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 130.1004 - Engineering or Work Practice Controls

Current through Register 1525, July 5, 2024
Hospitals shall include sharps injury prevention technology
				  as engineering or work practice controls to isolate or remove the bloodborne
				  pathogens hazard from the workplace consistent with the federal regulations
				  concerning occupational exposure to bloodborne pathogens,
				  29 CFR
				  1910.1030.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1005 - Exemption from the Inclusion of Sharps Injury Prevention Technology

Current through Register 1525, July 5, 2024
(A) Sharps injury prevention technology may
				be excluded as engineering or work practice controls in cases where the
				hospital or other appropriate party can demonstrate circumstances in which the
				technology does not promote employee or patient safety or interferes with a
				medical procedure.
(B) Where sharps
				injury prevention technology is not utilized, the hospital shall specify those
				circumstances, which shall include but not be limited to situations where the
				technology is medically contraindicated or not more effective than alternative
				measures used by the employer to prevent exposure incidents.
(C) In all cases the Department shall make
				the final determination as to whether a hospital or other appropriate party has
				demonstrated in a satisfactory manner those circumstances which warrant an
				exemption from the inclusion of sharps injury prevention technology.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1006 - Sharps Injury Log

Current through Register 1525, July 5, 2024
(A) Information
				concerning exposure incidents shall be recorded in a sharps injury log that
				includes, but is not limited to, the type and brand of device involved in the
				incident, the department or work area where the incident occurred, and an
				explanation of how the incident occurred;
(B) Sharps injury logs shall be kept within
				the hospital and shall be used as the basis for continuing quality improvement
				in reducing sharps injuries through the provision of education and the
				procurement of improved products; and
(C) Sharps injury logs shall be kept
				confidential.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1007 - Reporting

Current through Register 1525, July 5, 2024
Every licensed acute and non-acute care hospital shall report
				  annually to the Department information from its sharps injury logs and such
				  other information as the Department may require concerning exposure incidents.
				  The Department shall supply each reporting hospital with guidelines indicating
				  the specific data elements to be submitted.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1040 - Definition of Emergency Contraception

Current through Register 1525, July 5, 2024
For the purposes of
				  105 CMR
				  130.1041 through
				  130.1043,
				  "emergency contraception" means any drug that is approved by the federal Food
				  and Drug Administration and that is used as a contraceptive method after sexual
				  intercourse.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1041 - Emergency Contraception Information for Providers

Current through Register 1525, July 5, 2024
Each hospital that is licensed to provide emergency services
				  shall provide all persons who provide care to victims of sexual assault with
				  medically and factually accurate written information prepared by the Department
				  about emergency contraception.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1042 - Emergency Contraception Information and Services for Rape Victims

Current through Register 1525, July 5, 2024
Each hospital that is licensed to provide emergency services
				  shall promptly provide the following to each female rape victim of childbearing
				  age who presents at the emergency department:
(A) Medically and factually accurate written
				information provided by the Department about emergency contraception;
(B) An offer of emergency contraception at
				the hospital if medically indicated; and
(C) Dispensing of emergency contraception at
				her request unless medically contraindicated.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1043 - Reporting the Dispensing of Emergency Contraception

Current through Register 1525, July 5, 2024
(A) Each hospital shall report each time that
				it dispenses emergency contraception pursuant to
				105
				CMR 130.1042 on the Provider Sexual Crime
				Report that it completes in accordance with M.G.L. c. 112, §
				12A½.
(B) The report of the
				dispensing of emergency contraception made pursuant to 105 CMR 130.1043(A) is
				not a public record as defined in M.G.L. c. 4, § 7.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1101 - Interpreter Service - Requirement

Current through Register 1525, July 5, 2024
Each acute care hospital licensed by the Department and that
				  provides emergency services, shall provide competent interpreter services in
				  connection with all emergency department services. Such competent interpreter
				  services shall be provided to every non-English speaker who seeks or receives
				  emergency care or treatment. In the provision of competent interpreter
				  services, the hospital shall comply with the provisions of 105 CMR 130.1101
				  through
				  130.1108
				  and M.G.L. c. 111, § 25J.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1102 - Interpreter Service - Policies and Procedures

Current through Register 1525, July 5, 2024
Each acute care hospital shall develop written policies and
				  procedures, consistent with
				  105 CMR
				  130.1101 through
				  130.1108
				  that govern the provision of interpreter services and that include the
				  qualifications for a coordinator of interpreter 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 130.1103 - Interpreter Service - Coordinator

Current through Register 1525, July 5, 2024
In connection with its provision of emergency department
				  service each acute care hospital shall designate a coordinator of interpreter
				  services who shall be responsible for:
(A) conducting an annual language needs
				assessment of the service area that includes input from community-based
				organizations, and that includes identification of those languages for which
				notices shall be posted;
(B)
				developing written policies and procedures for use in the hospital's emergency
				department to assure timely early identification and ongoing access for
				patients in need of interpreter services;
(C) overseeing the training and assessment
				process for both interpreters and hospital staff who will be working with
				interpreters;
(D) developing an
				ongoing, documented quality assurance program that includes problem
				identification, action plans, evaluation and follow-up and which is a part of
				the hospital's ongoing quality assurance process;
(E) establishing and publicizing grievance
				procedures regarding access to interpreter 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 130.1104 - Interpreter Service - Notices

Current through Register 1525, July 5, 2024
Each acute care hospital shall provide oral and/or written
				  notification to patients or individuals seeking or receiving emergency services
				  in their primary language informing them of their right to receive interpreter
				  services at no charge. Each acute care hospital shall also provide translated
				  signage, as provided by the Department, that informs patients at key points of
				  contact in the emergency department of the availability of no cost interpreter
				  services. Each acute hospital shall have on file copies of M.G.L. c. 111,
				  § 25J in languages identified by the needs assessment, and shall furnish
				  such a copy in the language requested to any interested party on
				  request.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1105 - Interpreter Service - Access

Current through Register 1525, July 5, 2024
Each acute care hospital shall provide all non-English
				  speaking patients or individuals seeking or receiving emergency department
				  services with access to competent interpreter services at no charge, by using
				  bilingual staff, staff interpreters, or by contract arrangement. Provision and
				  acceptance or refusal of interpreter services shall be documented in the
				  patient's medical record. Interpreter services in the emergency department
				  shall comply with the following standards:
(A) Interpreter services shall be available,
				at a minimum, on an on-call basis 24 hours per day, seven days per
				week.
(B) The collection of
				information from family members about family history and other collateral
				information is an acceptable practice, but does not substitute for the
				provision of interpreter services.
(C) The hospital shall refrain from
				requiring, suggesting or encouraging patients to use family members or friends
				as interpreters.
(D) The use of
				minor children as interpreters is prohibited.
(E) Hospitals shall develop policies and
				procedures that identify those situations in which it will employ or contract
				for the on-call use of one or more interpreters for particular languages when
				needed, or use competent telephonic or televiewing services, provided that
				telephonic or televiewing interpreter services shall be used only where it can
				be documented that there is either:
(1) no
				reasonable way to anticipate the need for employed or contracted interpreters
				for a particular language; or
(2)
				there occurs, in a particular instance, an inability to provide competent
				interpreter services by an employed or contracted interpreter.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1106 - Interpreter Service - Training Education and Qualifications

Current through Register 1525, July 5, 2024
Each acute care hospital through its Coordinator of
				  Interpreter Services shall:
(A) Ensure
				that staff and contract interpreters can demonstrate current bilingual
				proficiency and have received training that includes the skills and ethics of
				interpreting, and knowledge in both languages regarding the specialized terms
				(
e.g
. medical terminology) and concepts relevant to clinical
				or non-clinical encounters. If the hospital uses bilingual staff or volunteers
				for medical interpretation, these staff and volunteers shall receive the same
				training and can demonstrate the same skills as staff interpreters and/or
				contract interpreters.
(B) Require
				and arrange for ongoing education and training for administrative, clinical and
				support staff in culturally and linguistically competent service delivery,
e.g
., patient cultural and health belief systems and working
				effectively with interpreters.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1107 - Interpreter Service - Patient and Other Records

Current through Register 1525, July 5, 2024
Each acute care hospital shall ensure that the primary spoken
				  language and self-identified race/ethnicity of all patients coming to the
				  emergency department are included in the hospital's management information
				  system as well as any patient records used by hospital staff.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1108 - Interpreter Service - Translated Materials

Current through Register 1525, July 5, 2024
Signage, commonly used written patient educational material,
				  and vital documents, such as consent forms, discharge instructions, advanced
				  directives, and applications for members of the predominant language groups in
				  the hospital's service area as identified by the needs assessment in
				  105 CMR
				  130.1103 shall be translated and made
				  available. For less commonly encountered languages, written notice of the right
				  to receive competent oral translation of written materials should be provided
				  in the primary language of non-English speaking patients.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1202 - Cardiac Surgery Patient Outcome Monitoring Requirements

Current through Register 1525, July 5, 2024
Each hospital that provides cardiac surgery services
				  shall:
(1) Submit patient-specific
				cardiac surgery outcome data for each patient who receives cardiac surgery
				services to the DAC as specified in
				105 CMR
				130.1203;
(2) Require that each hospital with a cardiac
				surgery program is enrolled in and participates in the STS National Database in
				accordance with the rules of the STS; and
(3) Develop, implement and maintain
				administrative procedures that ensure the confidentiality of the
				patient-specific data submitted to the DAC and to the STS National Database, if
				any.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1203 - Cardiac Surgery Patient Outcome Data Requirements

Current through Register 1525, July 5, 2024
Each hospital that provides cardiac surgery services shall
				  submit patient-specific data to the DAC for each of its patients who has
				  cardiac surgery in a manner defined by the Department using STS National
				  Database Standards and in accordance with requirements set forth by the
				  Department in guidelines:
(1) Cardiac
				surgery data submitted by hospitals are subject to audit by the Department. All
				acute hospitals providing cardiac surgery services are subject to random data
				audits that may include re-abstraction of a sample of patient medical records
				by the Department or its contractor.
(2) Each hospital shall reimburse the DAC for
				the hospital's share of the DAC's expenses according to a formula established
				by the Department, which shall be based on the volume of cardiac surgery
				services that the hospital provides. The Department shall set forth the formula
				and the procedures for disbursement to the DAC in 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 130.1302 - PCI Patient Outcome Monitoring Requirements

Current through Register 1525, July 5, 2024
Each hospital that provides PCI shall:
(1) Submit patient-specific PCI outcome data
				for each patient who receives PCI services to the DAC as specified in
				105 CMR
				130.1303;
(2) Require that each physician who performs
				PCI at the hospital is enrolled in and participates in the NCDR; and
(3) Develop, implement and maintain
				administrative procedures that ensure the confidentiality of the
				patient-specific data submitted to the DAC and to the NCDR.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1303 - PCI Patient Outcome Data Requirements

Current through Register 1525, July 5, 2024
Each hospital that provides PCI services shall submit
				  patient-specific data to the NCDR and to the DAC for all of its patients who
				  have PCI procedures. The hospital shall submit these data to the NCDR in full
				  compliance with the NCDR 's requirements. The hospital shall submit these data
				  to the DAC in a manner defined by the Department using NCDR standards and in
				  accordance with requirements set forth by the Department in guidelines.
(1) PCI data submitted by hospitals are
				subject to audit by the Department. All hospitals providing PCI services are
				subject to random data audits that may include reabstraction of a sample of
				patient medical records by the Department or its contractor.
(2) Each hospital shall reimburse the DAC for
				the hospital's share of the DAC's expenses according to a formula established
				by the Department, which shall be based on the volume of PCI services that the
				hospital provides. The Department shall set forth the formula and the
				procedures for disbursement to the DAC in 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 130.1401 - Definitions Applicable to 105 CMR 130.1401 Through 130.1413

Current through Register 1525, July 5, 2024
Acute Hemorrhagic Stroke (a Subtype of Acute
				  Stroke)
. The relatively rapid onset of a focal neurological
				  deficit with signs or symptoms persisting longer than 24 hours and not
				  attributable to another disease process. Initial CT/MRI may show evidence of
				  acute brain hemorrhage (either intracerebral or subarachnoid blood) or no
				  evidence of blood on imaging in the presence of blood in the subarachnoid space
				  by lumbar puncture.
Acute Ischemic Stroke (a Subtype of Acute
				  Stroke)
. The relatively rapid onset of a focal neurological
				  deficit with signs or symptoms persisting longer than 24 hours and not
				  attributable to another disease process. Initial CT/MRI may show evidence of
				  acute ischemic changes or no evidence of stroke.
Acute Stroke
. The relatively rapid
				  onset of a focal neurological deficit with signs or symptoms persisting longer
				  than 24 hours and not attributable to another disease process. Acute stroke
				  includes both ischemic and hemorrhagic stroke, and requires brain imaging to
				  define the stroke subtype.
Acute Stroke Expertise
. At least two
				  of the following:
(1) completion of a
				stroke fellowship;
(2)
				participation (as an attendee or faculty) in at least two regional, national,
				or international stroke courses or conferences each year;
(3) eight or more continuing medical
				education (CME) credits each year in the area of cerebrovascular disease;
				or
(4) other criteria approved by
				the governing body of the hospital.
Acute Stroke Team
. Physician(s) and
				  other health care professionals,
e.g
., nurse, physician's
				  assistant, or nurse practitioner, with acute stroke expertise available for
				  prompt consultation consistent with time targets acceptable to the
				  Department.
Primary Stroke Service
. Emergency
				  diagnostic and therapeutic services provided by a multidisciplinary team and
				  available 24 hours per day, seven days per week to patients presenting with
				  symptoms of acute stroke.
Time Targets
. Time frames
				  established by the Department in guidelines regarding Primary Stroke
				  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 130.1402 - Application to Provide Primary Stroke Service

Current through Register 1525, July 5, 2024
Each hospital seeking designation as a provider of a Primary
				  Stroke Service shall submit an application to the Department, on forms
				  prescribed by the Department, documenting how the hospital will meet the
				  standards in
				  105 CMR
				  130.1404 through
				  130.1413.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1404 - Stroke Service Director or Coordinator

Current through Register 1525, July 5, 2024
The hospital shall designate a licensed physician with acute
				  stroke expertise, who can represent the Primary Stroke Service and evaluate the
				  hospital's capabilities to provide the required services, as the Stroke Service
				  Director or Coordinator.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1405 - Written Care Protocols

Current through Register 1525, July 5, 2024
(A) The hospital
				shall develop and implement written care protocols for acute stroke. Such
				protocols shall include both the emergency and post-admission care of acute
				stroke patients by a multidisciplinary team. The hospital shall treat eligible
				patients according to its written care protocols consistent with time targets
				acceptable to the Department. These protocols shall address issues such as
				stabilization of vital functions, initial diagnostic tests, and use of
				medications (including but not limited to intravenous tissue-type plasminogen
				activator (t-PA) treatment), as applicable. These protocols shall be based on
				previously published guidelines or developed by a multidisciplinary team
				organized by the Stroke Service.
(B)
Emergency Department (ED)
				Stroke Protocols
. The hospital shall develop and implement written
				protocols, including, but not limited to:
(1)
				triage and treatment of patients presenting with symptoms of acute stroke in
				the Emergency Department (
e.g
., use of thrombolytic therapy,
				management of increased intracranial pressure and blood pressure and
				post-thrombolysis management plan, as applicable).
(2) communicating effectively with Emergency
				Medical Service (EMS) personnel in the pre-hospital setting during
				transportation of a patient with symptoms of acute stroke. The ED must be able
				to efficiently prepare for the arrival, to receive, and to triage patients with
				symptoms of acute stroke arriving
via
EMS
				transportation.
(3) a specific,
				well-organized system for promptly notifying and activating the Acute Stroke
				Team to evaluate patients presenting with symptoms of acute stroke.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1406 - Neuroimaging Services

Current through Register 1525, July 5, 2024
(A) The hospital
				shall promptly perform brain computed tomography (CT) or magnetic resonance
				imaging (MRI) scans, consistent with time targets acceptable to the
				Department.
(B) The hospital shall
				provide prompt interpretation after study completion by a physician with
				experience in acute stroke neuroimaging, consistent with time targets
				acceptable to the Department. Neuroimaging interpretation may be provided
				directly by a staff physician at the hospital or by contractual arrangement
				with consultant physician(s). Physicians providing neuroimaging interpretation
				shall be available in the hospital or through remote access
				(
e.g
., teleradiology).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1409 - Neurosurgical Services

Current through Register 1525, July 5, 2024
(A) The hospital
				shall develop and implement written protocols for patient access to
				neurosurgical evaluation and/or intervention within a reasonable period of
				time, which may include transfer to another hospital, consistent with time
				targets acceptable to the Department.
(B) If the written protocol includes the
				transfer of patients to another hospital, the hospital shall maintain a
				transfer agreement that describes the responsibilities of each hospital and is
				signed by the Stroke Service Director, the Medical Director of each hospital or
				his or her designee, and the Chief Executive Officer of each hospital or his or
				her designee.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1410 - Quality Improvement

Current through Register 1525, July 5, 2024
(A) The hospital
				shall implement and maintain an effective, data-driven quality assessment and
				performance improvement program for the Primary Stroke Service.
(B) The hospital shall collect and analyze
				data, as defined by the Department, on patients presenting to the ED with acute
				stroke, to identify opportunities for improvement in the service.
(C) The hospital shall submit data, in a
				manner defined by the Department, and in accordance with protocols established
				by the Department in 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 130.1411 - Continuing Health Professional Education

Current through Register 1525, July 5, 2024
The hospital shall provide hospital-based staff education
				  that addresses the needs of physicians, nurses, allied health professionals,
				  and Emergency Medical Services (EMS) personnel. The program shall include
				  ongoing formal training of ED and EMS system personnel in acute stroke
				  prevention, diagnosis and treatment.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1412 - Community Education

Current through Register 1525, July 5, 2024
The hospital shall offer community education that provides
				  information to the public regarding prevention of stroke, recognition of stroke
				  symptoms, and/or treatment of stroke.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1413 - Primary Stroke Service Review

Current through Register 1525, July 5, 2024
The Primary Stroke Service protocols referenced in
				  105 CMR
				  130.1405 shall be reviewed and revised as
				  necessary and at least annually by a committee designated by the governing body
				  of the hospital and including the Stroke Service Director or Coordinator. The
				  committee's review must incorporate at a minimum the number of stroke patients,
				  types of stroke evaluated, nature of any complications of thrombolytic therapy,
				  and compliance with
				  105 CMR
				  130.1404 through 130.1413, including
				  adherence to the time targets.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1502 - Standards for Hospitals that Provide a Medical Control Service

Current through Register 1525, July 5, 2024
Each hospital that provides a medical control service
				  shall:
(A) Enter into an affiliation
				agreement that meets the requirements set forth in
				105 CMR
				170.300:
Affiliation
				Agreements
with each service to which it provides medical
				control;
(B) Make on-line medical
				direction available 24 hours per day, seven days per week to all services with
				which it has an affiliation agreement;
(C) Designate an affiliate hospital medical
				director;
(1) The hospital shall ensure that
				the affiliate hospital medical director performs the duties specified in
				105 CMR
				130.1503.
(2) The hospital shall ensure that the
				affiliate hospital medical director meets the requirements set forth in
				105
				CMR 130.1504.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1503 - Duties of the Affiliate Hospital Medical Director

Current through Register 1525, July 5, 2024
The Affiliate Hospital Medical Director shall:
(A) Provide oversight to and ensure the
				clinical competency of the EMS personnel employed by the service with which the
				hospital has an affiliation agreement, including, but not limited to, the
				following:
(1) Authorization to
				practice;
(2) Remedial education to
				those EMS personnel found to be deficient in clinical practice; and
(3) Notification to the Department within 48
				hours of any instance in which he or she suspends, revokes, or restricts in any
				manner the authorization to practice of an affiliate EMS service's EMT or EFR.
				Such notice shall include the reasons for the suspension or revocation, and the
				affiliate hospital medical director's remediation plan for the EMT or
				EFR.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1504 - Standards for the Affiliate Hospital Medical Director and Physicians who Provide On-line Medical Direction

Current through Register 1525, July 5, 2024
Each hospital that operates a medical control service shall
				  ensure that each physician that provides on-line medical direction meets the
				  following standards.
(A) Current
				credentialing to practice as a physician in a Massachusetts hospital emergency
				department. Such credentialing shall, at a minimum, include demonstration of
				the following:
(1) Education for proper
				provision of on-line medical direction, as evidenced by:
(a) Successful completion of an Emergency
				Medicine residency program; or
(b)
				Previous training and experience in medical direction.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1600 - Rapid Response Method

Current through Register 1525, July 5, 2024
(A) Each acute care
				hospital licensed by the Department, shall establish a Rapid Response Method
				(RRM) suitable for the hospital's needs and resources, to enable health care
				staff members, patients and family members to directly request additional
				assistance from a specially-trained individual(s) when a patient's condition
				appears to be deteriorating. The hospital shall ensure that the RRM is
				available 24 hours per day, seven days per week.
(B)
Policies and
				Procedures
. A hospital shall develop and implement written
				policies and procedures for a RRM that encourage staff members, patients and
				family members to seek assistance when a patient's condition appears to be
				deteriorating. These policies and procedures shall include at a minimum the
				following:
(1) Description of the RRM
				including criteria and methods for activating the RRM by staff members,
				patient(s) and/or family members when a patient's condition appears to be
				deteriorating.
(2) Criteria for
				selection, training and evaluation of staff members who will be responsible for
				responding to a request for additional assistance.
(3) Education of staff members, patient(s)
				and/or family members about the RRM including the means by which staff members,
				patients and family members may request additional assistance.
(4) Requirement of written documentation for
				each instance of activation of the RRM, including assessment of patient and
				family member satisfaction with the RRM.
(5) A mechanism for measuring the utility and
				effectiveness of the RRM, including but not limited to:
(a) documentation of rates and effectiveness
				of utilization of the RRM by staff, patients and family members; and
(b) measurement of rates of cardiopulmonary
				arrest, respiratory arrest and mortality before and after implementation of the
				RRM.
(6) Documentation
				of actions taken to improve the RRM and to address underlying organizational
				issues raised byreview mechanism(s) and data collected pursuant to 105 CMR
				130.1600(B)(5).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1700 - Definitions Applicable to Healthcare-associated Infection Data Collection, Submission and Reporting

Current through Register 1525, July 5, 2024
The following definitions apply to
				  105
				  CMR 130.1701:
Healthcare-associated Infection
				  (HAI)
. A localized or systemic condition that results from an
				  adverse reaction to the presence of an infectious agent or its toxins
				  that:
(1) occurs in a patient in a
				hospital;
(2) was not present or
				incubating at the time of the admission during which the reaction
				occurs;
(3) meets the criteria for
				a specific site infection as defined by the federal Centers for Disease Control
				and Prevention in its National Healthcare Safety Network; and
(4) any additional elements as set forth in
				administrative guidelines of the Department based on the National Healthcare
				Safety Network.
National Healthcare Safety Network
				  (NHSN)
. The HAI tracking system operated by the Federal Centers
				  for Disease Control and Prevention.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1701 - Healthcare-associated Infection Data Collection, Submission and Reporting

Current through Register 1525, July 5, 2024
(A) In accordance with guidelines of the
				Department, specified hospitals shall:
(1)
				register with the NHSN; and
(2)
				grant access to the Department, in accordance with guidelines of the
				Department, to healthcare-associated infection data elements reportable to the
				NHSN.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1800 - Patient and Family Advisory Council

Current through Register 1525, July 5, 2024
A hospital shall establish a Patient and Family Advisory
				  Council to advise the hospital on matters including, but not limited to,
				  patient and provider relationships, institutional review boards, quality
				  improvement initiatives, and patient education on safety and quality matters to
				  the extent allowed by state and federal law.
(1) a hospital shall prepare an annual
				written report documenting the hospital's compliance with 105 CMR 130.1800 and
				130.1801
				and describing the Council's accomplishments during the preceding
				year.
(2) The hospital shall make
				the report required in 105 CMR 130.1800(A)(1) publicly available through
				electronic or other means, and to the Department upon request.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1801 - Policies and Procedures for Patient and Family Advisory Council

Current through Register 1525, July 5, 2024
(A) A hospital shall develop and implement
				written policies and procedures for the Council, which shall address, at a
				minimum, the following:
(1) The Council's
				purposes and goals.
(2) Membership
				of the Council including qualifications, selection, retention, term of service,
				and duties and election of officers. The Department recommends that the chair
				or co-chairs be current or former patient(s) or family member(s), or a staff
				person and a patient or family member.
(3) Orientation, training and continuing
				education for members of the Council.
(4) Roles of members of the Council, which
				may include the following as examples:
(a)
				participation on hospital committees, task forces and/or advisory
				boards;
(b) review of
				publicly-reported quality information;
(c) participation on committees addressing
				patient safety issues;
(d)
				participation on search committees and in the hiring of new hospital
				staff;
(e) participation in reward
				and recognition programs;
(f) as
				co-trainers for clinical and nonclinical staff, in-service programs, and health
				professional trainees; and
(g) any
				other role in accordance with the hospital's policies and procedures.
(5) Responsibilities of members of
				the Council, including policies that address confidentiality of patient
				information.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1900 - Definitions applicable to 105 CMR 130.1901

Current through Register 1525, July 5, 2024
The following definitions apply to
				  105
				  CMR 130.1901:
Appropriate Patient
. A patient whose
				  attending health care practitioner has:
(1) diagnosed a terminal illness or condition
				that can reasonably be expected to cause the patient's death within six months,
				whether or not treatment is provided, provided that the attending health care
				practitioner determines that discussion of the palliative care services is not
				contraindicated; or
(2) determined
				that discussion of palliative care services is consistent with the patient's
				clinical and other circumstances and the patient's reasonably known wishes and
				beliefs.
Attending Health Care Practitioner
.
				  A physician or nurse practitioner who has primary responsibility for the care
				  and treatment of the patient within or on behalf of the hospital; provided that
				  if more than one physician or nurse practitioner share that responsibility,
				  each of them shall have a responsibility under
				  105
				  CMR 130.1901, unless there is an agreement to
				  assign that responsibility to one such person.
Hospice Care Services
. Care provided
				  by an entity licensed pursuant to
				  105 CMR 141.000:
Licensure of Hospice Programs
.
Palliative Care
. The attempt to
				  prevent or relieve pain and suffering and to enhance the patient's quality of
				  life, and may include, but is not limited to, interdisciplinary end-of-life
				  care and consultation with patients and family members.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.1901 - Provision of Information on Palliative Care and End-of-life Options

Current through Register 1525, July 5, 2024
(A) Each hospital shall distribute to
				appropriate patients in its care, directly or through professionally qualified
				individuals, culturally and linguistically suitable information regarding the
				availability of palliative care and end-of-life options. This obligation shall
				be fulfilled by providing the patient with:
(1) A Department-issued informational
				pamphlet; or
(2) A similar
				informational pamphlet that meets the specifications in 105 CMR
				130.1901(B).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES › Section 130.2000 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				  105 CMR
				  130.000 are severable. If any provision herein is
				  declared unconstitutional or invalid by a court of competent jurisdiction, the
				  validity of the remaining portions shall not be so affected.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 135.000 - Use Of Blood, Blood Components, And Derivatives For The Purpose Of Transfusion › Section 135.002 - Authority

Current through Register 1525, July 5, 2024
105 CMR 135.000 is adopted
				under the authority of M.G.L. c. 111, §§ 3, 51 through 56, and
				184B.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 135.000 - Use Of Blood, Blood Components, And Derivatives For The Purpose Of Transfusion › Section 135.003 - Citation

Current through Register 1525, July 5, 2024
105 CMR 135.000 shall be
				known and may be cited as
				105 CMR 135.000:
Use of Blood, Blood Components, and Derivatives for the Purpose of
				Transfusion.
The short form of citation is Massachusetts Blood Banking
				Regulations,
				105 CMR
				135.000.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 135.000 - Use Of Blood, Blood Components, And Derivatives For The Purpose Of Transfusion › Section 135.010 - Scope

Current through Register 1525, July 5, 2024
105 CMR 135.000 applies to
				every blood bank and transfusion service operated in the Commonwealth in both
				hospital and non-hospital settings.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 135.000 - Use Of Blood, Blood Components, And Derivatives For The Purpose Of Transfusion › Section 135.020 - Definitions

Current through Register 1525, July 5, 2024
Blood Bank
means a facility equipped
				and staffed to procure, draw, process, store and/or dispense human whole blood
				and/or its components and/or derivatives.
Blood Bank Director
is a physician with
				training and experience in blood bank techniques who has the responsibility and
				authority for all medical and technical policies and procedures of a blood bank
				and/or transfusion service, and for supportive services that relate to the
				safety of patients and donors.
Component
means a product removed from
				whole blood by physical procedures.
Department
means the Massachusetts
				Department of Public Health.
Derivative
means a product removed
				from whole blood by chemical procedures.
Physician
means a doctor of medicine
				or doctor of osteopathy registered by the Board of Registration in Medicine
				under M.G.L.c. 112,§2.
Transfusion
means the administration
				of whole blood or any of its components and/or derivatives to humans.
Transfusion Service
means a service
				within a hospital designed, equipped, and staffed to dispense and/or administer
				whole blood and/or its components and/or derivatives by transfusion to
				humans.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 135.000 - Use Of Blood, Blood Components, And Derivatives For The Purpose Of Transfusion › Enforcement › Section 135.100 - Licensure and Approval

Current through Register 1525, July 5, 2024
Every blood bank in the Commonwealth shall operate in
				  accordance with
				  105 CMR 135.000 and either
				  be part of a hospital under the provisions of M.G.L. c. 111, § 51 or if
				  outside of a hospital, approved by the Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 135.000 - Use Of Blood, Blood Components, And Derivatives For The Purpose Of Transfusion › Enforcement › Section 135.110 - Inspections and Statements of Deficiency

Current through Register 1525, July 5, 2024
(A)
				All blood banks and transfusion services subject to
				105 CMR 135.000 will be
				inspected by the Department to assess their compliance with
				105 CMR 135.000. As
				evidence of such compliance, the Department will accept the American
				Association of Blood Banks (AABB) or the College of American Pathologists (CAP)
				accreditation; provided, however, that AABB or CAP, or both, if inspected by
				both, provide to the Department all statements of deficiencies and
				certification of compliance with requirement for accreditation. The Department
				retains the right to request a plan of correction and perform inspections as it
				deems necessary.
(B) Upon
				inspection, the Department will send a deficiency statement to notify the blood
				bank or transfusion service of any violation of 105CMR 135.000.The blood bank
				or transfusion service shall submit to the Department a written plan of
				correction for each violation within ten working days of receipt of the
				deficiency statement. The Department will notify the blood bank or transfusion
				service about whether the plan is acceptable or not.
(C) The Department will issue a letter of
				approval to any blood bank or transfusion service found to be in compliance
				with
				105 CMR 135.000 which is
				not part of a hospital subject to licensure by the Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 135.000 - Use Of Blood, Blood Components, And Derivatives For The Purpose Of Transfusion › Enforcement › Section 135.120 - Reports

Current through Register 1525, July 5, 2024
blood banks and transfusion services subject to
				  105 CMR 135.000 shall
				  report to the Department not later than the tenth of each month, on
				  Departmental forms, on their activities in the preceding month. The reportable
				  activities will be specified on the forms provided by the
				  Department.