Operation of Approved Hospitals Regulation

(Consolidated up to 294/2025) ALBERTA REGULATION 211/2025 Provincial Health Agencies Act OPERATION OF APPROVED HOSPITALS REGULATION Table of Contents 1 Definitions 2 Review by provincial health agency Designation and Governance of Approved Hospitals 3 Designation of approved hospitals 4 Meetings of members of hospital operators 5 Meeting minutes 6 Contents of general bylaws, rules and service contracts Approved Hospital Facilities 7 Approval of acquisition or disposal of land, facilities or equipment 8 Approval of construction, alteration or renovation 9 Approval of upgrading 10 Approval of plans, etc. 11 Approval of changes 12 Compliance with legislation, codes and standards Operation of Approved Hospitals 13 Capacity of approved hospitals with one health services sector 14 Capacity of approved hospitals with multiple health services sectors 15 Changes in capacity 16 Approval to introduce, change or terminate services 17 Approval to introduce, change or terminate education and training programs 18 Accreditation of hospital operators Hospital Staff 19 Procedures in medical staff bylaws 20 Appointment of medical staff 21 Hospital privileges 22 Fluoroscopy privileges 23 Meetings of medical and professional staff 24 Health examinations and vaccinations 25 Notice to regulatory body 26 Expenses incurred in transfers Admissions 27 Compliance with admissions provisions 28 Admission of patients 29 Persons not requiring hospital services Standards of Hospital Services 30 Clinical policies and procedures 31 Nursing coverage 32 Operating room management 33 Assistance at major surgery 34 Records relating to surgery 35 Anaesthetic services 36 Surgical anaesthetics 37 Deferral or relocation of surgery 38 Precautions re foreign bodies 39 Examination of removed tissues 40 Taking blood for transfusion and crossmatching 41 Syphilis testing of newborns 42 Salmonella reports 43 Disposal of needles and syringes 44 Autopsies 45 Removal of bodies Information and Records Management 46 Hospital service records 47 Verification of orders for treatment 48 Retention of hospital service records 49 Retention of Health Facilities Act records, etc. 50 Storage of records, etc. Financial Matters 50.1 Discretionary and offset revenue 50.2 Approved program operating expenditures 50.3 Approved program operating surpluses and discretionary revenue 50.4 Approved program operating deficits 50.5 Capital project costs 50.6 Interest on capital project funding Offences 51 Offences Expiry and Coming into Force 52 Expiry 53 Coming into force Definitions 1 In this Regulation, (a) “approved program operating deficit” means the excess of approved program operating expenditures over operating revenue in a fiscal year; (b) “approved program operating expenditures” means approved program operating expenditures as determined under section 50.2; (c) “approved program operating surplus” means the excess of operating revenue over approved program operating expenditures in a fiscal year; (d) “attending member” means an attending physician of a patient or an attending member of the professional staff of a patient; (e) “discretionary revenue” means discretionary revenue as determined under section 50.1(2); (f) “fiscal year” means the period from April 1 to the following March 31; (g) “foundation” means (i) a health foundation as defined in the Health and Hospital Foundations Regulation , (ii) a hospital foundation as defined in the Health and Hospital Foundations Regulation , or (iii) a foundation or other corporation with respect to which an exemption has been granted under section 46 of the Health and Hospital Foundations Regulation ; (h) “hospital service records” means the records referred to in section 1.9769992 of the Act; (i) “in‑patient” means a patient referred to in section 1.9761(k)(i) of the Act; (j) “offset revenue” means offset revenue as determined under section 50.1(4); (k) “operating grants” means grants made by the sector Minister with respect to approved program operating expenditures; (l) “operating revenue” means operating grants made for the fiscal year and offset revenue earned for the fiscal year but does not include discretionary revenue; (m) “out‑patient” means a patient referred to in section 1.9761(k)(ii) of the Act; (n) “private room” means a room with not more than one bed; (o) “semi‑private room” means a room with 2 beds; (p) “standard ward” means a room with more than 2 beds; (q) “upgrading” means work carried out for the purposes of ensuring compliance with the requirements in the applicable Acts, regulations, codes and standards that must be met for a health services sector in an approved hospital to operate. AR 211/2025 s1;294/2025 Review by provincial health agency 2 (1) Subject to subsection (2), if a provision of this Regulation requires a hospital operator to obtain the sector Minister’s approval of an activity proposed by the hospital operator, the sector Minister may, before giving approval, require that the proposed activity be reviewed and approved by the provincial health agency. (2) Subsection (1) does not apply with respect to an activity proposed by a hospital operator that is a provincial health agency. Designation and Governance of Approved Hospitals Designation of approved hospitals 3 For the purposes of section 1.9763 of the Act, the oversight Minister may designate a hospital as an approved hospital if the oversight Minister is satisfied that the hospital delivers or will deliver hospital services of a sufficient standard to qualify it as an approved hospital. Meetings of members of hospital operators 4 A hospital operator other than a provincial health agency or provincial health corporation may, by resolution, establish (a) requirements relating to attendance by members of the hospital operator at meetings of the hospital operator, (b) the amount payable to members of the hospital operator for attendance at meetings of the hospital operator that the hospital operator considers necessary for the management and operation of the health services sector in the approved hospital or for the discharge of the hospital operator’s responsibilities, and (c) the amount payable to members of the hospital operator for necessary travel and subsistence expenses incurred in the management and operation of the health services sector in the approved hospital. Meeting minutes 5 A hospital operator other than a provincial health agency or a provincial health corporation must provide a copy of the minutes of each meeting of the hospital operator to the sector Minister within 3 weeks after the meeting at which the minutes were adopted. Contents of general bylaws, rules and service contracts 6 A hospital operator must ensure that the general bylaws, the rules made under the general bylaws or any service contracts address the following matters with respect to the health services sector in the approved hospital: (a) the establishment of a system to clearly identify various classifications of the medical staff and professional staff; (b) the regular attendance to patients by an attending member and procedures respecting the naming of an alternate member of the medical staff or professional staff who may be called when the attending member is not available; (c) emergency call rosters of the medical staff and professional staff; (d) the management of the timing and rate of admission of patients, other than emergency admissions; (e) routine stop orders on antibiotics, narcotics, anticoagulants, sedatives and other potentially dangerous drugs; (f) the posting of no smoking signs in rooms where oxygen is used; (g) pre‑natal antibody screening and blood grouping; (h) the screening of newborns for treatable conditions; (i) procedures respecting the notification of the medical officer of health of all cases of notifiable diseases set out in the Communicable Diseases Regulation (AR 238/85); (j) procedures respecting the handling of infections and methods of isolation; (k) the establishment of an infection control committee and its powers, duties, responsibilities and functions; (l) post‑mortem care; (m) requirements respecting the completion of hospital service records within a minimum period after a patient’s transfer or discharge from the health services sector in the approved hospital and the specific actions to be taken if the requirements are not met; (n) any other matters the hospital operator considers necessary. Approved Hospital Facilities Approval of acquisition or disposal of land, facilities or equipment 7 (1) A hospital operator other than a provincial health agency or provincial health corporation must not (a) purchase or otherwise acquire land for purposes related to the health services sector in the approved hospital without the sector Minister’s approval of the general location and the specific site, or (b) sell, lease or otherwise dispose of land or facilities in the health services sector in the approved hospital without the sector Minister’s approval. (2) A hospital operator that is a provincial health agency or provincial health corporation must not dispose of by lease any land or facilities in the health services sector in the approved hospital without the sector Minister’s approval. (3) A hospital operator must not dispose of equipment of the health services sector in the approved hospital except in accordance with the policy established by the sector Minister. (4) For greater certainty, the Real Property Governance Act applies to a hospital operator that is a provincial health agency or provincial health corporation. Approval of construction, alteration or renovation 8 (1) Subject to subsection (2), a hospital operator must not undertake or authorize any construction, alteration or renovation of the facilities in the health services sector in the approved hospital without the sector Minister’s approval. (2) Subsection (1) does not apply with respect to normal or emergency repair work. Approval of upgrading 9 (1) A hospital operator must not undertake or authorize any upgrading of the facilities in the health services sector in the approved hospital without the sector Minister’s approval. (2) The sector Minister must consider the following factors when determining whether to approve the upgrading of the facilities in a health services sector in an approved hospital: (a) the utilization of the hospital services delivered in the health services sector in the approved hospital; (b) the condition of the facilities; (c) the need for hospital services in the health services sector in the approved hospital, as determined by the oversight Minister and sector Minister. Approval of plans, etc. 10 (1) A hospital operator must, in accordance with the procedures established by the sector Minister, submit to the sector Minister for approval all plans for the proposed construction, alteration, renovation or upgrading of the facilities in the health services sector in the approved hospital. (2) A hospital operator must not enter into an agreement for the construction, alteration, renovation or upgrading of the facilities in the health services sector in the approved hospital before the sector Minister approves the final plans, specifications and contract documents, including tenders, for the construction, alteration, renovation or upgrading. (3) Subsection (2) does not apply with respect to the construction, alteration, renovation or upgrading of the facilities in the health services sector in an approved hospital if (a) the hospital operator and the sector Minister enter into an agreement setting out the responsibilities of each party with respect to the construction, alteration, renovation or upgrading of the facilities, and (b) the sector Minister approves the hospital operator’s use of a contract management system in respect of the construction, alteration, renovation or upgrading of the facilities. Approval of changes 11 A hospital operator must not, without the sector Minister’s approval, make changes to (a) a construction, alteration, renovation or upgrading approved by the sector Minister, or (b) the final plans, specifications or contract documents, including tenders, approved by the sector Minister. Compliance with legislation, codes and standards 12 (1) A hospital operator must ensure that the construction, alteration, renovation or upgrading of the facilities in the health services sector in the approved hospital is carried out in compliance with (a) applicable building codes and standards and related Acts or regulations, (b) the minimum standards of basic construction for approved hospitals as determined by the Minister responsible for the Real Property Governance Act , and (c) the planning requirements approved by the oversight Minister. (2) A hospital operator must ensure that the facilities in the health services sector in the approved hospital comply with the applicable Acts, regulations, codes and standards during and after construction, alteration, renovation or upgrading. Operation of Approved Hospitals Capacity of approved hospitals with one health services sector 13 (1) In an approved hospital with one health services sector, (a) the oversight Minister must establish the official rated capacity of the approved hospital, and (b) the sector Minister must establish the rated bed capacity of the health services sector in the approved hospital. (2) The rated bed capacity of the health services sector in the approved hospital must not exceed the official rated capacity of the approved hospital. Capacity of approved hospitals with multiple health services sectors 14 (1) In an approved hospital with more than one health services sector, (a) the oversight Minister must, after consulting with the sector Minister for each health services sector in the approved hospital, establish the official rated capacity of the approved hospital, and (b) the sector Minister for each health services sector in the approved hospital must, after consulting with the oversight Minister, establish the rated bed capacity of the health services sector for which the sector Minister is responsible. (2) The rated bed capacity of a health services sector in the approved hospital, when combined with the rated bed capacity of the other health services sectors in the approved hospital, must not exceed the official rated capacity of the approved hospital. Changes in capacity 15 (1) A hospital operator must not, without the sector Minister’s approval, change the rated bed capacity of the health services sector in the approved hospital if the change in the rated bed capacity is intended to continue for more than 60 days. (2) The sector Minister must not approve a proposed change under subsection (1) with respect to (a) an approved hospital with one health services sector if that change would cause the number of beds in the health services sector in the approved hospital to exceed the official rated capacity of the approved hospital established by the oversight Minister under section 13(1)(a), and (b) an approved hospital with more than one health services sector if that change would, when combined with the rated bed capacity of the other health services sectors in the approved hospital, exceed the official rated capacity of the approved hospital established by the oversight Minister under section 14(1)(a). Approval to introduce, change or terminate services 16 A hospital operator must not, without the sector Minister’s approval, (a) introduce (i) a new hospital service, or (ii) a new service related to the management and operation of the health services sector in the approved hospital, or (b) make a major change to or terminate (i) an existing hospital service, or (ii) an existing service related to the management and operation of the health services sector in the approved hospital. Approval to introduce, change or terminate education and training programs 17 (1) In this section, (a) “education and training program” means a program operated or provided by a hospital operator in the health services sector in the approved hospital for the education and training of hospital staff or students associated with the health services sector in the approved hospital but does not include on‑the‑job training for hospital staff; (b) “relevant Minister” means (i) the sector Minister, with respect to an education and training program not directly associated with a hospital‑based nursing education program, and (ii) the Minister responsible for the Post‑secondary Learning Act , with respect to an education and training program directly associated with a hospital‑based nursing education program. (2) A hospital operator must not, without the approval of the relevant Minister, (a) introduce a new education and training program, or (b) make a major change to or terminate an existing education and training program. Accreditation of hospital operators 18 A hospital operator must not operate a health services sector in an approved hospital or deliver hospital services in a health services sector in an approved hospital unless it holds a valid certificate of accreditation from an accrediting body, as determined by the oversight Minister, with respect to the health services sector in the approved hospital. Hospital Staff Procedures in medical staff bylaws 19 A hospital operator and the medical staff must carry out the provisions of sections 20 to 22 in accordance with the procedures set out in or established under the medical staff bylaws. Appointment of medical staff 20 (1) A hospital operator may appoint or reappoint a member of the medical staff on a permanent basis or for a specified term. (2) A hospital operator may review, suspend or terminate the appointment of a member of the medical staff. (3) The medical staff must be involved in the procedures for the establishment of medical staff bylaws and appointments to medical staff. Hospital privileges 21 (1) A hospital operator must delineate the hospital privileges granted to each member of the medical staff, taking into consideration (a) the member’s training and ability, (b) the circumstances, environment and context in which the member practices, (c) the training, level of experience and availability of other hospital staff, (d) the hospital services delivered in the health services sector in the approved hospital, (e) the need for the types of hospital services delivered in the health services sector in the approved hospital and for the medical staff who deliver those types of hospital services, (f) the capacity of the hospital staff and facilities, equipment and resources of the health services sector in the approved hospital, and (g) the location of the approved hospital. (2) A hospital operator may vary, suspend or terminate the hospital privileges granted to a member of the medical staff. (3) Only a member of the medical staff may be granted hospital privileges. (4) A physician has no hospital privileges in a health services sector in an approved hospital unless appointed to the medical staff. Fluoroscopy privileges 22 (1) I n an emergency situation where no specialist radiologist is available within a reasonable time, a member of the medical staff or professional staff may request that a member of the medical staff who is not a specialist radiologist carry out a fluoroscopy procedure. (2) A hospital operator must not grant hospital privileges to carry out fluoroscopy in the situation described in subsection (1) to a member of the medical staff who is not a specialist radiologist unless that member is approved by the College of Physicians and Surgeons of Alberta to carry out fluoroscopy. (3) The member of the medical staff or professional staff who makes a request under subsection (1) must accept full professional responsibility for the procedure. Meetings of medical and professional staff 23 (1) A hospital operator must ensure that the medical staff and professional staff meet regularly for the purposes of reviewing and evaluating the delivery of hospital services in the health services sector in the approved hospital. (2) The hospital operator must determine the composition and frequency of the meetings. (3) The medical staff or professional staff, as applicable, must provide the administrator with a copy of the minutes of a meeting within 7 days after the meeting at which the minutes were adopted. (4) The administrator must retain the minutes of meetings in the records of the health services sector in the approved hospital. Health examinations and vaccinations 24 (1) A hospital operator must establish and maintain a program of health examinations for hospital staff based on the minimum requirements the medical staff consider necessary for the protection of hospital staff and patients. (2) Notwithstanding subsection (1), the hospital operator, medical staff and professional staff must comply with the provincial smallpox and mpox vaccine policy for at‑risk medical staff and professional staff. Notice to regulatory body 25 (1) In this section, “regulatory body”, with respect to a member of the medical staff or professional staff, means the college under the Health Professions Act that regulates the health profession of the member. (2) A hospital operator must advise the regulatory body of a member of the medical staff or professional staff if any of the following occur: (a) the member’s appointment as a member of the medical staff or professional staff is suspended or terminated; (b) the member’s hospital privileges are significantly varied, suspended or terminated due to the member’s incompetence, negligence or misconduct; (c) the member resigns while the member’s competence, negligence or conduct is under investigation by the hospital operator, the member’s regulatory body or another body. Expenses incurred in transfers 26 (1) In this section, (a) “transfer” means, (i) with respect to a patient, a transfer under section 1.976993(2)(a)(iii) of the Act, or (ii) with respect to an unadmitted person, a transfer to another location that the sector Minister, provincial health agency, hospital operator or administrator considers appropriate; (b) “unadmitted person” means a person who receives health services in the health services sector in the approved hospital but who is not admitted as a patient. (2) If the attending member of a patient or of an unadmitted person recommends that a member of the hospital staff accompany the patient or unadmitted person during a transfer, the hospital operator must reimburse the member of the hospital staff who accompanies the patient or unadmitted person for any necessary expenses incurred with respect to the transfer. Admissions Compliance with admissions provisions 27 A hospital operator is responsible for ensuring compliance with sections 28 and 29. Admission of patients 28 (1) Only members of the medical staff and professional staff may admit patients to a health services sector in an approved hospital. (2) A member of the medical staff or professional staff who admits a patient must record the following: (a) a medical history of the patient; (b) other relevant history; (c) a description of pertinent physical findings; (d) a description of pertinent findings respecting the mental health of the patient; (e) a statement of the provisional diagnosis and treatment; (f) the results of pertinent investigations previously carried out, if possible; (g) reports resulting from the diagnostic procedures prescribed under the rules made under the medical staff bylaws as the minimum required for a class of patient or medical procedure. (3) Subject to subsections (4) and (5), a member of the medical staff or professional staff who admits a patient in an emergency situation must record the information referred to in subsection (2) as soon as possible and no later than 24 hours after the patient’s admission. (4) A resident or medical student who is appointed or employed in the health services sector in the approved hospital and who is under the direction of a member of the medical staff or professional staff may record the information referred to in subsection (2)(a) or (b) for an emergency or non‑emergency admission. (5) A resident or medical student who records information in accordance with subsection (4) must do so no later than 48 hours after the patient’s admission. Persons not requiring hospital services 29 (1) In this section, “person not requiring hospital services” means a person who accompanies a patient admitted to a health services sector in an approved hospital but does not include a patient who has been declared eligible for transfer or discharge under section 1.976993(1) of the Act. (2) The hospital operator is responsible for the management of the admissions and stays in the health services sector in the approved hospital of persons not requiring hospital services. (3) An attending member of a patient must assess whether it is clinically necessary for a person not requiring hospital services to be admitted to the health services sector in the approved hospital for the purpose of accompanying the patient during the patient’s stay in the health services sector in the approved hospital. (4) The hospital operator must ensure that the attending member’s assessment is considered by (a) the members of the medical staff or professional staff designated by the hospital operator for that purpose, (b) a hospital utilization committee, if one has been established for the health services sector in the approved hospital, or (c) another body designated by the hospital operator for that purpose. (5) If the member, committee or body considering the attending member’s assessment determines that it is not clinically necessary to admit the person not requiring hospital services, the person is (a) deemed not to be in need of hospitalization, (b) not entitled to receive insured hospital services under Part 2 of the Alberta Health Care Insurance Act , and (c) required to pay the non‑entitled rate established by the regulations made under that Part. (6) The hospital operator must ensure that the attending member’s assessment and the determination of the member, committee or body that considers the assessment are included in the patient’s hospital service records. AR 211/2025 s29;294/2025 Standards of Hospital Services Clinical policies and procedures 30 (1) A hospital operator must establish and maintain written clinical policies and procedures with respect to the delivery of hospital services by members of the medical staff and professional staff in the health services sector in the approved hospital. (2) A hospital operator must ensure that (a) the policies and procedures referred to in subsection (1) are reviewed at least annually, and (b) the up‑to‑date versions of the policies and procedures are readily available to all members of the medical staff and professional staff. Nursing coverage 31 A hospital operator must ensure that adequate nursing coverage is provided at all times in the health services sector in the approved hospital. Operating room management 32 The person in charge of an operating room must be a member of the medical staff or professional staff with training in operating room management or with equivalent experience. Assistance at major surgery 33 (1) In a health services sector in an approved hospital with a clinical department, the primary physician performing an operation must determine whether the assistance of a second physician is required for the operation, taking into consideration (a) the type of surgery, (b) the circumstances of the operation, and (c) the knowledge and experience of the primary physician. (2) In a health services sector in an approved hospital without a clinical department, the assistance of a second physician is required when performing the following operations: (a) an operation within or on the contents of the following cavities: (i) the cranium; (ii) the thorax; (iii) the abdomen; (iv) the pelvis; (b) an operation that, because of the type of surgery or the circumstances of the operation, may constitute a distinct hazard to life or health, including the following: (i) amputation of limbs; (ii) anterior or posterior colporrhaphy; (iii) axis ligation, deep ligation and stripping of varicose veins; (iv) caesarian section; (v) deep biopsy of lymph nodes; (vi) deep removal of foreign body; (vii) elective tracheostomy; (viii) excision of branchial cleft cyst or sinus; (ix) excision of thyroglossal duct cyst or sinus; (x) open reduction of fracture of long bones; (xi) operative reduction of compound fracture, excluding digits; (xii) operative treatment of acute osteomyelitis or acute suppurative arthritis; (xiii) operative treatment of internal derangement of the knee or other joints; (xiv) operative treatment of severe hand injuries; (xv) plastic repair of vaginal atresia; (xvi) radical mastoidectomy; (xvii) repair of complicated fistula in ano; (xviii) repair of inguinal, double inguinal, femoral, umbilical or strangulated hernia; (xix) simple, total or radical mastectomy; (xx) thyroidectomy; (xxi) total or subtotal excision of parotid gland; (xxii) vaginal operation combined with laparotomy. (3) The provincial health agency established for the acute care health services sector must consult the Alberta Medical Association with respect to any proposed amendments to subsection (2)(b). Records relating to surgery 34 (1) Subject to subsection (2), the following information must be completed with respect to a patient on whom an operation is to be performed and made accessible to the surgical team before the operation is performed: (a) a medical history; (b) other relevant history; (c) a description of pertinent physical findings; (d) a description of pertinent findings respecting the mental health of the patient; (e) a statement of the provisional diagnosis and treatment; (f) the results of pertinent investigations previously carried out, if possible; (g) reports resulting from the diagnostic procedures prescribed under the rules made under the medical staff bylaws as the minimum required for a class of patient or medical procedure. (2) In an emergency situation in which a delay in performing an operation could have serious consequences for a patient, (a) subsection (1) does not apply, and (b) the information referred to in subsection (1) must be completed and made accessible to the medical staff and professional staff as soon as possible after the operation is performed. Anaesthetic services 35 (1) Where reasonably possible and subject to section 36(1), a member of the medical staff who provides anaesthetic services in a health services sector in an approved hospital must have a minimum of 6 months’ training in an anaesthetic training program approved by the College of Physicians and Surgeons of Alberta. (2) A member of the medical staff or professional staff administering a surgical anaesthetic must not commence administration of the anaesthetic before the surgical team is available in the health services sector in the approved hospital and prepared to begin the operation. Surgical anaesthetics 36 (1) In an emergency situation where no member of the medical staff having the training referred to in section 35(1) is available within a reasonable time, the primary physician performing an operation or the physician assisting with the operation may request that a member of the medical staff or professional staff administer a surgical anaesthetic. (2) A hospital operator must not (a) grant hospital privileges to administer a surgical anaesthetic in the situation described in subsection (1) to a member of the medical staff who does not have the training referred to in section 35(1) unless the member of the medical staff is approved by the College of Physicians and Surgeons of Alberta to administer surgical anaesthetics, or (b) allow a member of the professional staff to administer a surgical anaesthetic unless the situation described in subsection (1) exists. (3) The physician who makes a request under subsection (1) must accept full professional responsibility for the administration of the surgical anaesthetic. Deferral or relocation of surgery 37 (1) Before an operation is performed on a patient, an attending member must critically review, with respect to the patient’s need for mechanical ventilator support in the immediate post‑operative period, (a) the state of the patient, and (b) the anaesthetic techniques to be used during the operation. (2) If the attending member determines under subsection (1) that mechanical ventilator support may be required but the equipment or the medical staff or professional staff trained in its use will not be available for the patient, the attending member must defer the operation or arrange for the operation to be performed in a health services sector in an approved hospital where adequate post‑operative care is available. (3) In a health services sector in an approved hospital where adequate post‑operative care for a high‑risk patient requiring major elective or emergency surgery may not be available, the attending member must consider arranging for the operation to be performed in a health services sector in an approved hospital where adequate post‑operative care is available. Precautions re foreign bodies 38 (1) A hospital operator must ensure that the medical staff and professional staff take adequate precautions to prevent the retention of an undesirable foreign body in a patient’s (a) peritoneum in abdominal surgery, (b) pleura in chest surgery, or (c) subcutaneous tissue in other surgery. (2) An attending member must record the precautions taken on the patient’s hospital service record. Examination of removed tissues 39 (1) Subject to subsection (5), a hospital operator must ensure that tissues removed during an operation are preserved and delivered for examination to a pathologist registered in that specialty in Alberta and appointed to the medical staff. (2) Notwithstanding subsection (1), if a hospital operator has not appointed a pathologist to the medical staff, the hospital operator must ensure the tissues are delivered to a pathologist employed by a provincial public health laboratory and may use the staff and facilities of the provincial public health laboratory for the purposes of this section. (3) All tissues must be accompanied by a report that includes the patient’s name, sex, age, brief medical history and the circumstances under which the tissue was removed. (4) Pathology reports on tissues examined under this section must be provided to (a) the hospital operator or the administrator for inclusion in the patient’s hospital service records, and (b) the primary physician who performed the operation in which the tissues were removed. (5) This section does not apply with respect to the following tissues: (a) blood clots; (b) bone fragments and ligaments; (c) bony ossicles (ears); (d) cartilage, external ear (plastic); (e) fingers; (f) foreign bodies (including bone plates, nails and screws); (g) hernial sac; (h) hydrocele sac; (i) intervertebral discs; (j) meningocele sac; (k) nasal septa when removed for obstruction only; (l) optic lens; (m) prepuces; (n) ribs removed incidental to chest surgery; (o) scar tissue; (p) secondary amputation stumps; (q) semilunar cartilages; (r) teeth; (s) tendon segments removed incidental to orthopaedic procedures; (t) toes; (u) toenails and fingernails; (v) tonsils and adenoids (patients under 40); (w) vaginal wall fragments (plastic repair); (x) varicocele; (y) vein strippings. Taking blood for transfusion and crossmatching 40 For the purposes of blood transfusion and crossmatching, only a member of the medical staff or a qualified member of the professional staff may take blood in the health services sector in the approved hospital. Syphilis testing of newborns 41 The hospital operator must ensure that (a) a blood sample is taken from each newborn born in the health services sector in the approved hospital immediately after delivery, and (b) the blood sample is provided to a provincial public health laboratory for a serological test for syphilis. Salmonella reports 42 (1) If a hospital operator receives positive salmonella reports from a provincial public health laboratory within a one‑week period with respect to 3 or more patients admitted to the health services sector in the approved hospital, the administrator must notify the sector Minister of the scope of infection and the factors that caused or contributed to its spread. (2) Subsection (1) does not absolve a hospital operator from notifying the medical officer of health of all cases of notifiable diseases set out in the Communicable Diseases Regulation (AR 238/85). Disposal of needles and syringes 43 A hospital operator must ensure that disposable needles and syringes used in the health services sector in the approved hospital are (a) rendered useless prior to their disposal, and (b) disposed of in such a manner that a person handling the disposed needles and syringes will not be injured. Autopsies 44 (1) A hospital operator must ensure that an autopsy is performed, whenever possible and provided facilities are available, in the following cases: (a) deaths with respect to which the cause of death is in doubt; (b) deaths that occur during an operation or within 10 days after an operation is performed. (2) A medical examiner may request an autopsy. (3) The medical staff must consider performing an autopsy if the autopsy may add to the medical knowledge of the medical staff. (4) An autopsy must not be performed under subsection (3) unless permission for the autopsy has been received from the next of kin of the deceased or the personal representative of the deceased as defined in the Estate Administration Act . Removal of bodies 45 (1) A body must not be removed from a health services sector in an approved hospital until (a) a member of the medical staff (i) examines the body, (ii) records the time of death, and (iii) signs the applicable certificate required under the Vital Statistics Act , (b) the administrator authorizes the removal of the body, and (c) if an autopsy was performed, the person who performed the autopsy or a representative of the hospital operator on behalf of the person who performed the autopsy (i) records that (A) the next of kin of the deceased has been informed that an autopsy was performed, or (B) if the next of kin of the deceased is unavailable, the appropriate person, as determined in accordance with section 36 of the Funeral Services General Regulation (AR 226/98), has been informed that an autopsy was performed, and (ii) signs the record. (2) If death was caused by a communicable disease as defined in the Public Health Act , the hospital operator must notify the relevant funeral home of the cause of death when the body is removed from the health services sector in the approved hospital. Information and Records Management Hospital service records 46 (1) The hospital service records of an in‑patient must contain sufficient information to justify the diagnosis and the hospital services delivered to the in‑patient, including (a) the information required under section 28(2), (b) provisional and final diagnoses, (c) reports of diagnostic and treatment procedures, (d) reports of consultations, (e) surgical and anaesthetic records, (f) progress notes, (g) orders for treatment, and (h) a discharge summary, as applicable. (2) The records referred to in subsection (1) must be signed by an attending member. (3) In addition to the records referred to in subsection (1), the hospital service records of an in‑patient must contain any records provided to the hospital operator by the following persons if they are sufficiently recent to be relevant to the in‑patient’s current status: (a) the hospital operator of another health services sector in the approved hospital; (b) the hospital operator of a health services sector in another approved hospital; (c) the medical director of an accredited medical facility as defined in Schedule 21 of the Health Professions Act ; (d) a continuing care home operator as defined in the Continuing Care Act ; (e) the operator of a location to which the in‑patient had previously been transferred or discharged under section 1.976993(2)(a)(iii) or (b)(iii) of the Act; (f) any health services provider or the operator of any other hospital or facility in which health services are delivered in Alberta or outside Alberta. (4) An attending member of an out‑patient must complete the medical record portion of the hospital service records in the prescribed form within 24 hours after the hospital services have been delivered to the out‑patient. (5) If a patient dies during an operation or within 10 days after an operation is performed, the primary physician who performed the operation and the member of the medical staff or professional staff who administered the surgical anaesthetic must prepare reports of the surgical and anaesthetic events, respectively, preceding the patient’s death in addition to the routine surgical and anaesthetic records that must be kept with respect to surgical patients. (6) The hospital operator must ensure that hospital service records are legible, accurate and complete. Verification of orders for treatment 47 (1) An order for treatment issued by a member of the medical staff or professional staff must be (a) in writing, and (b) signed and dated by the member or by a resident or medical student who is appointed or employed in the health services sector in the approved hospital and who is under the direction of the member of the medical staff or professional staff. (2) An order for treatment is considered to be in writing if (a) the member of the medical staff or professional staff issuing the order dictates it to another member of the medical staff or professional staff, (b) the member to whom the order is dictated dates the order, writes their name on it and signs it on behalf of the member issuing the order, and (c) the member issuing the order dates the order and countersigns it within 24 hours after dictating it. Retention of hospital service records 48 (1) Subject to subsection (2), a hospital operator must retain a patient’s hospital service records for a period of 10 years after the date on which the patient is transferred or discharged from the health services sector of the approved hospital in which the hospital services were delivered. (2) If the patient was a minor at the time the hospital services were delivered, the hospital operator must retain the patient’s hospital service records for the longer of (a) 10 years after the date on which (i) the in‑patient is transferred or discharged from the health services sector in the approved hospital, or (ii) the out‑patient last received hospital services in the health services sector in the approved hospital, or (b) 2 years after the date of the patient’s 18th birthday. (3) A hospital operator may retain hospital service records for any additional period that the hospital operator considers necessary. (4) Notwithstanding subsections (1) and (2), (a) if a patient’s hospital service records are microfilmed after the patient has been transferred or discharged from the health services sector in the approved hospital, the original records may be destroyed one year after the date on which the patient was transferred or discharged, and (b) a patient’s x‑ray films may be destroyed 5 years after the date on which the patient is transferred or discharged from the health services sector in the approved hospital. Retention of Health Facilities Act records, etc. 49 (1) Subject to subsection (2), a hospital operator must retain a statement referred to in section 5(3)(b) of the Health Facilities Act for a period of at least 10 years after the date on which the patient was transferred or discharged from the health services sector in the approved hospital in which the insured surgical service was provided. (2) If the patient was a minor at the time the insured surgical service was provided, the hospital operator must retain the statement for the longer of (a) 10 years after the date on which the patient is transferred or discharged from the health services sector in the approved hospital, or (b) 2 years after the date of the patient’s 18th birthday. (3) A hospital operator must retain all records and documents necessary to determine whether the Health Facilities Act and the regulations under that Act have been complied with respecting the provision of enhanced medical goods or services and non‑medical goods or services in the health services sector in the approved hospital that (a) relate to the provision of insured surgical services in the health services sector in the approved hospital, or (b) arise out of an admission to the health services sector in the approved hospital. (4) The hospital operator must retain the records and documents referred to in subsection (3) for a period of 6 years after they are created. Storage of records, etc. 50 A hospital operator may store hospital service records and the statements, records and documents referred to in section 49 in a format that will provide a copy of the hospital service records or the statements, records or documents in a legible written form within a reasonable time. Financial Matters Discretionary and offset revenue 50.1 (1) In this section, (a) “ancillary operations” means commercial operations of a health services sector in an approved hospital that are approved by the sector Minister as ancillary operations and that are not directly related to the care of patients, including the operation of gift shops and parking areas; (b) “authorized charges” means authorized charges as defined in section 45(c) of the Alberta Health Care Insurance Act ; (c) “preferred accommodation charges” means the charges for semi‑private room and private room accommodation in a health services sector in an approved hospital. (2) The discretionary revenue of a hospital operator with respect to a health services sector in an approved hospital consists of revenue received by the hospital operator from the following sources: (a) preferred accommodation charges in excess of the aggregate amount collected from that source during the 1982/83 fiscal year, up to the aggregate amount collected from that source at rates not exceeding $8 per day for semi‑private room accommodation or $16 per day for private room accommodation; (b) 50% of any amount collected in daily authorized charges for semi‑private or private room accommodation in excess of $8 or $16, as the case may be; (c) the amount from each daily authorized charge collected under section 9(1) of the Insured Hospital Services Regulation that is in excess of the amount chargeable under that section in respect of standard ward accommodation in the health services sector in the approved hospital; (d) donations that are not subject to prior trust conditions; (e) foundations; (f) user charges; (g) net income from ancillary operations; (h) subject to section 50.6(4), interest earned on grants or investments. (3) Notwithstanding subsection (2), the discretionary revenue of a hospital operator of a health services sector in the Lloydminster Hospital does not include revenue from the following sources: (a) authorized admission charges; (b) preferred accommodation charges. (4) The offset revenue of a hospital operator with respect to a health services sector in an approved hospital consists of revenue received by the hospital operator from the following sources: (a) preferred accommodation charges up to the aggregate amount collected from that source during the 1982/83 fiscal year; (b) 50% of any amount collected in excess of $8 or $16, as the case may be, in daily authorized charges for semi‑private or private room accommodation;

(c) the amount from each daily authorized charge collected under section 9(1) of the Insured Hospital Services Regulation that is equivalent to the amount chargeable under that section in respect of standard ward accommodation; (d) charges for goods and services provided by the hospital operator in connection with non‑insured health services referred to in section 59 of the Alberta Health Care Insurance Act ; (e) fees charged in excess of the cost of providing enhanced goods and services referred to in section 11(2) of the Insured Hospital Services Regulation ; (f) fees charged to non‑entitled persons under section 12 of the Insured Hospital Services Regulation or cost recoveries with respect to non‑entitled persons; (g) charges for equipment or space rentals; (h) charges for goods and services provided to other institutions or organizations; (i) other sources of revenue identified by the sector Minister as being offset revenue. AR 294/2025 s4 Approved program operating expenditures 50.2 (1) Subject to subsection (2), the approved program operating expenditures of a hospital operator with respect to a health services sector in an approved hospital consist of the operating expenditures incurred by the hospital operator in delivering approved programs in the health services sector in the approved hospital during a fiscal year. (2) The approved program operating expenditures of a hospital operator do not include the following expenditures: (a) an interest expense; (b) depreciation; (c) a debt incurred with respect to the health services sector in an approved hospital that the hospital operator considers to be uncollectable; (d) a capital expenditure, except where it is amortized over several years and where the sector Minister has approved both the capital expenditure as an approved program operating expenditure and the amortization period; (e) an expenditure with respect to a specific program; (f) other expenditures identified by the sector Minister as not being approved program operating expenditures. AR 294/2025 s4 Approved program operating surpluses and discretionary revenue 50.3 (1) An approved program operating surplus and any discretionary revenue remaining after a hospital operator complies with subsections (2) and (3) may be used (a) for any purpose within the authority of the hospital operator that will benefit the health services sector in the approved hospital, and (b) if the approved hospital has a foundation, for transfers to the foundation. (2) A hospital operator shall return an approved program operating surplus to the sector Minister to the extent that it is attributable to a reduction or transfer of services, programs or activities that the sector Minister has not approved or to duplicate payments or overpayments made by the sector Minister. (3) A hospital operator may retain an approved program operating surplus and discretionary revenue, other than that surplus that must be returned to the sector Minister under subsection (2), and must use them to offset approved program operating deficits and deficits for programs other than approved programs. (4) A hospital operator shall not make an appropriation or disposition from an approved program operating surplus or discretionary revenue under this section without the written approval of the sector Minister. AR 294/2025 s4 Approved program operating deficits 50.4 If a hospital operator cannot eliminate an approved program operating deficit incurred during a fiscal year through the use of accumulated approved program operating surplus or discretionary revenue, the hospital operator shall, within 4 months after the beginning of the following fiscal year, submit a plan to the sector Minister outlining how the approved program operating deficit will be eliminated during the 2 fiscal years following the fiscal year in which the deficit was incurred. AR 294/2025 s4 Capital project costs 50.5 (1) In this section and in section 50.6, (a) “capital project costs” includes the following capital project costs, in whole or in part: (i) the approved cost of construction, alteration, renovation or upgrading of the facilities in a health services sector in an approved hospital; (ii) the approved cost of construction of (A) staff residences and health services clinics in isolated areas of Alberta, as determined by the sector Minister, and (B) parking structures; (iii) the cost of essential services approved by the sector Minister, including (A) roads and sidewalks, (B) gravelled parking lots, including essential lighting, (C) all grading, levelling and spreading of existing topsoil, (D) mechanical and electrical services from site boundaries to buildings, including fire protection, (E) outdoor signs, and (F) necessary demolition of existing buildings obstructing approved construction; (iv) the approved cost of construction contingencies; (v) approved consulting fees incurred for a project; (vi) approved (A) furniture and equipment allowances, (B) administrative planning costs, and (C) pre‑opening expenses related to a project; (b) “CLS” means the Consolidated Liquidity Solution established by the President of Treasury Board and Minister of Finance as a cash‑pooling structure for the purposes of financial management; (c) “minor construction” means a capital construction project for which the estimated capital project costs are initially established at less than $5 000 000. (2) A hospital operator must not incur an expenditure for capital project costs, whether funded through the issue of debentures or otherwise, (a) with respect to a project other than minor construction, without the written approval of the Treasury Board, and (b) with respect to minor construction requiring a grant, without the written approval of the sector Minister. (3) A hospital operator shall not borrow, whether through the issue of debentures or otherwise, in respect of capital project costs without the sector Minister’s approval. (4) If a hospital operator issues debentures for capital project costs approved under subsection (2), the sector Minister shall make grants to the hospital operator with respect to repayment of principal and interest on the debentures. (5) If a hospital operator has not issued debentures for capital project costs approved under subsection (2), the sector Minister shall make grants to the hospital operator with respect to payment of the capital project costs. (6) The sector Minister may make grants in respect of approved capital project costs necessarily incurred prior to the commencement of the construction phase on a reimbursement basis. (7) Except as provided in subsection (6), the sector Minister shall, in advance, make grants referred to in subsection (5) into the CLS to the credit of the hospital operator. (8) The sector Minister shall deposit into the CLS funds received through the issue of debentures. (9) The sector Minister shall deposit into the CLS funds received from federal sales tax and excise tax refunds. (10) The sector Minister may only expend funds from the CLS for the purposes of capital project costs. (11) Any unexpended balance in the CLS shall be refunded by the hospital operator to the President of Treasury Board and Minister of Finance following completion of the project audit or as directed by the sector Minister. AR 294/2025 s4 Interest on capital project funding 50.6 (1) Grants made by the sector Minister to a hospital operator with respect to interest on debt resulting from capital project costs shall be based on the lesser of (a) the interest rate contracted by the hospital operator to finance the debt, and (b) the interest rate that would have been charged by the Crown, as determined in the sole discretion of the President of Treasury Board and Minister of Finance, on the date on which the hospital operator entered into the financing contract, if the debt had been financed under the Local Authorities Capital Financing Act . (2) Subject to subsection (4), all interest earned on the CLS shall remain in the CLS until disposed of in accordance with section 50.5 and this section. (3) Expenditures approved by the sector Minister for interest paid by a hospital operator on short‑term borrowings for capital project costs may be reimbursed from the CLS. (4) Interest earned on grants made under section 50.5 with respect to capital project costs may be expended only (a) to offset capital interest expenses related to that project, or (b) instead of grants due under section 50.5(5), if authorized by the sector Minister. AR 294/2025 s4 Offences Offences 51 A person who contravenes section 7(1), (2) or (4), 8(1) , 16 or 50.3(4) is guilty of an offence and liable to a fine of not more than $2000 in the case of a first offence and $5000 in the case of a subsequent offence. AR 211/2025 s51;294/2025 Expiry and Coming into Force Expiry 52 For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on July 30, 2035. Coming into force 53 This Regulation comes into force on the coming into force of section 45(15) of the Health Statutes Amendment Act, 2025 .