reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.810 - Birth Center Services

Current through Register 1525, July 5, 2024
An applicant to add a birth center to its license shall
				  develop, through an interdisciplinary team, written policies and procedures to
				  ensure the safe operation of the birth center prior to submitting an
				  application for approval. A birth center shall implement, and review and revise
				  through an interdisciplinary team as needed but not less than once a year, its
				  written policies and procedures. A birth center shall ensure that all staff,
				  including any temporary staff and volunteers, are trained and determined to be
				  competent as needed for their duties on the policies and procedures developed
				  by the facility. A birth center's policies shall include at a minimum, but not
				  be limited to:
(A) Patient admission
				criteria including specific information by which a woman's risk status will be
				established.
(B) Off-hour
				coverage.
(C) Consultation and
				referral for obstetric and pediatric care.
(D) Specific patient transfer
				criteria.
(E) Emergency procedures,
				including adult and neonatal intubation and resuscitation.
(F) Standards for medication procurement,
				storage and administration.
(G)
				Protocols for screening newborns for critical congenital heart disease with
				pulse oximetry or another test approved by the Department in accordance with
				Department guidelines.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.811 - Staffing

Current through Register 1525, July 5, 2024
A birth center shall have adequate, trained staff who are
				  licensed as required are available at all times to meet the needs of its
				  patients, including but not limited to:
(A)
Director of the Birth
				Center
.
(1) A birth center shall
				have a director who shall be responsible to the facility administrator for the
				operation and maintenance of the center.
(2) The director must be a certified
				nurse-midwife, or an obstetrician or family practitioner with obstetrical
				privileges in a nearby hospital licensed in Massachusetts or operated by the
				Commonwealth.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.812 - Equipment and Supplies

Current through Register 1525, July 5, 2024
Each birth center shall have safe and adequate equipment is
				  available to meet the needs of its patients, including those with disabilities,
				  to include at a minimum:
(A) A standard
				neonatal warming device and a transfer incubator.
(B) A microscope for routine office
				examination of vaginal smears.
(C)
				A sufficient number of sphygmomanometers and auscultation equipment.
(D) Equipment and supplies for administration
				of intravenous fluids, and full adult and infant resuscitation as required by
				procedures outlined in the birth center's protocols.
(E) A supply of oxygen including portable
				oxygen available for emergency use.
(F) Portable suction available for both the
				mother and the infant.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.813 - Patient Records

Current through Register 1525, July 5, 2024
A birth center shall maintain accurate and complete records
				  on all of its patients that include at a minimum the following information with
				  respect to each newborn:
(A) The
				condition of the infant at birth to include Apgar Score (or its equivalent) at
				one minute and five minutes, time of sustained respiration, details of physical
				abnormalities and pathological states.
(B) Date and hour of birth, birth weight and
				period of gestation.
(C) Number of
				cord vessels and any abnormalities of the placenta.
(D) Verification of eye
				prophylaxis.
(E) Metabolic
				screening.
(F) Treatments,
				medications and special procedures.
(G) Condition at discharge or
				transfer.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.814 - Care and Services

Current through Register 1525, July 5, 2024
(A) The birth center
				shall provide a program of care to include at least the following:
(1) A personal and family history;
(2) A physical examination and appropriate
				laboratory tests;
(3) A program of
				prenatal care that shall include components of self-help, self-care, and fetal
				assessment;
(4) A program of
				prenatal education that shall include the importance of nutrition, preparation
				for birth and breast feeding, and information on adverse effects of smoking,
				alcohol and other drugs;
(5)
				Intrapartum and postpartum services that foster parental control and
				responsibility for the birth experience and infant parental bonding;
(6) Labor support for the mother and her
				family;
(7) Immediate postpartum
				care and newborn assessment;
(8)
				Required eye prophylaxis;
(9)
				Postpartum laboratory examination and program for prevention of Rh
				immunization;
(10) Newborn
				metabolic screening and other such tests as may be required;
(11) A postpartum examination and family
				planning; and
(12) A plan for well
				woman routine gynecologic health care.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.815 - Prohibited Practices

Current through Register 1525, July 5, 2024
(A) Surgical
				procedures shall be limited to those normally accomplished during uncomplicated
				childbirth, such as episiotomy and repair.
(B) The following practices are prohibited in
				a birth center:
(1) Surgical procedures such
				as forceps delivery, tubal ligation, abortion, or Cesarean section.
(2) The use of any analgesics subject to
				regulation under M.G.L. c. 94C for pain control during labor.
(3) Inhibition, stimulation or augmentation
				of the first or second stage of labor with controlled substances,
(4) The use of general or regional
				anesthesia. Local anesthesia for the infiltration of the perineum for
				episiotomy repair may be administered in accordance with patient specific
				standing orders written by the physician.
(5) The provision of controlled substances
				for self-administration outside of the birth center.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.816 - Off-hour Coverage

Current through Register 1525, July 5, 2024
Each birth center shall make arrangements for the provision
				  of services 24 hours a day. These requirements can be met through on call
				  coverage by a certified nurse-midwife or physician on the staff of the birth
				  center. These arrangements shall be reflected in a written policy that is made
				  available to all the birth center's clients.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.817 - System for Referral

Current through Register 1525, July 5, 2024
(A) The
				free-standing birth center shall have a written agreement with a
				board-certified obstetrician/gynecologist, and a pediatrician or neonatologist
				for the provision of 24 hour consultation, referral and transfer to appropriate
				hospital facilities for obstetric/newborn care.
(B) Each hospital-affiliated birth center
				shall develop written agreements or policies for the provision of 24 hour
				consultation with an obstetrician/gynecologist and a pediatrician or
				neonatologist with clinical privileges at the parent hospital. If the parent
				hospital does not provide obstetrics and newborn services, the birth center
				must meet the requirements set forth in
				105 CMR
				142.506(A).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.818 - Reporting Requirements

Current through Register 1525, July 5, 2024
(A) Birth centers
				shall report all births to the Department, and to registrars and city or town
				clerks, in accordance with M.G.L. c. 46.
(B) Birth centers shall report any child with
				low birth weight, congenital abnormalities, and other high risk infants in
				accordance with guidelines as may be established by the Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.821 - Approval for Satellite Emergency Facility

Current through Register 1525, July 5, 2024
No hospital shall operate a SEF without filing an application
				  and proposal with and having received written approval from the
				  Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.822 - Application and Proposal

Current through Register 1525, July 5, 2024
A hospital proposing to establish an SEF shall file a written
				  application and proposal with the Department at least 90 days prior to the date
				  proposed for the opening the SEF.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.823 - Notice to Affected Parties

Current through Register 1525, July 5, 2024
No later than the date of the filing of a hospital's
				  application and proposal pursuant to
				  105 CMR
				  130.822, the hospital shall send written
				  notice,
via
certified mail, to affected parties within the
				  hospital's service area. Affected parties shall include but not be limited to
				  local fire departments, ambulance services, police, regional EMS Councils
				  designated pursuant to
				  105 CMR 170.000:
Emergency Medical Services System
, local boards of selectmen
				  or mayors, and local boards of health. A copy of the notice shall be included
				  with the application filed pursuant to
				  105 CMR
				  130.822.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.824 - Content of Notice

Current through Register 1525, July 5, 2024
The notice required pursuant to
				  105 CMR
				  130.823. at a minimum, shall include:
(A) a statement of the type of care that will
				be provided at the SEF;
(B) to the
				extent that there is a proposed modification in services currently provided at
				the site of the SEF, a description of the services that will no longer be
				available at the site;
(C) a
				description of the level of ambulance transport that will be appropriate at the
				proposed SEF; and
(D) a description
				of appropriate alternative facilities that offer emergency services and that
				are available to residents of the hospital's service area.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.825 - Public Meeting

Current through Register 1525, July 5, 2024
No earlier than 60 days prior to submitting its application
				  pursuant to
				  105 CMR
				  130.822 and not later than 60 days after it
				  submits said application, a hospital proposing to establish an SEF shall hold a
				  public meeting in its service area. At the public meeting, the hospital shall
				  describe the services to be provided at the SEF and any proposed modifications
				  in services provided at the site prior to the establishment of the SEF, and
				  shall afford the opportunity for interested parties to present their comments
				  on the hospital's proposal.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.826 - Public Notice

Current through Register 1525, July 5, 2024
At least 30 days prior to the date of the meeting required
				  pursuant to
				  105 CMR 130.825,
				  the hospital proposing to establish a SEF shall publish a notice of the public
				  meeting in the legal notice section of local newspapers serving residents of
				  the hospital's service area. The notice shall contain as its caption, in 14
				  point type: "Public Announcement Concerning the Establishment of a Satellite
				  Emergency Facility by (name of hospital)". The notice shall set forth the name
				  and address of the proposed location of the SEF, briefly describe any
				  modifications in existing services, if any, and indicate the date, time and
				  location of the meeting. The hospital shall forward a copy of the notice to the
				  Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.827 - Public Education

Current through Register 1525, July 5, 2024
A hospital proposing to establish an SEF shall develop and
				  implement a public education plan that, at a minimum, shall include:
(A) written notification to ambulance
				services and regional councils, of the services to be provided at the SEF and a
				description of the type of ambulance transport that is appropriate for the
				SEF;
(B) a public information
				campaign about the services available at the SEF, modifications in preexisting
				services, and the circumstances under which it is appropriate to call
				"911";
(C) the creation of a
				community network for the early and ongoing exchange of information regarding
				emergency services (for example, a hospital may establish a community advisory
				committee composed of representatives of ambulance services, local police and
				fire departments, public officials and other community members to assist in the
				development of an effective education campaign for all cities and towns in the
				hospital's service area);
(D) a
				list of meetings to be held with public officials and the affected parties
				listed in
				105 CMR
				130.823;
(E) a clear and understandable description of
				the services available at the SEF and any changes in services previously
				provided at the SEF site; a plan for the dissemination of the description of
				services at the hospital, providing copies to the affected parties listed in
				105 CMR
				130.823 and including it in a public
				information campaign using local print and electronic media;
(F) a list of alternative facilities that
				provide emergency services to residents of the hospital's service
				area;
(G) a plan to provide
				accurate and appropriate road signage in the hospital's service area;
(H) notice of the date when the SEF will
				commence operations; and
(I) public
				information and education initiatives that address public safety issues and
				prevention including, but not limited to, operation of motor vehicles while
				under the influence of alcohol or drugs, seat belt awareness, helmet use,
				recognition of the symptoms of heart attack, stroke and pediatric
				illnesses.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.828 - Physician Staffing

Current through Register 1525, July 5, 2024
A SEF shall be staffed at all times with at least one
				  physician. All physicians working at the SEF shall be board certified or board
				  eligible in emergency medicine as recognized by the American Board of Emergency
				  Medicine (ABEM) or the American Board of Osteopathic Emergency Medicine
				  (ABOEM). All physician staff of a SEF shall also provide traditional clinical
				  emergency services at a full service hospital-based emergency department for at
				  least 25% of their total working hours per year.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.829 - Nurse Practitioners and Physician Assistant - Qualifications

Current through Register 1525, July 5, 2024
Nurse Practitioners and Physician Assistants employed at the
				  SEF shall be ACLS, APLS or PALS certified, have a minimum of three years full
				  time experience working in a full service hospital emergency department setting
				  and provide traditional clinical emergency services at a full service hospital
				  based emergency department for at least 25% of their total working hours per
				  year.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.830 - Nursing Qualifications

Current through Register 1525, July 5, 2024
Nurses employed at the SEF must be ACLS (Advanced Cardiac
				  Life Support), APLS (Advanced Pediatric Life Support) or PALS (Pediatric
				  Advanced Life Support) and CEN (Certified Emergency Nurse) certified, have a
				  minimum of three years' experience working in a full service hospital emergency
				  department and provide traditional clinical emergency services at a full
				  service hospital emergency department for at least 25% of their total working
				  hours per year.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.831 - Radio Communications

Current through Register 1525, July 5, 2024
All radio communications between the SEF and pre-hospital
				  providers shall be in compliance with applicable statewide emergency
				  communications plans.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.832 - Medical Director - Responsibilities

Current through Register 1525, July 5, 2024
The SEF's medical director shall oversee and validate the
				  quality assurance processes of the pre-hospital system, which shall include
				  mortality and morbidity case conferences.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.833 - Quality Assurance

Current through Register 1525, July 5, 2024
(A) SEF specific
				quality assurance screens shall be developed. These screens, at a minimum,
				shall include reviews of:
(1) patients who die
				in the SEF;
(2) if known to the
				SEF, patients admitted to a hospital within 72 hours of having been seen at the
				SEF;
(3) all patients transferred
				from the SEF to an inpatient hospital, in which case said reviews shall include
				the review of the management of the patient, whether transport was by
				ambulance, and whether transport was done at the appropriate level of
				care;
(4) walk-in patients who are
				transferred; and
(5) all patients
				arriving by ambulance.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.834 - Ancillary Services and Support

Current through Register 1525, July 5, 2024
Each SEF shall have:
(A) on site basic diagnostic radiology
				available 24 hours per day;
(B) the
				capability of performing on site basic laboratory testing with results
				available in less than one hour;
(C) laboratory services capable of performing
				blood gas analysis and routine hematology and chemistry available 24 hours per
				day;
(D) radiology services
				including CT scans and ultrasound with a clinically appropriate turnaround time
				from the ordering to the reporting of results; if done off-site the SEF must
				have in place appropriate transport protocols; and
(E) plain film radiography available on site
				with technicians available 24 hours per day.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.835 - Clinical Services and Equipment

Current through Register 1525, July 5, 2024
Each SEF shall have:
(A) monitored and unmonitored beds in
				sufficient quality to meet projected patient volume;
(B) the availability, at all times, of
				pediatric and adult code carts and other standard and specialty equipment
				described in the hospital's policies and procedures;
(C) surgical or other emergency consultative
				services available, on site or at an appropriate full service hospital, within
				30 minutes of a decision that said services are warranted;
(D) written policies that assure that all
				transfers from the SEF are carried out in accord with all applicable state and
				federal laws and the Massachusetts Statewide Interfacility Transfer Guidelines;
				and
(E) a written list of the
				medical conditions and problems that are appropriate and inappropriate for
				ambulance transport to the SEF based on the capability of the SEF and regional
				point of entry plans.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.836 - Reports

Current through Register 1525, July 5, 2024
Each hospital operating an SEF shall submit a report to the
				  Department on a quarterly basis for the first two years of operation. The
				  report shall include:
(A) total patient
				volume, including the number of walk in patients and patients transported by
				either BLS or ALS ambulance;
(B)
				the number of patients transferred to other facilities categorized by method of
				transport to the SEF;
(C) if known,
				the number of patients admitted to a hospital within 72 hours of having been
				seen at the SEF;
(D) deaths
				occurring at the SEF; and
(E)
				detailed description of community education and training activities.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.840 - Definition

Current through Register 1525, July 5, 2024
The following definition applies to 105 CMR 130.840 through
				  130.841.
Diversion Status System
. A web-based
				  application established by the Department to allow hospitals, CMED centers and
				  ambulance services access to real-time information regarding the diversion
				  status of all hospitals in Massachusetts licensed to provide emergency services
				  or operate a satellite emergency facility.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.841 - Requirements Regarding the Diversion Status System

Current through Register 1525, July 5, 2024
(A) A hospital that is licensed to provide
				emergency services, including satellite emergency facilities, shall participate
				in the Department's web-based diversion status system.
(B) The hospital or its designee shall keep
				current the web-based diversion status system with regard to:
(1) the status of the emergency department
				and any satellite emergency facility, including but not limited to, whether the
				emergency department or satellite emergency facility is open to all ambulances,
				on diversion status, or closed; and
(2) any other directly related data
				recommended by the diversion status advisory committee.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.850 - Trauma Service

Current through Register 1525, July 5, 2024
Hospitals must provide one of two levels of trauma services
				  as described in
				  105 CMR
				  130.851 and
				  130.852
				  in order to be licensed to provide emergency services.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.851 - Trauma Service as a Designated Trauma Center

Current through Register 1525, July 5, 2024
A hospital may provide a trauma service as a designated
				  trauma center if:
(A) The hospital has
				been verified by the American College of Surgeons (ACS) as a level 1, 2 or 3
				adult trauma center or a level 1 or 2 pediatric trauma center.
(B) The hospital enters into transfer
				agreements and provides consultation to lower level trauma centers and/or
				hospitals that are not Designated Trauma Centers;
(C) The hospital provides to the Center for
				Health Information Analysis (CHIA) the designated trauma center data set
				specified in Department guidelines; and
(D) The hospital meets such other standards
				as the Department may require.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.852 - Trauma Services at a Hospital That is not a Designated Trauma Center

Current through Register 1525, July 5, 2024
A hospital that is not a Designated Trauma Center may be
				  licensed to provide Emergency Services only if:
(A) The hospital provides to CHIA the trauma
				service hospital data set to be specified in
				105 CMR
				130.851(D); and
(B) The hospital enters into formal written
				agreements with one or more Designated Trauma Centers that address the transfer
				of patients to those centers.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.853 - Trauma Service Advertising

Current through Register 1525, July 5, 2024
No hospital may use the terms "trauma facility", "trauma
				  center", or similar terminology in its signs or advertisements or in materials
				  and information it provides to the public unless it provides a trauma service
				  as a Designated Trauma Center.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.854 - Change in Designation Status

Current through Register 1525, July 5, 2024
Any Designated Trauma Center that plans to change its ACS
				  verification status or take action that will result in a loss of designation as
				  a Trauma Center shall notify its Regional EMS Council as defined in
				  105 CMR 170.020:
Definitions
, and the Department 90 calendar days prior to the
				  proposed effective date of such change.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.860 - Surgical Technology Definitions

Current through Register 1525, July 5, 2024
For the purposes of
				  105 CMR
				  130.861 the following terms have the
				  following meanings:
Operating Room Circulator
. A
				  licensed registered nurse who is educated, trained and experienced in
				  perioperative nursing, who is immediately available to physically intervene in
				  providing care to a surgical patient.
Surgical Technologist
. Any person
				  who provides surgical technology services who is not licensed or registered
				  under M.G.L. c. 112, §§ 2, 16, 74 or 74A, or who is not an intern,
				  resident, fellow or medical officer who conducts or assists with the
				  performance of surgery.
Surgical Technology
. Surgical
				  patient care including, but not limited to, one or more of the
				  following:
(1) collaboration with an
				operating room circulator prior to a surgical procedure to carry out the plan
				of care by preparing the operating room, gathering and preparing sterile
				supplies, instruments and equipment, preparing and maintaining the sterile
				field using sterile and aseptic technique and ensuring that surgical equipment
				is functioning properly and safely;
(2) intraoperative anticipation and response
				to the needs of a surgeon and other team members by monitoring the sterile
				field and providing the required instruments or supplies;
(3) performance of tasks at the sterile
				field, as directed in an operating room setting, including:
(a) passing supplies, equipment or
				instruments;
(b) sponging or
				suctioning an operative site;
(c)
				preparing and cutting suture material;
(d) transferring and irrigating with
				fluids;
(e) transferring, but not
				administering, drugs within the sterile field;
(f) handling specimens;
(g) holding retractors; and
(h) assisting in counting sponges, needles,
				supplies and instruments with an operating room circulator.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.861 - Surgical Technology

Current through Register 1525, July 5, 2024
(A) Each hospital
				that provides surgical services in operating rooms shall adopt policies and
				procedures that address the following requirements set forth in M.G.L. c. 111,
				§ 229.
(1) The hospital may not employ or
				otherwise retain the services of any person to perform surgical technology
				tasks or functions unless such person:
(a)
				has successfully completed an accredited educational program for surgical
				technologists and holds and maintains a certified surgical technologist
				credential administered by a nationally recognized surgical technologist
				certifying body accredited by the National Commission for Certifying Agencies
				and recognized by the American College of Surgeons and the Association of
				Surgical Technologists;
(b) has
				successfully completed an accredited school of surgical technology but has not,
				as of the date of hire, obtained the certified surgical technologist
				certification required in 105 CMR 130.861(A)(1)(a); provided, however, that
				such certification shall be obtained within 12 months of the graduation
				date;
(c) was employed as a
				surgical technologist in a surgical facility on or before July 1,
				2013;
(d) has successfully
				completed a training program for surgical technology in the Army, Navy, Air
				Force, Marine Corps or Coast Guard of the United States or in the United States
				Public Health Service which has been deemed appropriate by the commissioner;
				or
(e) is performing surgical
				technology tasks or functions in the service of the federal government, but
				only to the extent the person is performing duties related to that
				service.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.900 - Standards for Operation of Hospital-based Invasive Cardiovascular Services

Current through Register 1525, July 5, 2024
105 CMR 130.900 through
				  130.980
				  sets forth standards for the operation of hospital-based adult cardiac
				  catheterization and electrophysiology laboratories. Cardiac catheterization
				  procedures shall not be performed in a satellite facility or a freestanding
				  clinic. Any hospital wishing to provide cardiac catheterization services shall
				  be licensed by the Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.915 - Application to Provide Cardiac Catheterization Services

Current through Register 1525, July 5, 2024
(A) Each hospital seeking approval to provide
				adult cardiac catheterization services, pediatric cardiac catheterization
				services, or electrophysiology services shall submit an application for review
				by the Department which demonstrates hospital adherence to the standards and
				requirements in
				105
				CMR 130.900 through
				130.980,
				as applicable, and all corresponding Department guidelines.
(B) All applicants for approval of pediatric
				catheterization services shall at a minimum have a licensed Level III pediatric
				service.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.930 - Establishment of Invasive Cardiac Services Advisory Committee

Current through Register 1525, July 5, 2024
The Department may establish an Invasive Cardiac Services
				  Advisory Committee to advise the Department on issues related to invasive
				  diagnostic and interventional cardiac services licensed by the Department. The
				  Committee's membership shall be multidisciplinary and shall include but not be
				  limited to physicians and nurses who are clinical experts in the field of
				  cardiac catheterization, cardiac surgery and electrophysiology studies,
				  hospital administrators and consumers. The committee shall be representative of
				  the geographical areas of the Commonwealth and of community and tertiary
				  hospitals.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.935 - Minimum Workload Requirements

Current through Register 1525, July 5, 2024
(A) Each
				approved cardiac catheterization service shall maintain a minimum annual
				caseload volume in accordance with Department guidelines, based on guidelines
				and standards issued by American College of Cardiology, American Heart
				Association and Society for Cardiac Angiography and Interventions.
(1) Any cardiac catheterization service
				providing fewer than the specified number of procedures per year shall, within
				30 days of the end of the Department's fiscal year reporting period, submit to
				the Department a copy of the previous year's Quality Assessment and Performance
				Improvement (QAPI) quarterly reports required under
				105
				CMR 130.965(E).
(2) In addition to the requirements of 105
				CMR 130.935(A)(1), any cardiac catheterization service providing fewer than the
				specified number of procedures per year shall, within 30 days of the end of the
				Department's fiscal year reporting period, request a review of the
				catheterization service by an appropriately qualified professional peer review
				organization or individual(s) approved by the Department. Any physician
				conducting the peer review shall certify that he or she does not have any
				conflict of interest regarding the hospital and physicians to be reviewed.
The results of the review shall be submitted to the
				  Department within ten days of receipt.
(3) Based on a review of the QAPI reports
				and, if applicable, the results of the assessment of the quality of the cardiac
				catheterization service by an appropriately qualified peer review organization
				or individual(s) approved by the Department, the Department shall determine
				whether a facility will continue to be approved to provide the service and, if
				applicable, subject to any conditions determined to be appropriate.
(4) New services shall reach the minimum
				specified number of procedures within 24 months of approval of the
				service.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.940 - Staff

Current through Register 1525, July 5, 2024
(A) The hospital shall designate a licensed
				physician director who shall have responsibility for the cardiac
				catheterization service.
(1) The physician
				director of a cardiac catheterization service that performs diagnostic
				procedures shall be board-certified in cardiovascular disease. The physician
				director shall have training and experience in cardiac
				catheterization.
(2) The physician
				director of a cardiac catheterization service that performs interventional
				procedures shall be board certified in interventional cardiology.
(3) A hospital that performs diagnostic and
				interventional electrophysiology procedures (excluding those cardiac
				catheterization services that only implant pacemakers and perform no other
				electrophysiology procedures), shall designate a licensed physician director of
				electrophysiology services who is board-certified in clinical cardiac
				electrophysiology (CCEP).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.950 - Equipment and Supplies

Current through Register 1525, July 5, 2024
Each cardiac catheterization service and EPS shall
				  appropriately equip itself and be responsible for appropriate maintenance,
				  pursuant to hospital policy.
The service must make an intra-aortic balloon pump available
				  to the laboratory.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.960 - Space

Current through Register 1525, July 5, 2024
(A) A cardiac catheterization/EPS laboratory
				shall meet the cardiac catheterization laboratory standards set forth in
				administrative guidelines of the Department based on the Facility Guidelines
				Institute's Guidelines, as referenced in
				105
				CMR 130.107.
(B) The patient recovery area must be
				directly accessible from the procedure room and designed according to the
				standards applicable to recovery areas for ambulatory surgery set forth in
				administrative guidelines of the Department based on the Facility Guidelines
				Institute's Guidelines, as referenced in
				105
				CMR 130.107.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.962 - Assurance of Continuity of Care

Current through Register 1525, July 5, 2024
Each hospital must develop and implement policies and
				  procedures that assure the continuity of patient care, from the
				  pre-catheterization teaching and obtaining of written consent through
				  post-procedure care and discharge.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.965 - Hospital-based Quality Assurance and Performance Improvement Program

Current through Register 1525, July 5, 2024
(A) Each cardiac catheterization or
				electrophysiology service shall establish and maintain an effective, ongoing,
				data-driven, evidence-based quality assessment and performance improvement
				(QAPI) program for all catheterization procedures, including electrophysiology
				procedures, if applicable, that focuses on patient outcomes while assessing
				individual operator clinical proficiency as well as overall laboratory safety
				and efficiency.
(B) The hospital,
				through its QAPI program, shall:
(1) Identify
				quality measures, based on nationally accepted standards, that capture the
				quality of care provided and patient safety;
(2) Collect and maintain data pertaining to
				these measures in a systematic manner;
(3) Perform statistical analyses of the data
				for comparison with nationally accepted quality indicator benchmarks and
				longitudinally within the hospital on a routinely scheduled basis;
(4) Analyze comparison results and identify
				areas for improvement; and
(5)
				Develop, implement and evaluate evidence-based improvement interventions to
				address the identified areas, and incorporate feedback for catheterization
				service staff on the effectiveness of the solutions and/or triggers for further
				opportunities for improvement.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.970 - Reporting to the Department of Public Health

Current through Register 1525, July 5, 2024
When requested by the Department, each hospital shall submit
				  information regarding volume of procedures, patient outcomes and
				  utilization.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.975 - Cardiac Catheterization Services without Cardiac Surgery Services

Current through Register 1525, July 5, 2024
A hospital that operates a cardiac catheterization service
				  and does not provide cardiac surgery services shall not perform procedures
				  specified in Department guidelines and shall maintain a current written
				  collaboration agreement with at least one tertiary hospital with a cardiac
				  surgery program. The agreement shall include all of the following:
(1) Guidelines for the selection of patients
				appropriate for cardiac catheterization at the hospital without cardiac
				surgery.
(2) Provisions for
				emergency and routine transfer of patients including timely transfer of
				appropriate patient information. Language shall be included that describes the
				agreed upon cardiac catheterization image standard, to avoid redundant
				catheterization.
(3) Provisions
				that specify that cardiac surgery staff and facilities shall be immediately
				available to the patient upon notification of an emergency.
(4) Provisions that specify the
				responsibility for arranging transportation to the receiving
				hospital.
(5) Provisions for joint
				quality assurance reviews.
(6)
				Provisions for joint training and ongoing education of staff.
(7) Explicit description of responsibilities
				of each party to the agreement.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.980 - Prerequisites to the Performance of Electrophysiology Services (EPS)

Current through Register 1525, July 5, 2024
Hospitals shall not perform electrophysiology procedures with
				  the exception of implanting pacemakers, defibrillators and monitoring devices
				  unless the hospital is approved to provide cardiac catheterization
				  services.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1001 - Definitions Applicable to 105 CMR 130.1001 through 130.1008

Current through Register 1525, July 5, 2024
As used in 105 CMR 130.1001 through
				  130.1008, the following
				  definitions shall apply:
Advisory Committee
. A committee
				  composed of, but not limited to: the Department's director of infectious
				  disease; a consumer to be selected by the commissioner; a technical expert to
				  be selected by the commissioner; and a representative from the Massachusetts
				  Nurses Association, the New England Association of Occupational and
				  Environmental Medicine, the Massachusetts Medical Society and the Massachusetts
				  Hospital Association.
Commissioner
. The Commissioner of
				  the Massachusetts Department of Public Health.
Department
. The Massachusetts
				  Department of Public Health.
Engineering and Work Practice
				  Controls
. Controls such as, but not limited to, sharps disposal
				  containers, needleless systems, and sharps with engineered injury protection,
				  that isolate or remove the bloodborne pathogens hazard from the
				  workplace.
Exposure Control Plan
. A plan that
				  includes an effective procedure for identifying and selecting existing sharps
				  injury prevention technology.
Exposure Incident
. A specific eye,
				  mouth, other mucous membrane, non-intact skin, or parenteral contact with blood
				  or other potentially infectious materials that result from the performance of
				  an employee's duties.
Health Care Worker
. All workers
				  employed by the hospital, working within the hospital but employed by other
				  agencies, those providing patient care services without pay such as students,
				  or providers who are delivering care but receiving compensation from sources
				  other than the hospital.
Hospital
. Any hospital licensed by
				  the Department pursuant to M.G.L. c. 111, § 51.
Reportable Exposure Incident
. An
				  exposure incident that is a result of events that pierce the skin or mucous
				  membranes.
Sharp
. Any object that can penetrate
				  the skin or any part of the body, and to result in an exposure incident,
				  including, but not limited to, needle devices, scalpels, lancets, broken glass,
				  broken capillary tubes and exposed ends of dental wires.
Sharps Injury Log
. A log to be kept
				  within acute and non-acute hospitals that records information concerning
				  exposure incidents, including but not limited to, the type and brand of device
				  involved in the incident.
Sharps Injury Prevention Technology
.
				  Devices or other technology that minimizes the risk of injury to health care
				  workers from hypodermic syringes, needles or other sharps.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1002 - Minimizing Risk of Injury

Current through Register 1525, July 5, 2024
Every hospital shall:
(A) Ensure the provision of services to
				individuals through the use of safe needle devices or other technology that
				minimizes the risk of injury to health care workers from hypodermic syringes,
				needles, and sharps; and
(B) Except
				as provided in
				105
				CMR 130.1005, use only such devices designed
				to reduce risk of percutaneous exposure to bloodborne pathogens.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1003 - Written Exposure Control Plans

Current through Register 1525, July 5, 2024
Hospitals shall develop written exposure control plans that
				  include an effective procedure for identifying and selecting existing sharps
				  injury prevention technology consistent with the federal regulations concerning
				  occupational exposure to bloodborne pathogens,
				  29 CFR
				  1910.1030, the Occupational Safety &
				  Health Administration's (OSHA) Occupational Exposure to Bloodborne Pathogens
				  Standards. Written exposure control plans shall be updated when necessary to
				  reflect progress in sharps injury prevention technology as determined by the
				  Department.