under this Act where it would entertain complaints from patients, consumers, and public. The State Nursing Home Registration Board would only act on receipt of complaints to the board if the complainant is not satisfied with the decision of the District Nursing Home Registration Board.
vii. Conduct regular meetings of the board.
viii. The State Nursing Home Registration Board will assess its own performance at the end of each year.

12. Functioning of the State Nursing Home Registration Board
i. The meeting of the State Nursing Home Registration Board will be called by the Chairperson with a minimum notice of 15 days and will need a minimum quorum of 50% of members.
ii. The State Nursing Home Registration Board (SNHRB) would meet at least once in three months to transact business.
iii. The intervening period between two meetings shall not exceed 90 days.
iv. Emergency meetings could be called by the Chairperson or Local Supervisory Authority or any of the members of the State Nursing Home Registration Board with the sanction of the chairperson, with a three clear days notice. Emergency meetings can be called on receipt of serious complaints made to the State Nursing Home Registration Board.
v. The constitution of the board should be valid for the period of five years.
vi. The government and non- government members appointed to the state board will be entitled to traveling allowance and daily allowance according to the traveling allowance rules of the state government, for attending the meeting.
vii. All orders and decisions of the board shall be authenticated by the signature of the chairperson or any member authorized by the board.

13. Formation of District and State Nursing Home Registration boards
The District and State Nursing Home Registration Boards would be set up within a stipulated time of two months of publication of rules in the gazette.

14. Temporary association of the person with the board for particular purpose
A person, who is not the member of the State Nursing Home Registration Board (SNHRB), whose assistance or advice may be required for the functioning of the board may be appointed by the SNHRB.

15. Disqualification for appointment as members to State Nursing Home Registration Board
A person shall be disqualified as member of the board if,
i. Has been convicted by the court of law for offence of moral turpitude.
ii. Vacates or is dismissed from the position by virtue of which he/she was appointed.
iii. Incase of medical practitioners if they are found guilty by court or the respective medical council of medical negligence or professional misconduct.

16. Prohibition to carry on nursing home without registration
i. No nursing home shall be operated unless it is duly registered or its registration is duly renewed and the registration in respect thereof has not been cancelled under Section 7.
ii. Provided that nothing in the section shall apply in the case of a nursing home which, is in existence at the date of the commencement of this Act, for a period of three months from such date or if an application for registration is made within that period in accordance with the provisions of rule 16 until such application is finally disposed of.

17. Application of Registration/Renewal of a Nursing home
i. An application for registration, renewal of the registration shall be made to the Local Supervisory Authority),in duplicate, on Form A or B respectively
ii. An application for the renewal of registration shall be made in advance on the prescribed form at least three months before the date on which the registration is to expire and shall be accompanied by the fee prescribed.
iii. For a duplicate certificate an application should be made on a plain paper to the Local Supervisory Authority after paying the amount stipulated by the District Nursing Home Registration Board.
iv. The Local Supervisory Authority or any person authorized on its behalf shall assign an acknowledgement number immediately if delivered at office of the Local Supervisory Authority or within 15 days if received by post.
v. If an applicant submits an application for renewal of registration upto one month from the expiry of the date of registration, such application shall not be treated as a case of renewal of registration and shall be accompanied by up to date fee for original registration.
vi. The intervening period, that is, from the date of expiry of the previous registration up to the date before issue of the new registration, unless the case is under appeal, shall be treated as irregular period of running the Nursing Home by the applicant. Without providing any information the licensing authority can then proceed to seal the Nursing home during that period. The registration can subsequently be obtained only after making a fresh application to the LOCAL SUPERVISORY AUTHORITY after receiving the full payment towards the fee for original registration, unless affected by any order from the District Nursing Home Registration Board or State Nursing Home Registration Board or any other law of the land, under a notice mentioning the irregular period of running incorporated in the body of the registration to be issued.
vii. If the last date of submitting an application is a gazette holiday, the application shall be submitted on the immediate next working day.

18. Procedure for granting registration or renewal of registration
i. The Local Supervisory Authority or authorized representative on receiving the application form A and details must check the application for compliance with all requirements provided.
ii. After the Local Supervisory Authority is satisfied that the applicant has complied with all the requirements as mentioned in the Act and the Rules, the Local Supervisory Authority should ensure inspection of the nursing home by any person or persons appointed by Local Supervisory Authority to verify the adherence to standards prescribed from time to time by the State Nursing Home Registration Board or the Rules framed under the Act.
iii. The Local Supervisory Authority shall dispose of every application received within three months from the date of receipt of application. The Nursing Home would be deemed to have been registered in case there is no response from the Local Supervisory Authority in three months from the date of receipt of the application.
iv. In case of non-compliance to standards found on inspection and refusal of registration the registration fees will not be refunded.

19. No registration for nursing home shall be granted unless the Local Supervisory Authority is satisfied that the applicant and the Nursing home fulfill the following conditions
i. The person supervising the Nursing Home is a qualified and registered medical practitioner.
ii. Application Form A shall be filled in with the particular name of the applicant and not with the name of Registered Firm, Company or Partnership Organization so that responsibility of the Nursing home shall be fixed upon a particular person. So in case of a Firm, Company or a Partnership Organization, the name of a person from amongst the Directors, Partners or Owners, that may be the Applicant, shall be specified through a resolution of the personnel in the management of such Firm, Company or Partnership Organization
iii. The premises and equipments are reasonably suitable and adequate with a stock of emergency and lifesaving drugs.
iv. The nursing home adheres to all the minimum standards as prescribed in the Rules.

20. Validity of registration
A certificate of registration issued will be in force and shall be valid until the 31st day of March of the third year next following the date on which such certificate is issued or renewed, as the case may be.

21. Application fees
The application Form A should be accompanied with the registration fees.

The fees shall be paid by Demand draft in favor of the Local Supervisory Authority.

22. Refusal or Cancellation of registration of nursing home
i. The Local Supervisory Authority may refuse to register the applicant or renew the registration or cancel the registration if it is satisfied that
a. The nursing home is not under the supervisory management of a person who is qualified and registered in the council recognized by the government,
b. The rules and by-laws under the act are not followed,
c. The conditions under which it is registered are being violated
d. Used for purposes which are in violation of any other law which the Nursing Home is expected to comply with or it is found that the Nursing Home is carrying out activities for which it is not registered.(The owner of the Nursing home could be a non-medical person but it should be under the supervisory management of a person who is a qualified and registered medical practitioner.)
ii. If at any time after the nursing home has been registered and granted a registration therefore, the Local Supervisory Authority is satisfied that the terms of registration are not being complied with, may cancel such registration or renewal.
iii. Local Supervisory Authority would reject or cancel the registration only after enquiry and giving opportunity of being heard to the applicant and is satisfied that the applicant has not complied with the requirements of the Act and Rules.
iv. It shall for the reasons to be recorded in writing, reject the application for registration or cancel existing registration and communicate such rejection/ cancellation to the applicant within three months of the date of the application.
v. The Local Supervisory Authority should make a detailed note of observations made and its comments on inspection of the premises of the applicant. It should indicate the applicant about the deficiencies and submit a report to the board.
Unless the deficiencies are gross, a reasonable rectification period of three months be given to the applicant to make-up for the deficiencies pointed out in the Local Supervisory Authority's report. This would be followed by reapplication by the owner and reinspection by the Local Supervisory Authority before a final decision is taken by the Local Supervisory Authority.

23. Redressal for refusal to register or renew or cancellation of registration
i. If the applicant is not satisfied with the decision of the Local Supervisory Authority and wants to seek redressal, the applicant should appeal to the District Nursing Home Registration Board, with the reasons given by the Local Supervisory Authority for refusal of registration, within a period of 30 days from the date of order of the Local Supervisory Authority.
ii. The District Nursing Home Registration Board should render its decision within 90 days of receipt of the appeal, after hearing all the parties as well as getting the nursing home inspected afresh if it is so found necessary.
iii. The applicant, if aggrieved by the decision of the District Nursing Home Registration Board can appeal to the State Nursing Home Registration Board within a period of 30 days from the date of order of the District Nursing Home Registration Board.
Rule 23(i) and 23(ii), would also be applicable to the State Nursing Home Registration Board when it serves as an appellate body for redressal.

24. Inspection of Nursing Home
i. Every nursing home shall offer reasonable facilities for inspection of the place, equipment and records to the Local Supervisory Authority or the District Nursing Home Registration Board or any other officer duly authorized by the Local Supervising Authority or the District Nursing Home Registration Board. This authority may, subject to such general or special orders as may be made by the Local Supervising Authority at all reasonable times enter and inspect any premises which are used, or which that officer has reasonable cause to believe to be used, for the purpose of nursing home and inspect any relevant records, register, document, equipment and article as board may deem necessary for the purpose of the provision of the Act.
ii. The routine inspection will be done at the time of original registration and/or at time of renewal/and if the nature of the work is being changed, after prior intimation. Such routine inspection will be done at a time which is unlikely to disturb /interfere with the treatment of the patient and/or doctor's work.
iii. Non-routine/surprise inspection would be done only when there is a written complaint from a patient or a representative body of patients/citizens alleging non-compliance of the provision of the act. Suo moto inspection can be initiated by the Chairperson of the District Nursing Home Registration Board.
iv. In case of specific complaint, the Local Supervisory Authority ordering inspection must record in writing the reasons for inspection. The Local Supervisory Authority will designate the relevant government medical officer to be in charge of a team of three persons.
v. Person in charge of inspection should be a Medical Doctor, who may be assisted by others.
vi. The decision to do unscheduled inspection should be taken by the Local Supervisory Authority in cases of emergency or a serious complaint. Such emergency inspection along with reasons for the same must be reported to the District Nursing Home Registration Board post facto in the next meeting.
vii. Frivolous /vexatious complaint would be punishable with a fine of Rs.5000/-
viii. Nothing in this Act shall be deemed to deter any such officer to inspect any clinical/ medical record relating to any patient in a Nursing Home maintaining confidentiality provided care is taken that it doesn't come into public domain.
ix. If any person refuses to allow any such officer to enter or inspect any such premises as aforesaid, or to inspect any such records as aforesaid or obstructs any such officer in the execution of his powers under this section, he shall be guilty of an offence under this Act and the registration will be liable to be cancelled or not renewed.

25. Funds for Functioning of Local Supervising Authority
i. The State Government shall provide all the funds required for full and necessary functioning of the Local Supervisory Authority.
ii. Any fees or service charges received under this Act shall be deposited into the fund of the Local Supervising Authority, in a personal ledger account and used only for the implementation of the Act and logistics for the same.
iii. The Local Supervisory Authority should be allocated suitable resources, which would include a secretary and data entry officer, computer and logistic expenses to conduct meetings and carry out it's responsibilities including inspection of Nursing Homes, secretarial work, maintaining records, etc.

26. Offences by Corporations
i. Where a person committing an offence under this Act is a company or other body corporate, government and or an association of persons (whether incorporated or not), every person who at the time of the commission of the offence was a director, manager, secretary, agent or other officer or person specified in the registration form and concerned with the management thereof shall, unless the person proves that the offence was committed without his/her knowledge or consent be deemed to be guilty of such offence.

27. Penalty for non-registration
i. Whoever contravenes any of the provisions of this Act shall, if no other penalty is elsewhere provided in this Act or the Rules for such contravening, on conviction be punished with fine which may extend to five thousand rupees and in the case of a continuing offence to a further fine of fifty rupees in respect of each day on which the offence continues after such conviction up to six months following which the registration of the nursing home would be cancelled.
ii. On finding contravention of provision of Section 3 from the Act, a show cause notice may first be served to the owner and asked to register within a month after paying a fine amounting to 50% of registration fee.
iii. Whoever continues to contravene the provisions of Section 3 from the Act, shall on conviction, be punished with imprisonment which may extend to six months or with fine which may extend to ten thousand rupees or with both.
iv. On further contravention will be liable for punishment as per the act. Contravention of renewal after three years, will also invite a show cause notice, along with a fine as per Section 12 of Act. Failure to renew registration three months after show cause notice will amount to non-registration.
v. It shall be obligatory on the nursing home to inform to the nearest police station about all grievous cases of injury treated in the nursing home and maintain records of all injuries examined and retain it for a period of the complete disposal of the case.

28. A report of Notifiable Diseases will have to be submitted within 48 hours of its diagnosis to the Director Health Services as per prescribed Form of that bureau by the Nursing Home. Notifiable disease register and a record of information given to local authorities must be maintained. A list of notifiable diseases is annexed (See ANNEXURE I).

29. The nursing home shall keep the following registers of the patients received or accommodated or both at the nursing home as an out-door or in-door patient namely -
i. Register of admission and discharge/death of the patient;
ii. Register of expenditure incurred by the patients for treatment in the Nursing home;
iii. Records of treatment, both outpatient and inpatient.
Copies of the above shall be kept in the record room of the nursing home concerned for at least 3 years as per the Indian Medical Council Act 1956 (Professional Ethics And Regulations, 2002) or in accordance to any other relevant act in force at the time. The information in this regard shall be supplied to the registration authority, as and when required.

30. The nursing home shall,
Within 24 hours of the death of any patient or any child born to a patient at the nursing home send to the local Registrar of Birth and Death, in this behalf a notice in writing by registered post or through a messenger stating
a. The date and hour of birth,
b. The date and hour of death,
c. If a medical certificate of the cause of death has been signed by a registered medical practitioner the name and registration number of such medical practitioner, or,
If such certificate has not been given or obtained, the cause of death to the best of knowledge.
If an inquest is held in respect of any such death, send a notice in writing by registered post or in an equally suitable manner within 24 hours of the conclusion thereof to such authorities as may be prescribed by the Director of Health Services, Maharashtra, stating the date of inquest and the cause of death as found by the Coroner or Jury thereat.
Maintain a separate register of all deaths occurring in the nursing home or of patients brought dead.
Maintain a separate register of all births occurring in the nursing home.

31. Every nursing home shall maintain an inspection book and a complaint register (for the patients party), which shall be produced before the inspecting officer/s as and when required.

32. The Nursing Home shall adhere to the following minimum standards regarding the Functional Programme of the Nursing Home.
I. Emergency First Aid - The basic minimum functions provided by a nursing home should include Emergency First Aid.
i. Emergency first aid is care provided initially to minimize potential for further injury during transport to referral service. The Nursing Home will provide assistance in transport, with all medical records (including X-rays, investigation reports, clinical notes) to the next doctor who will be treating the patient.
ii. In case of Discharge against medical advice also, it is expected that patient records, including investigation reports and clinical notes will be handed over to the patient.
iii. Emergency first aid includes airway maintenance, Intra Venous drip, wound care and dressing, haemostasis, shock management, splint, severe pain management and starting of nasal O2.
iv. Emergency first aid services should be provided to all patients in need of them and assistance in arrangements made to transport them irrespective of their capacity to pay.
v. A nursing home which claims to provide Emergency Cardiology Services should possess intensive care facilities.
II. All emergency patients attending a nursing home, must be attended primarily to save the life without considering the financial capability of the patient, and then, may be referred with relevant medical reports about the ailments, as early as possible to the nearest suitable referral unit. No advance payment may be demanded for such emergency care. It is also the responsibility of the patient or his/her party to pay all the dues to the nursing home. Non-payment of dues cannot become ground for refusal of emergency care for that person or for future cases.
III. Define disciplines of treatment: When the Nursing Home applies for registration, they should broadly define the disciplines of treatment offered and the facilities should match these.
IV. Type of facilities: The type of facilities provided at the Nursing Home, e.g. Emergency Cardiac Care Unit, Orthopedic and Trauma Care Hospital etc, should be displayed prominently. (Detailed list of minimum services should be made available to the patients)
V. Declare routinely offered facilities: The nursing home should declare on its sign boards / notice boards / informational literature about the nature of facilities routinely offered and should not ordinarily treat those patients for which facilities are not routinely available in that nursing home.
i. Regarding General Surgical Services: A general surgical nursing home should declare the range of surgical services provided there and adhere to the same.
ii. In case a surgical nursing home provides 'Emergency General Surgical Facilities', this should be clearly mentioned in the functional programme of the nursing home as well as in any information brochure put up by the nursing home. In such nursing homes emergency care for cases of acute abdomen, strangulated hernia, torsion testis, etc. would be provided. For this purpose access to X-ray facilities, Blood Bank and Ultrasonography should be available.
iii. Minor surgery should be performed only in standard-sized theatres provided with the usual level of lighting, ventilation, equipment and staffing. Such surgery may become major ones due to unforeseen circumstances (e.g. Rupture of uterus during termination of pregnancy).
iv. Regarding Maternity Facilities: All nursing homes providing maternity facilities (with and without OT) should provide basic obstetric and neonatal facilities. Every maternity home should have a working arrangement with nearby blood banks and all due care be taken to anticipate the blood transfusions and arrange for the same. Also ultrasonography facilities should be available within one hour. The functional programme of the nursing home should mention nearest availability of neonatal intensive care facilities.

33. Regarding other disciplines:
Disciplines like Dentistry, Ophthalmology, ENT, Orthopedics etc., and diagnostic facilities like ultrasonography, C.T. scan, etc. if provided by a nursing home would require design, equipment, space as well as personnel according to minimum standards worked out by committees under the rules to the act.

34. Pathology laboratory:
The Nursing Home may or may not have a Pathology laboratory. All Pathology Laboratories within the Nursing Home will be subject to Minimum Standards as outlined from time to time by committees formed under rules of this act.

35. Radiology: The Nursing Home may or may not have an x-ray facility. In nursing homes providing emergency surgical/ trauma facilities following X-ray services should be made available, either by contract with nearby radiology facility or by portable facility- X ray chest, abdomen, pelvis, femur and skull. In case of radiotherapy or nuclear medicine facilities are provided, guidelines by local statutory bodies should be followed.

36. Co-operation in the National Health Programmes and as per notifiable diseases act/epidemic act.
a. All medical personnel in nursing homes should be aware of the various national programmes and notifiable diseases for control of these diseases and should integrate with programmes/ activities for the same. For e.g., on detecting a case of Tuberculosis, information regarding the same must be directed to Medical Officer in-charge of the local PHC/UHC where the survey, education and treatment centre of the Revised National Tuberculosis Control Programme is situated.
b. Nursing homes should maintain records of all cases of notifiable diseases and concerned authorities should be intimated within 48 hrs of diagnosis to the concerned authorities.

37. Patient Transport Services:
All nursing homes should have access to patient transport services within half an hour.

38. Medical Records:
Maintenance of medical records of all patients attending the nursing home is of utmost importance.
a. The "OPD paper" should be maintained in duplicate, one for patient and one for the hospital. OPD paper should contain name of doctor and other details like qualifications, area of specialization, contact details, etc., It should also contain patient's name, age, occupation, chief complaints, diagnosis, and relevant clinical details and treatment given and advised. A separate prescription should be available for the medication that has been advised. Records will be retained as per the existing laws.
b. The OPD paper should be given to the patient along with X-rays and all investigation reports. Nursing homes should maintain a copy of the OPD paper. All indoor papers should be complete, i.e. clinical notes (as detailed above) should be written along with whatever treatment has been given during the admission and reports of investigation carried out.
c. In case of operated patients detailed operation and preanesthesia and anesthesia notes should be written.
d. In case of Maternity Services, labour room notes should be complete.
e. On discharge or on transfer a discharge summary should be given as outlined above. Also all X-rays and investigation reports should be handed over to the patient. In Discharge Against Medical Advise too, patient records, reports of diagnostic tests and other relevant documents should be handed over to patient.
f. Duplicate copies must be maintained of all certificates, such as Birth, Death, and Age Certification, issued by the nursing home.

39. Universal biosafety guidelines and bio-medical waste treatment and disposal rules
shall be followed by all nursing homes to protect environment, public and personnel employed from occupation related diseases as per the Bio-Medical Waste (Management and Handling) Rules, 1998. (See ANNEXURE II)

40. The general cleanliness of the premises including sanitary arrangement, furniture and Equipments must be properly maintained along with 24 hours adequate potable water supply for the beneficiaries.

41. Engineering and Environmental
standards for the Nursing Home should be followed according to standards set by local bodies and as prescribed in Annexure V.

42. Minimum Standards Regarding Nursing Homes:
The State Nursing Home Registration Board should appoint committees with relevant experts to decide on minimum standards regarding Physical Space, Human Resources, Infrastructure, Clinical Standards and Facilities for 30 bedded, 50 bedded, 100 bedded, single and multiple specialty hospitals, which should then be incorporated in the rules as ANNEXURE III and serve as standards for purposes of registration. The standards for 10 bedded General, Surgical and Maternity hospital may be seen in ANNEXURE III The committees may predominantly have three doctors from the relevant specialty, one of whom owns a private nursing home and is member of the hospital owners association, one is a doctor associated with a network of health NGOs or consumer groups, and one is from the government medical hospital, along with one government official and one representative from a state level NGO. Standards should be worked out according to those found in ANNEXURE III.

43. Fulfillment of minimum standards with regard to equipments/drugs/medicines listed:
The fulfillment of these standards is absolutely necessary for purposes of patient care. However for purposes of registration, where a list of essentials/ drugs/ medicines/ equipments is prescribed, compliance with 80% of total prescribed will be sufficient.

44. Medical personnel:
A Nursing Home would have Consultant/s from the relevant discipline and Duty Medical Officer/s The DMO should have completed one year of internship. Responsibility regarding clinical decisions, procedures etc. is that of the consultant and not the DMO. The DMO must be able to see the patient within five to ten minutes. A formal training programme should be worked out for DMO's by the concerned consultant.

45. Nursing staff:
The clause of employment of qualified nurses would be implemented in a phased manner, in the following manner -
Municipal Corporations - Within one year of rules coming into force
Municipal Councils - Within two years of rules coming into force
Gram Panchayats - Within three years of rules coming into force.
The implementation of this clause will be reviewed at the end of five years.

46. Education of Nurses:
With regard to education of nurses, two categories of qualified nurses will be recognized.
a. Qualified Nurses - Nurses registered with the Nursing Council would be included here.
b. Trained Nurses - All those who have taken a minimum of six months nursing training in any government approved institution would be considered trained nurses, and eligible to be employed as nurses in the Nursing Homes.

47. Minimum number of nurses:
One qualified/trained nurse for 10 beds or part there of on every shift and if on different floors then in same proportion on different floors. Taking into account the weekly offs and leaves, this would mean totally more than 3 nurses employed per 10 beds.

48. Adequate efforts need to be taken to procure qualified nurses. For the time being nurses from all courses, of a minimum duration of six months, meant for training nurses, may be considered qualified nurses. Seats in government colleges for Nursing need to be increased, as also relevant courses for Nursing need to be introduced to bridge the gap.

49. Training for Nursing Aids:
For nursing aides with no formal qualification to be a nurse but with minimum three year's experience currently working in a nursing home, the Nursing Home may send them for a formal nurses' training programme recognized by the government, government approved Council or Open University.

50. Nursing aids:
One ayahbai or one ward boy for every 10 beds in three shifts. Taking into account the weekly offs and leaves, this would mean totally more than 3 nursing aids/ ward boys employed per 10 beds. Ayahbai/ward boy/sweeper need to undergo training in nursing care skills like measuring of urine output, assisting in inserting an I.V. line, transferring patients from trolleys to beds, etc.,

51. Other Paramedical staff:
Availability of paramedical staff should be adequate to satisfy basic functions as specified in the functional program.

52. Engineering staff:
a. One plumber (To be available on call)
b. One electrician (on call)

53. Administrative and Ancillary staff:
Receptionist should be available during OPD hours or as specified in relevant minimum standards.

54. All nursing homes must adopt the Standard Charter of Patient's Rights (displayed at a prominent place), observe it and orient their staff for the same. It should contain all relevant provisions contained in these rules.

55. Patients have a right to access heath care.
a. All emergency patients attending a nursing home, must be attended primarily to save the life without considering the financial capability of the patient, and then, may be referred with suitable medical report about the ailments, as early as possible to the nearest Government hospital if necessary. No advance payment may be demanded for such emergency care. It is also the responsibility of the patient or his/her party to pay all the dues to the nursing home. Non payment of dues cannot become ground for refusal of emergency care for that person or for future cases.
b. No person suffering from HIV may be denied care only on the basis of the HIV status, provided the curative or diagnostic care is available at the NURSING HOME. Not having a Voluntary Testing and Counseling Centre cannot become grounds to refuse care.
c. All patients have a right to access health care appropriate to the level of the nursing home. This care should be provided without any discrimination on the basis of gender, religion, caste/ethnicity, social background, language etc.,
d. In times of epidemics or communal riots, every citizen has the right to access available health care facility.

56. Patients have a right to information.
a. All charges of the Nursing Home, like bed charges, consultation charges, operation charges, charges for diagnostic tests (If Nursing Home has a diagnostic center) must be displayed.
b. Where the Nursing Home provides diagnostic services, and employs consultants or full time specialists or MBBS, as the case may be, in various departments, it must display in a prominent place the time of the OPD of the consultant / full time specialist / MBBS .If the consultant /full time specialist / MBBS is not available on 2 successive occasions during the stipulated time, necessary measures will be taken by the Local Supervisory Authority. The consultant / full time specialist / MBBS, as the case may be, should put their signature and date in the report issued by the diagnosis unit
c. The nursing home should inform the patients and families about its services and how to access those services.
d. An information booklet in the local language must be provided to the beneficiaries. The nursing home is to offer an estimate of expenditure likely to be incurred to the in-door patients either for the whole package for investigations, treatment and management or by furnishing item-wise estimate for investigations, treatment or management, separately.
e. Information about the Local Supervisory Authority and Nursing home Registration Board, within the area of the Nursing Home, along with the respective name and telephone number, must be displayed prominently in the nursing home.
f. When a patient is admitted to a nursing home, he/she shall be informed about the doctor(s) under the care as well as the hospital rules and the procedures of stay.
g. The patient at the time of discharging from the nursing home should be provided with discharge card which should mention the diagnosis, the medical treatment given and the state of his/her health.
h. If the patient chooses, he/she may seek a second medical opinion as to such diagnosis, treatment or state of health. All relevant reports must be made available to facilitate second opinion.
i. All charges incurred by the patient at any stage of medical care, and all payments made by the patient should be supported by a detailed statement/receipt, which should be provided with or without a request made by the patient.
j. The patient shall be provided with a copy of the diagnosis, the medical treatment at the time of discharge and the state of his/her health, and if he/she so chooses, he/she may seek a second medical opinion as to such diagnosis, treatment or state of health. All relevant reports must be made available to facilitate second opinion.
k. The patient must have an access to his / her clinical records at all reasonable times during admission to NH. A photocopy of the same should be available within 24 hrs when admitted to NH or within 72 hrs of making an application by patient or legal heir after discharge or death, after photocopy charges.

57. Patient's have right to autonomy and participation in decision making
a. The patient/designated person shall be given relevant information about the state of his/her health, advantages of every alternative procedure and treatment and the possible effects of the non use of medical treatment. Such information may be withheld from the patient only in exceptional circumstances, when there is sound reason to believe that such information could cause serious harm.
b. Any treatment or operation, including procedures like surgery, anesthesia, blood and blood product transfusions and any invasive / high risk procedures / treatment shall be provided or performed only after informed consent is received from the patient.
c. Such informed consent is to be taken in writing (language understood by patient, excepting emergencies), by the patient signing on the consent form which is to clearly state the nature of the treatment, operation or procedure to be undertaken.
d. Consent should be the responsibility of the doctor, and should be taken by the treating doctor well in advance. (Refer to IPC) Consent is to be treated as informed consent only if it is given after the patient is given information on the benefits, risks, discomforts, side-effects, and alternatives of the treatment or procedure in a language and manner in which the patient is able to understand it. This information must be given in advance (except in emergency situations or exceptional circumstances) to enable the patient to actively participate in the therapeutic choices regarding his or her state of health.
e. In the case of a minor, the consent of a parent or guardian should be taken. The health care provider may request the presence of a person or persons of patient's choice during the procedure of granting consent.
f. Only in cases where the patient lacks the capacity to give or withhold consent, and where a qualified medical doctor determines that the treatment or other procedure is urgently necessary in order to prevent immediate or imminent harm, may treatment be given without consent, unless it is obvious that under the circumstances he/she would have reasonably objected.
g. Patients have the right to participate in decision making regarding the course of their treatment.
h. Patients have the right to buy prescribed drugs from any medical store/ and of any standard brand of the same medicine, from any pharmaceutical shop.

58. Patients have the right to adequate care and protection
It is the duty of the doctor to devote adequate time to their patients, including specific time dedicated to providing information.
HIV positive cases cannot be denied care solely on the basis of this status. Non-availability of a Voluntary Counseling and Testing Centre cannot be grounds to refuse care (NACO).
Patients have the right to be appropriately referred, or to seek a second opinion on request, from a health provider of one's choice.

59. Patient has a right to personal dignity and privacy
a. Patient has a right to personal dignity and privacy during examination, procedures and treatment.
b. HIV testing may be done only after counseling and obtaining consent.
c. No unnecessary testing, including for HIV status before procedures or any other treatment will be done.
d. The Nursing Home must protect and maintain in a confidential manner, data and information relating to an individual's state of health and medical/surgical treatments to which he or she is subjected. Patient has the right to maintain confidentiality of reports and information even from intimate partners and close family members.
e. Such information is to be disclosed only on the request of the patient to make available details of his/her relevant records, to himself or any person or doctor so designated by him.
f. Medical or surgical treatments (diagnostic exams, specialist visits, medications, etc.), must take place in an appropriate environment and in the presence of only those who absolutely need to be there (unless the patient has explicitly given consent or made a request).
g. Any examination, treatment or management of female patients must be conducted in the presence of an employed female attendant/female nurse or relative/friend
h. Patients shall be interviewed and examined in surroundings designed to ensure reasonable privacy and shall have the right to be chaperoned during any physical examination or treatment, except in cases of emergency where such conditions may not be possible.

60. A functional grievance redressal mechanism must be set up at the nursing home and the information of the procedure should be given to the patient.

61. Adult and conscious patient has the right to refuse treatment if so allowed under the existing Laws.

62. Any Nursing Homes undertaking clinical research must ensure that the following conditions are fulfilled:
a. Any nursing home that is undertaking clinical research must ensure that it is done in compliance with ICMR guidelines.
b. Patient's informed consent is obtained before involving them in any clinical research protocols.
c. Patients are informed of their right to withdraw from the clinical research at any stage and also of the consequences (if any) of such withdrawal.

63. Written polices on patients rights must be available, disseminated or made visible to the patient, in the patient's own language.

64. The hospital should have a policy for personal possessions of the patients.