reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart A - LICENSING AND OTHER ADMINISTRATIVE PROCEDURES › Section 130.127 - Emergency Department Wayfinding, Signage, Lighting and Security Requirements

Current through Register 1525, July 5, 2024
On and after January 1, 2024, hospitals with emergency
				  departments must adhere to the wayfinding, signage, and security requirements
				  in 105 CMR 130.127 and in guidelines of the Department.
(A)
Signage and
				Wayfinding
.
(1) Public entrances
				to the emergency department shall be clearly marked from external approaches
				and shall be identified by exterior signage and visible from public
				thoroughfares. Signs identifying the emergency department shall read
				"EMERGENCY" in all caps in red on a white background or white on a red
				background and public entrances to emergency departments when applicable, shall
				be distinguishable from the emergency department ambulance entrance.
(2) Emergency department patient drop off and
				entry areas and hospital perimeter doors, which include, but may not be limited
				to, doors that are locked at night, main entrance doors, emergency department
				entrance doors, ambulance entrances and any door a patient may typically use to
				enter the hospital, shall be well lit and include directions to the emergency
				department. Emergency patient vehicle drop off and external and internal entry
				areas shall be lit to be distinguishable from other entrances.
(3) Exterior hospital entry points shall be
				clearly identified from all major exterior routes including roadways, public
				transportation stops, and vehicular parking.
(4) Exterior hospital emergency department
				identification and directional signs shall be sufficiently lit to allow drivers
				and pedestrians to see signage after dark and during inclement weather.
				Hospitals must place directional signs leading to the emergency department in
				such a manner as to ensure visual continuity in accordance with guidance from
				the Department.
(5) Exterior
				wayfinding shall clearly define the access pathways from public thoroughfares
				to the hospital main entrance and emergency department entrance.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart A - LICENSING AND OTHER ADMINISTRATIVE PROCEDURES › Section 130.128 - Annual Review

Current through Register 1525, July 5, 2024
Hospitals with emergency departments shall conduct an annual
				  review of security, wayfinding, signage and lighting policies and procedures,
				  technologies and features. At minimum, the review shall take place during the
				  daytime and nighttime, and shall include plans to maintain and keep lighting,
				  footpaths and signs clear of debris, vegetation, or snow; include a review of
				  surveillance monitoring and patrols by hospital security; include a review of
				  the effectiveness of hospital signs and symbols for patients for whom English
				  is not their first language; and any additional requirements included in
				  guidelines of the Department. Hospital personnel from multiple departments,
				  including security, facilities maintenance, risk management and the emergency
				  department, or their equivalent positions, shall participate in the annual
				  review. Policies and procedures should be reviewed annually and made available
				  to DPH upon request.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart A - LICENSING AND OTHER ADMINISTRATIVE PROCEDURES › Section 130.130 - Grounds for Refusal to Renew and Revocation of a License

Current through Register 1525, July 5, 2024
The Department may refuse to renew, or revoke a license,
				  either wholly or with respect to a specific service or specific services, or a
				  part or parts thereof, for cause. Cause shall include, but shall not be limited
				  to, the following:
(A) Lack of legal
				capacity to provide the service(s) to be covered by a license;
(B) Lack of responsibility and suitability to
				operate a hospital;
(C) Failure to
				submit the required license fee;
(D) Violation of any relevant state or
				federal statute or regulation pertaining to operation of the
				hospital;
(E) Violation of any
				applicable provision of
				105 CMR
				130.000 and failure to submit an acceptable plan of
				correction pursuant to
				105 CMR
				130.112; or failure to remedy or correct a
				cited violation by the date specified in the plan;
(F) Willful misrepresentation of information
				or data submitted to the Department or any other agency of the Commonwealth;
				or
(G) Failure to participate in
				risk management programs as required under M.G.L. c. 111, §
				203(d).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart A - LICENSING AND OTHER ADMINISTRATIVE PROCEDURES › Section 130.131 - Refusal to Renew or Revocation of a License or Part of a License: Right to Prior Adjudicatory Proceeding

Current through Register 1525, July 5, 2024
Whenever the Commissioner decides to revoke or refuse to
				  renew a license or part of a license, he or she shall initiate an adjudicatory
				  hearing in accordance with the requirements of M.G.L. c. 30A. All such
				  adjudicatory proceedings shall be conducted in accordance with
				  801 CMR 1.00:
Adjudicatory Rules of Practice and
				  Procedure
.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart A - LICENSING AND OTHER ADMINISTRATIVE PROCEDURES › Section 130.132 - Grounds for Suspension: Right to Subsequent Adjudicatory Proceeding

Current through Register 1525, July 5, 2024
(A) The Commissioner may suspend a hospital's
				license or a part of its license covering a specific service or specific
				services or a part or parts thereof, or suspend admissions to the hospital or
				further functioning of its emergency department or operating room(s), if he or
				she decides that any violation of state law or
				105 CMR
				130.000 poses an imminent risk to the safety or proper
				medical care of the hospital's patients. The Commissioner shall give the
				licensee written notice thereof, stating the reason(s) for the suspension. The
				suspension or other sanction shall take effect immediately upon issuance of the
				notice. The Department shall commence an adjudicatory hearing within 21
				calendar days of the notice of suspension as set forth in
				105
				CMR 130.131. The subject of such a hearing
				shall be limited to the facts relating to the suspension.
(B) In the event the Commissioner determines
				that the violation of state law or of
				105 CMR
				130.000 that posed an imminent risk to the safety or
				proper medical care of the hospital's patients is corrected prior to the
				decision of the hearing officer, the Commissioner may lift the suspension by
				giving written notice to the hospital.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart A - LICENSING AND OTHER ADMINISTRATIVE PROCEDURES › Section 130.133 - Final Agency Decision and Judicial Review

Current through Register 1525, July 5, 2024
The decision of a hearing officer in any adjudicatory
				  proceeding conducted pursuant to
				  105
				  CMR 130.131 or
				  130.132
				  shall be reviewed by the Commissioner. The Commissioner's decision upon this
				  review shall constitute a final agency decision in an adjudicatory proceeding
				  subject to judicial review pursuant to M.G.L. c. 30A, §
				  14.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart B - GENERAL REQUIREMENTS › Section 130.200 - Incorporation of Medicare Conditions of Participation in Hospitals

Current through Register 1525, July 5, 2024
Each hospital shall meet all of the requirements of the
				  Medicare Conditions of Participation for Hospitals,
				  42
				  CFR 482.11 through
				  482.62
				  (Conditions of Participation), except the requirement for institutional plan
				  and budget specified in
				  42 CFR
				  482.12(d), for utilization
				  review specified in
				  42 CFR
				  482.30, the requirement for compliance with
				  the Life Safety Code specified in
				  42 CFR
				  482.41(b), and any
				  requirement that conflicts with the Supplementary Standards in
				  105 CMR
				  130.000.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart B - GENERAL REQUIREMENTS › Section 130.202 - Accreditation as Equivalent: Deemed Status

Current through Register 1525, July 5, 2024
(A)
				If a hospital is currently accredited by the Joint Commission, AOA, or another
				accrediting body approved by CMS and the Commissioner, the Commissioner may
				deem the hospital to meet all the requirements of the Conditions of
				Participation except any requirement promulgated by regulation by the Secretary
				of Health and Human Services pursuant to
				42
				U.S.C. §
										1395x(e)(9)
				which the Secretary, after consulting with the Joint Commission, AOA or another
				accrediting body approved by CMS and the Commissioner, identifies as being more
				stringent or more precise than the requirements for accreditation; and except
				the requirements for utilization review specified in
				105
				CMR 130.200; and with respect to psychiatric
				hospitals subject to licensure.
(B)
				Each accredited hospital which desires to obtain deemed status shall release to
				the Commissioner a copy of the hospital's current accreditation letter and the
				accrediting agency's explanation of its survey findings. The hospital shall
				also sign a Department consent form indicating it:
(1) Agrees to permit Department observers at
				the summation conferences scheduled at the completion of an accreditation;
				and
(2) Agrees upon request to
				release to the Commissioner any other accreditation information
				requested.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart B - GENERAL REQUIREMENTS › Section 130.203 - Validation Survey

Current through Register 1525, July 5, 2024
The Commissioner may require a survey of an accredited
				  hospital to verify the hospital has implemented the accrediting agency's
				  recommendations for correction of deficiencies. The Department may identify
				  hospitals for such surveys on a selective sample basis, or on the basis of the
				  severity of deficiencies cited by the accrediting agency, or on the basis of
				  the hospital's history of noncompliance with
				  105 CMR
				  130.000.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart B - GENERAL REQUIREMENTS › Section 130.204 - Loss of Deemed Status

Current through Register 1525, July 5, 2024
(A) The
				Commissioner may revoke the deemed status of an accredited hospital if:
(1) The hospital fails to cooperate in the
				conduct of a Department validation survey or complaint investigation;
(2) The hospital fails to comply with any of
				the provisions of
				105
				CMR 130.202(A) and (B);
				or
(3) The Commissioner finds the
				hospital is out of compliance with one or more Conditions of Participation and
				a significant deficiency is determined to exist.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart B - GENERAL REQUIREMENTS › Section 130.205 - Requirements for Non-accredited Hospitals

Current through Register 1525, July 5, 2024
If a hospital is not accredited by the Joint Commission, AOA,
				  or another accrediting body approved by CMS and the Commissioner, or chooses
				  not to participate in the deemed status licensure program as set forth in
				  105
				  CMR 130.202 through
				  130.204, it shall be subject
				  to a full survey for licensure by the Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart B - GENERAL REQUIREMENTS › Section 130.206 - Prohibition Against Discrimination

Current through Register 1525, July 5, 2024
(A) No
				hospital shall discriminate in the provision of service against any person on
				the basis of race, creed, color, sex, handicap, or national origin.
(B) No hospital which participates in the
				Medicaid program under Title XIX of the Social Security Act shall discriminate
				in the provision of service against any Medicaid recipient.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.310 - Director of Nursing Service

Current through Register 1525, July 5, 2024
Each hospital shall establish a nursing service under the
				  direction of a registered nurse, currently registered by the Board of
				  Registration in Nursing under M.G.L. c. 112, § 74, who holds a
				  baccalaureate degree in nursing and who has had at least four years experience
				  in nursing practice, at least two of which were in an administrative or
				  supervisory capacity.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.311 - Registered Nurse Coverage

Current through Register 1525, July 5, 2024
There shall be a sufficient number of registered nurses on
				  duty at all times to plan, supervise and evaluate nursing care, as well as to
				  give patients the nursing care that requires the judgment and specialized
				  skills of a registered nurse.
(A)
Supervisory Coverage
. Registered nurses shall be
				assigned to supervise nursing care and nursing personnel according to a written
				staffing plan that provides for adequate coverage for all nursing units during
				each shift.
(B)
Unit
				Coverage
. At least one registered nurse shall be assigned to work
				in each nursing unit at all times. The only exceptions to
				105
				CMR 130.311(B)  shall be the
				following:
(1) If a registered nurse is on
				duty in one nursing unit of a skilled nursing unit or of a chronic disease
				hospital, an adjoining nursing unit (on the same floor or floor above or below,
				if readily accessible) may be staffed by licensed practical nurses, provided
				that the registered nurse on duty shall be readily available to go from one
				nursing unit to another when skilled nursing services are needed.
(2) If a registered nurse is available to
				provide supervision and skilled nursing services when needed, an outpatient
				ambulatory care unit (not an emergency service unit) in which skilled nursing
				care is not routinely needed, may be staffed by licensed practical
				nurses.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.312 - Registered Nurses, Licensed Practical Nurses, and Ancillary Staff Coverage

Current through Register 1525, July 5, 2024
The number of registered nurses, licensed practical nurses
				  and unlicensed nursing personnel assigned to each nursing unit shall be
				  consistent with the types of nursing care needed by the patients and the
				  capabilities of the staff.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.313 - Licensed Mental Health Professionals in Emergency Departments or Satellite Emergency Facilities

Current through Register 1525, July 5, 2024
(A) A hospital
				shall ensure that a sufficient number of licensed mental health professionals
				are available at all times in an emergency department or a satellite emergency
				facility to assess, evaluate and stabilize, either in person or
via
telehealth, or electronic or telephonic consultation, a
				person who presents with a primary mental health concern, and, if appropriate,
				to refer such person for appropriate follow up, treatment or inpatient
				admission.
Individuals with a master's degree in a clinical behavioral
				  health practice pursuing licensure post master's under the supervision of an
				  appropriately licensed and credentialed clinician may be considered a "licensed
				  mental health professional" for purposes of 130.313.
(B) A hospital with an emergency department
				or satellite emergency facility must establish policies and procedures for an
				expedited assessment, evaluation and stabilization process for a person younger
				than 22 years old presenting with a primary mental health concern.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.320 - Satellite Units

Current through Register 1525, July 5, 2024
A satellite unit shall comply with all relevant requirements
				  in 105 CMR
				  130.000.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.325 - Requirement That Personnel Be Vaccinated against Influenza Virus

Current through Register 1525, July 5, 2024
(A)
Definitions
.
(1) For purposes of
				105
				CMR 130.325, personnel means an individual or
				individuals who either work at or come to the licensed hospital and who are
				employed by or affiliated with the hospital, whether directly, by contract with
				another entity, or as an independent contractor, paid or unpaid including, but
				not limited to, employees, members of the medical staff, contract employees or
				staff, students, and volunteers, whether or not such individual(s) provide
				direct patient care.
(2) For
				purposes of
				105
				CMR 130.325, the requirement for influenza
				vaccine or vaccination means immunization by either influenza vaccine,
				inactivated or live; attenuated influenza vaccine, including seasonal influenza
				vaccine pursuant to
				105
				CMR 130.325(B); and/or other
				influenza vaccine pursuant to
				105
				CMR 130.325(C).
(3) For purposes of
				105
				CMR 130.325, mitigation measures mean
				measures that personnel who are exempt from vaccination take to prevent viral
				infection and transmission.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.326 - Requirement That Personnel Be Vaccinated against Coronavirus Disease 2019 (COVID-19) Caused by the Virus SARS-CoV-2

Current through Register 1525, July 5, 2024
(A)
Definitions
.
(1) For
				purposes of
				105
				CMR 130.326, personnel means an individual or
				individuals who either work at or come to the licensed hospital and who are
				employed by or affiliated with the hospital, whether directly, by contract with
				another entity, or as an independent contractor, paid or unpaid including, but
				not limited to, employees, members of the medical staff, contract employees or
				staff, students, and volunteers, whether or not such individual(s) provide
				direct care.
(2) For purposes of
				105
				CMR 130.326, COVID-19 vaccination means being
				up-to-date with COVID-19 vaccines recommended by the Centers for Disease
				Control and Prevention (CDC).
(3)
				For purposes of
				105
				CMR 130.326, mitigation measures mean
				measures that personnel who are exempt from vaccination take to prevent viral
				infection and transmission.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.330 - Serious Complaint Procedure

Current through Register 1525, July 5, 2024
Each hospital shall develop a written procedure that assures
				  prompt and complete investigations of all serious complaints filed against the
				  hospital, employees of the hospital or members of its medical or professional
				  staff. The procedure shall include, at a minimum, the following
				  provisions:
(A) Designation of a
				senior member of the hospital administration as the person responsible for
				overseeing the investigation of serious complaints lodged against the hospital,
				an employee or member of the medical staff;
(B) Establishment of a reporting procedure
				that ensures the designated administrator will receive within one day from
				hospital staff, in writing, reports of serious complaints;
(C) Development by the designated
				administrator of a written process of investigation, which shall include the
				following:
(1) A process of fact-gathering
				that he or she will utilize, including provision for interviewing of the
				complainant, patient, and relevant witnesses;
(2) Creation of a complaint file that
				includes the original report of complaint, progress reports as investigation is
				carried out and outcome of investigation including action taken, if
				any;
(3) Notification of the
				complainant of the outcome of the investigation.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.331 - Serious Incident and Accident Reports

Current through Register 1525, July 5, 2024
(A)
				Each hospital shall immediately report to the Department, pursuant to
				Department guidelines, any of the following occurring on premises covered by
				its license:
(1) Death that is unanticipated,
				not related to the natural course of the patient's illness or underlying
				condition, or that is the result of an error or other incident as specified in
				guidelines of the Department;
(2)
				Full or partial evacuation of the facility for any reason;
(3) Fire;
(4) Suicide;
(5) Serious criminal acts;
(6) Pending or actual strike action by its
				employees, and contingency plans for operation of the hospital; and
(7) Other serious incidents or accidents as
				specified in guidelines of the Department.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.332 - Serious Reportable Events (SREs) and Serious Adverse Drug Events (SADE)

Current through Register 1525, July 5, 2024
(A)
Definitions Applicable to
				105
				CMR 130.332
.
National Quality Forum (NQF)
. The
				  not-for-profit membership organization created to lead national collaboration
				  to improve health and measurement and reporting.
Preventable
. An event that could
				  have been anticipated and prepared for, but that occurs because of an error or
				  other system failure, including, but not limited to lack of adherence to best
				  practices, patient safety guidelines or established policies and
				  procedures.
Serious Adverse Drug Event (SADE)
.
				  Any untoward, preventable medical occurrence associated with the use of a
				  controlled substance, as defined in M.G.L. c. 94C, § 1, in humans that
				  results in any of the following outcomes:
(1) death;
(2) a life-threatening outcome;
(c) inpatient hospitalization or prolongation
				of existing hospitalization;
(d) a
				persistent or significant incapacity or substantial disruption of the ability
				to conduct normal life functions; or
(e) a congenital anomaly or birth defect;
				provided, however, that adverse medical occurrences directly associated with
				the use of a controlled substance in humans that may not immediately result in
				one of the outcomes listed in
				105
				CMR 130.332:
Serious Adverse Drug
				Event (SADE)
(a) through (e) may be considered a serious adverse
				drug event when they develop into or result in any of the outcomes listed in
				105
				CMR 130.332:
Serious Adverse Drug
				Event (SADE)
(a) through (e).
Serious Reportable Event (SRE)
. An
				  event that occurs on premises covered by a hospital's license that results in
				  an adverse patient outcome, is clearly identifiable and measurable, has been
				  identified to be in a class of events that are largely preventable and harmful,
				  and of a nature such that the risk of occurrence is significantly influenced by
				  the policies and procedures of the hospital. The Department will issue a list
				  of SREs based on those events included on the NQF table of reportable events to
				  which
				  105
				  CMR 130.332 applies.
Unambiguously the Result of a System
				  Failure
. Events determined by the hospital to result
				  from:
(1) a failure to follow
				the hospital's policies and procedures;
(2) inadequate or non-existent hospital
				policies and procedures; or
(3)
				inadequate system design.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.333 - Required Hospital Capacity Reporting

Current through Register 1525, July 5, 2024
(A) Each
				hospital shall report data to the Department documenting the hospital's staffed
				beds and occupied bed capacity to inform the Department's and hospitals'
				awareness of hospital capacity in the Commonwealth; to support the
				identification of patterns and trends in overall hospital capacity, resource
				utilization, and other key metrics; and to inform the Department's response to
				potential or active urgent or emergent situations, as determined by
				Department.
(B) Each hospital shall
				report in accordance with Department guidelines for reporting hospital capacity
				data, including the means of reporting. Such means of reporting may include a
				secure, Internet-based, emergency information management platform utilized by
				the Department for this purpose or any other platform, manner, or method
				identified in Department guidelines.
(C) Data reported to the Department pursuant
				to 105 CMR 130.333 shall
				include, but not be limited to:
(1) staffed
				beds by licensed bed type;
(2)
				occupied beds by licensed bed type;
(3) patient demographics for beds reported
				pursuant to
				105
				CMR 130.333(A);
				and
(4) other information as
				specified in the Department's guidelines necessary for the Department and
				hospitals to understand hospital capacity in the Commonwealth.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.340 - Discharge Planning Service Required

Current through Register 1525, July 5, 2024
(A)
				Each acute-care hospital shall organize a multi-disciplinary discharge planning
				service to aid the attending physician and the patient and/or as appropriate
				the patient's family/patient representative in planning for the continuing care
				needs of the patient upon discharge from the hospital. The discharge planning
				service shall be responsible for coordinating the transfer of the patient from
				the hospital setting to an appropriate independent living arrangement or to
				another institution.
For the purposes of 105 CMR 130.000, a patient representative
				  may be a court-appointed guardian; a person with written authorization to act
				  on the patient's behalf; or if neither of the above is available, a person who
				  has been known to the patient and determined by the discharge planning service
				  to be acting responsibly on the patient's behalf.
(B) Each patient receiving discharge planning
				services in a hospital licensed under 105 CMR 130.000 shall have the following
				rights as set forth in 105 CMR 130.000:
(1) To
				participate in the discharge planning process to the maximum extent possible,
				with the assistance of family members or other representatives where the
				patient does not object to such assistance.
(2) To review any information which the
				hospital has about out-of-hospital resources including community based services
				capable of meeting the patient's discharge needs.
(3) To receive a written discharge plan, in
				non-technical language, along with sufficient oral explanations to assist the
				patient in understanding the plan.
(4) To acknowledge participation in and
				receipt of the discharge plan by signing it and, where the patient is unable or
				refuses to sign the plan, to have the reasons for such inability or refusal
				noted in the patient's medical records.
(5) To meet with the discharge planning
				coordinator and physician to attempt to resolve questions or disagreements
				about the discharge plan.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.341 - Discharge Planning Coordinator and Staff

Current through Register 1525, July 5, 2024
(A) The hospital administrator in conjunction
				with the nursing and Case Management department and other hospital departments
				as appropriate shall designate a specific individual or unit to be responsible
				for coordination of discharge planning.
(B) If an individual, the coordinator for
				discharge planning shall be a licensed professional approved by the hospital.
				The individual shall have competence to carry out discharge planning
				responsibilities based on education, experience, and knowledge of community
				resources.
(C) Whenever a specific
				discharge planning unit is designated, there shall be at least a licensed
				professional approved by the hospital assigned to the unit to assess patient
				needs and to plan together for continuity of patient care. Accountability for
				all aspects of the service of the unit shall be clearly delineated in the
				hospital's organizational and administrative documents.
(D) The hospital shall retain sufficient
				staff to provide discharge planning services to all patients requiring such
				services.
(E) A discharge planning
				coordinator shall be a member of the Utilization Review Committee.
(F) There shall be an effective mechanism in
				place that establishes timely communication between discharge planning staff
				and the utilization review coordinator.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.342 - Discharge Planning

Current through Register 1525, July 5, 2024
(A) There shall be
				written policies and procedures concerning the implementation of discharge
				planning services, which reflect acceptable standards of practice and
				compliance with applicable regulations.
(B) The coordinator of discharge planning or
				discharge planning unit shall be responsible for the coordination of patients'
				plans for continuing care in cooperation with the patient's physician, nurse
				practitioner or physician's assistant and in cooperation with the patient,
				and/or the family/representative as appropriate and other members of the
				professional staff.
(C) The
				coordinator of discharge planning or the discharge planning unit shall
				establish effective systems for identifying patients in need of the hospital's
				discharge planning service. The goal of these systems shall be the early, as
				well as ongoing, identification of patients in need of discharge planning
				assistance.
(1) These systems shall include
				but not be limited to:
(a) requests for
				discharge planning consultation from the professional staff, the patient, or
				his or her family/patient representative;
(b) regular multidisciplinary meetings to
				review an individual patient's need for continuing care; and
(c) implementation of a high risk screening
				system to identify patients who may require discharge planning
				services.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.343 - Discharge Plan

Current through Register 1525, July 5, 2024
(A) Each patient
				determined to need assistance with arrangements for post-hospital care shall
				have a comprehensive, individualized discharge plan, which is in writing and is
				consistent with medical discharge orders and identified patient needs. A
				discharge plan for patients treated in the emergency department of an acute
				hospital shall mean a plan that addresses the specific problem for which the
				patient is seen in the emergency department.
Except for the requirements of 105 CMR 130.343(B) and (D)
				  through (F), the requirements of
				  105 CMR
				  130.342 do not apply to Medicare patients who
				  are transferred from the emergency department of one acute hospital to another
				  acute hospital and to a Medicare patient residing in a nursing home who, after
				  treatment in an emergency department, is returned back to that nursing home
				  provided appropriate transfer/referral forms are properly completed to include
				  information to assure continuity of care.
The plan shall include at least the following
				  information:
(1) identification of the
				post hospital services needed by the patient including home health and
				homemaker service, and of the post-hospital social needs of the patient, as
				determined in accordance with procedures set forth in
				105 CMR
				130.342;
(2) the services arranged for the
				patient;
(3) the names, addresses
				and telephone numbers of service providers;
(4) the service schedule as requested by the
				hospital;
(5) medications
				prescribed and instructions for their use or verification that such information
				was provided separately; and
(6)
				scheduled follow-up medical appointments or verification that such information
				was provided separately.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.344 - Patient Signature Requirement

Current through Register 1525, July 5, 2024
(A) The
				discharge plan provided to the patient or as appropriate the patient's
				family/patient representative shall include a signature line for the patient
				and/or as appropriate the patient's family/patient representative to
				acknowledge their participation in the development of the discharge plan and
				their receipt of the written plan.
(B) A copy of the signed discharge plan shall
				be retained in the patient's record.
(C) If the patient or as appropriate the
				patient's family/patient representative does not sign the plan, the reason for
				not signing, including any objection to the plan, shall be noted on the written
				plan and a copy shall be retained in the patient's medical record.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.346 - Timely Transfer of Information and Notice of Discharge

Current through Register 1525, July 5, 2024
(A) The discharge planning service shall be
				responsible for the coordination of the timely transfer of appropriate
				information from the hospital to the post-hospital institution or agency caring
				for the patient in order to ensure continuity of patient care. The discharge
				planning coordinator or discharge planning unit shall carry out this function
				in conjunction with other health care professional(s) responsible for the
				completion of referral information required by
				105 CMR
				130.000 and in accordance with hospital policy.
(1) When a patient is transferred to another
				institution, a patient assessment form with pertinent patient care information
				to assure continuity of care shall be completed and shall accompany the
				patient.
(2) When a patient is
				discharged and referred to a community agency for continuing care, a patient
				care referral form with pertinent patient care information to assure continuity
				of care shall be completed and sent to the agency prior to or at the time of
				patient discharge.
(3) The medical
				discharge summary shall be sent by the hospital to the receiving inpatient
				institution at the time of the patient's discharge or to the appropriate
				community agency no later than 72 hours following discharge of the
				patient.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.347 - Discharge Planning Records

Current through Register 1525, July 5, 2024
The discharge planning service shall maintain records that
				  enable appropriate hospital personnel to prepare periodic reports about
				  discharge planning services, including the number and types of placement and
				  referrals.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.348 - Monitoring Quality of Service

Current through Register 1525, July 5, 2024
The discharge planning service shall develop and implement a
				  system to monitor the quality of the discharge planning services provided by
				  the hospital.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.349 - Follow-up Monitoring

Current through Register 1525, July 5, 2024
There shall be a program for the routine follow-up monitoring
				  of selected discharged patients for whom post-hospital services were
				  arranged.
(1) The program shall at
				least include follow-up monitoring of patients discharged with multiple
				services or otherwise complex post-hospital needs and lack of an informal
				personal support network.
(2) There
				shall be a written plan for follow-up monitoring that at a minimum describes
				which patients will be monitored, the time frame for the follow-up monitoring,
				including which patients require a follow-up contact within 24 hours of the
				planned initiation of service.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.365 - Substance Use Disorder Services

Current through Register 1525, July 5, 2024
No hospital may offer a substance use disorder treatment
				  program unless issued an approval for such program by the Department's Bureau
				  of Substance Abuse Services.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.371 - Posting of Notice of Patients' Rights

Current through Register 1525, July 5, 2024
A hospital shall have visibly posted a notice that has the
				  heading "NOTICE OF PATIENTS' RIGHTS" in block letters at least one inch high
				  that contains all the rights provided by M.G.L. c. 111, § 70E. The notice
				  shall be posted in at least one central area where all patients are likely to
				  see it. In addition, each patient, upon admittance to the hospital, shall be
				  given a written document containing all the rights provided by M.G.L. c. 111,
				  § 70E.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.380 - Anatomical Donations

Current through Register 1525, July 5, 2024
In accordance with M.G.L. c. 113A and the terms defined
				  therein, each hospital shall enter into agreements or affiliations with organ
				  procurement organizations for coordination of procurement and use of anatomical
				  gifts. Each hospital shall make a reasonable search of an individual whom the
				  hospital reasonably believes to be dead or near death for a document of gift or
				  other information identifying the individual as a donor or as an individual who
				  has made a refusal. For the purposes of 105 CMR 130.380, an individual who has
				  sustained either:
(1) irreversible
				cessation of circulatory and respiratory functions; or
(2) irreversible cessation of all functions
				including the entire brain, including the brain stem, is dead. Determination of
				death shall be made in accordance with accepted medical standards.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.382 - Autopsy Consent Procedures

Current through Register 1525, July 5, 2024
(A) No hospital
				shall permit the autopsy of a decedent without the consent of the authorized
				person named in
				105 CMR
				130.386. Any such consent shall meet the
				requirements set forth in
				105 CMR
				130.384.
(B) No hospital that performs an autopsy
				shall use organs removed from the body for any purpose other than to determine
				a medical disease or condition, or the cause or manner of death unless the
				person authorizing the autopsyconsents to such other use, or unless otherwise
				required by law. Any such consent shall meet the requirements set forth in
				105 CMR
				130.384(A)(6).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.383 - Autopsies Performed Pursuant to M.G.L. c. 38, Section 4

Current through Register 1525, July 5, 2024
The requirements of
				  105 CMR
				  130.382 through
				  130.387
				  shall not apply to autopsies performed by a hospital pursuant to M.G.L. c. 38,
				  § 4; provided, however, that when the chief medical examiner or his or her
				  designee releases the body of a decedent, the hospital shall not retain or
				  otherwise dispose of any organs released with the body without consent that
				  meets the requirements of
				  105 CMR
				  130.384(A)(6).
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.384 - Autopsy Consent Requirements

Current through Register 1525, July 5, 2024
(A) The
				hospital shall use a standardized written autopsy consent form that includes at
				a minimum:
(1) the name of the decedent and
				date and time of death;
(2) the
				name of the hospital where the autopsy is to be conducted;
(3) the general purpose for which the autopsy
				is to be conducted;
(4) opportunity
				for the person authorizing the autopsy to state any specific requests or
				concerns regarding the autopsy. If the hospital is unable to comply with any
				such request or address any such concern, the hospital shall not perform an
				autopsy on the decedent.
(5)
				opportunity for the person authorizing the autopsy to specify any limitations
				on the autopsy;
(6) a separate
				section regarding disposition of the organs following the autopsy, including:
(a) notification that the person authorizing
				the autopsy has the right to control the final disposition of the
				organs;
(b) a statement that the
				hospital will return all organs with the body of the decedent at the time the
				body is released, except for those organs for which prolonged fixation or
				complete detailed examination is required to complete the autopsy, unless the
				person authorizing the autopsy affirmatively designates an alternate
				disposition. The hospital shall specify those particular organ(s) for which
				prolonged fixation or detailed examination is required to complete the autopsy
				and inform the person authorizing the autopsy that he or she has the right to
				control the final disposition of the organ(s) being retained. If at the time
				consent is requested the hospital cannot specify with certainty the organs for
				which prolonged fixation or detailed examination is required, it shall so state
				and shall specify the time and manner in which it will provide the information
				about such organs to the person authorizing consent.
(c) opportunity to designate the disposition
				of the organs, including but not limited to for research purposes. The hospital
				may limit such disposition to those methods that conform to all applicable
				requirements for safe handling and disposal of organs.
(7) the signature and printed name of the
				person who obtained the consent, including his or her title and relationship to
				the hospital;
(8) the signature and
				printed name of a witness to the consent;
(9) the date and time of the signing of the
				consent form;
(10) the printed name
				of the person who is authorized to consent to the autopsy pursuant to
				105 CMR
				130.386, including his or her relationship to
				the decedent; and
(11) the
				signature of the person authorizing the autopsy.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.385 - Telephonic Consent

Current through Register 1525, July 5, 2024
A hospital may obtain consent to autopsy by telephone. Such
				  consent shall be valid without the signature of the person authorizing consent
				  if it meets all of the following requirements:
(A) The consent shall follow a conversation
				that meets the following requirements:
(1) The
				person requesting the consent shall read in its entirety the consent form
				specified in
				105 CMR
				130.384 to the person authorizing consent and
				shall mark answers to all items in the presence of the witness;
(2) The person authorizing consent shall have
				the opportunity to ask questions regarding the scope and purpose of the
				autopsy; and
(3) The witness shall
				listen to the conversation in its entirety, with the permission of all parties
				to the conversation.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.386 - Classes of Persons Authorized to Consent

Current through Register 1525, July 5, 2024
(A)
				The following order of priority is set forth for persons authorized to give
				consent for an autopsy:
(1) an agent of the
				decedent including, but not limited to, a health care agent appointed under a
				health care proxy pursuant to M.G.L. c. 201D, unless the power of attorney for
				health care or other record prohibits the agent from consenting to an
				autopsy;
(2) the spouse of the
				decedent;
(3) an adult child of the
				decedent;
(4) a parent of the
				decedent;
(5) an adult sibling of
				the decedent;
(6) an adult
				grandchild of the decedent;
(7) a
				grandparent of the decedent;
(8) an
				adult who exhibited special care and concern for the decedent;
(9) a person who was acting as a guardian of
				the decedent at the time of death; or
(10) any other person having the authority to
				dispose of the decedent's body.
Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.387 - Responsibilities of Hospital Regarding Consent to Autopsy

Current through Register 1525, July 5, 2024
The hospital shall establish written policies and procedures
				  consistent with
				  105 CMR
				  130.382 through 105 CMR 130.387, including
				  procedures for obtaining and documenting consent that meets the requirements in
				  105 CMR
				  130.384 and
				  130.385.