Notices > Policy Guidelines for the Licensing of Residential and/or Day Care Facilities for Persons with Mental Illness and/or Severe or Profound Intellectual Disability > 17. Clinical Governance and Clinical Care

17.1	The proprietor /manager must create and maintain a system of health records of the mental health care users concerned in accordance with the requirements of the National Health Act, 2003 (Act No. 61 of 2003).

17.2	The records must include the following information in respect of a mental health care user:

(a)	Biographical data of the user;

(b)	Identification document of the user;

(c)	Contact information of the user and his or her next of kin;

(d)	Information relating to examination and health care interventions of the user; and

(e)	Periodic reviews and reports in accordance with the Act.

17.3	In the event that a user is discharged from the facility, the manager must issue a discharge report to mental health care users in accordance with the Act.

17.4

The proprietor and manager may not disclose any information which a mental health care user at the facility is entitled to keep confidential in terms of any law except if it is in accordance with the Act, the National Health Act, 2003 (Act No. 61 of 2003), and the Protection of Personal Information Act, 2013 (Act No. 4 of 2013).

17.5	The proprietor /manager must compile daily statistics and submit a report containing those statistics to the relevant provincial department of Health on a monthly basis.

17.6	The proprietor /manager must report abscondments, deaths, notifiable diseases and adverse events in accordance with applicable legislation.

17.7

The proprietor /manager must establish and maintain clinical assessment and treatment services management systems, facilities, structures and operational procedures that give effect to appropriate medical, psychiatric, nursing, psychological and occupational therapy management, as per acceptable clinical practice, as well as to national and provincial policies and guidelines regarding standard treatment guidelines and essential medications appropriate for the level of service.

17.8	The proprietor /manager must ensure that the clinical management of a mental health care user's condition, whether in a maintenance, acute or emergency care phase, occurs in terms of the user's capacity of making informed decisions about his or her mental health care as prescribed in the Act.

17.9	The proprietor /manager must establish and maintain any other system, structure and procedure to manage clinical risk as prescribed in the Norms and Standards Regulations Applicable to Different Categories of Health Establishments.

17.10

The proprietor /manager must maintain an environment which minimizes the risk of disease outbreaks and the transmission of infection to mental health care users, health care personnel and visitors.

17.11

The Facility must manage waste as prescribed in the Environmental Health Norms and Standards.

17.12

The facility must manage deaths in accordance with the Birth and Deaths Registration Act, 1992, (Act No. 51 of 1992).

17.13

Mental health care users who are on psychotropic drugs and other medications for co- morbid conditions should be monitored for side -effects.

17.14

Only appropriately trained and licensed staff members are allowed to administer medication.

17.15

Where the User is incapable of managing their medication, all medicines are stored according to package instructions in a lockable cupboard and keys are kept by a responsible person.

17.16

The facility should have appropriate rehabilitation, stimulation, skills development and recreational programmes for the users.