243 Mass. Reg. 3.11

Current through Register 1523, June 7, 2024
Section 3.11 - Miscellaneous Provisions
(1) In addition, as part of its Qualified Patient Care Assessment Program, the health care facility's bylaws shall authorize the establishment of the following provisions:
(a) At least annually, every health care provider as defined by M.G.L. c. 111, § 1, who is employed by or has privileges at the health care facility, or provides patient care on behalf of an HMO, shall receive written notice of the requirements and rights in M.G.L. c. 112, § 5F.
(b) Violation of any health care facility bylaw or regulation required as part of a Qualified Patient Care Assessment Program may be grounds for summary suspension of employment, practice, association for the purpose of providing patient care, or privileges at the health care facility or on behalf of an HMO.
(c)Patients' Rights. Prior to or within 24 hours following admission to a health care facility, every patient (or the person from whom informed consent must be obtained) shall receive written notice, in plain language, of the rights established by M.G.L. c. 111, § 70E, except that if the patient is a member of a health maintenance organization and the health care facility is owned by or controlled by such organization, such notice shall be provided at the time of enrollment in such organization and also upon admittance to said facility. Such rights shall be conspicuously posted in the health care facility. In addition, all such patients shall be informed that they may file complaints with a designated office, person or committee established under 243 CMR 3.07(3)(f), and of the existence of the Board, the Department of Public Health, and their addresses and telephone numbers.
(d) The health care facility shall require that the appropriate personnel respond promptly and in no event in more than 30 days to a second health care facility's "reasonable inquiry" under 243 CMR 3.05 regarding a health care provider's application for employment, practice, association or privileges at the second health care facility. The health care facility shall maintain personnel records regarding its health care providers for a minimum of ten years.
(2) Where it appears that a health care facility has engaged in a pattern and practice of violating M.G.L. c. 111, § 203 or 243 CMR 3.00, or if there is any other indication of a serious violation, the Board shall report same to the Department of Public Health or Division of Insurance for such action as is warranted.
(3) Before taking formal enforcement action or referring a suspected violation to another agency for any enforcement action, the Board shall provide at least 30 days prior written notice to the health care facility to allow it to implement corrective measures, unless the Board, by majority vote, determines that the public health, safety or welfare necessitates earlier referral or enforcement action.
(4) The following information shall be filed annually as part of the report and according to the schedule described in 243 CMR 3.07(3)(g) (except all Health Maintenance Organizations shall file annual reports by January 31st of each year):
(a) A summary analysis of patient complaints and their disposition.
(b) The names of all full licensees who have terminated their relationship with the health care facility.
(c) Any amendments to the Patient Care Assessment Plan and any proposed amendments thereto, pursuant to 243 CMR 3.03(1).
(d) The number of Major Incident Reports filed pursuant to 243 CMR 3.08.
(e) The written instructions for the Patient Care Assessment Plan, pursuant to 243 CMR 3.06(3).
(f) Summary information on the handling of impaired physicians.

243 CMR 3.11