Section 3.03 - Establishment of and Participation in Qualified Patient Care Assessment Program(1) A Qualified Patient Care Assessment Program shall be described in a written plan, shall be reviewed and updated at least annually by the governing body of the health care facility, and shall be submitted to the Board when adopted or amended. The plan shall include, at a minimum, procedures for compliance with 243 CMR 3.00, including: (a) governing body responsibility for the program including, but not limited to, patient care assessment related committees established pursuant to governing body authorization;(b) risk identification and analysis including, but not limited to, internal incident reporting/auditing and incident reporting to the Board;(c) loss prevention and risk reduction activities including, but not limited to, policies/procedures regarding medication errors, credentialing, identification of and counseling impaired health care providers and the establishment of guidelines and standards for clinical specialties;(d) patient communications and documentation activities including, but not limited to, informed consent policies, maintenance of medical records, and the processing of patient complaints; and(e) policies governing the responsibilities of the Patient Care Assessment Coordinator and Committee.(2) Effective July 1, 1987, pursuant to M.G.L. c. 111, § 203(d), every hospital and nursing home, as a condition of licensure, shall establish a Qualified Patient Care Assessment Program.(3) Pursuant to M.G.L. c. 112, § 5, every licensee must participate in the Qualified Patient Care Assessment Program established by a health care facility where the licensee has employment, practice, association for the purpose of providing patient care, or privileges, and a licensee may not accept employment, practice, association for the purpose of providing patient care, or privileges at a health care facility unless it has a Qualified Patient Care Assessment Program. However, to ease the transition and to enhance eventual compliance with 243 CMR 3.00, the Board hereby allows participation until July 1, 1987 in a pre-existing, Non-Qualified Patient Care Assessment Program. After June 30, 1987, all licensees must participate in a Qualified Patient Care Assessment Program.(4) Whether or not a licensee is employed by, associated with for the purpose of providing patient care, or has practice or privileges at a health care facility with a Qualified Patient Care Assessment Program, the licensee must, as a condition of licensure, adhere to 243 CMR 3.10.