Hospital Circular Letters

• General
• Emergency Department
• Healthcare Associated Infections
• Influenza Speciality Care Unit
• MASS COMM Trial
• Maternal and Newborn Services
• Medical Control Service
• Primary Angioplasty
• Reporting Cardiac Surgery and Angioplasty
• Reporting Serious Incidents
• Stroke Services
• Trauma Centers
• Treatment of Victims of Sexual Assault
  
  

General

• #09-11-524 Waiver or Modification of Federal Requirements Under Section 1135 of the Social Security Act - 11/3/2009 (PDF) | RTF 

  • Attachment A - waiver or modification of requirements (PDF) | RTF

  • Attachment B - Fact Sheet (PDF) | RTF

  • Attachment C - Requesting an 1135 Waiver (PDF) | RTF

• #09-10-523 Compliance with Regulations Regarding Influenza Vaccination of Employees when Vaccine is Unavailable - 10/21/2009 (PDF) | RTF

• #09-08-521 Guidelines for the Vaccination of Employees Against Seasonal Influenza and Pandemic A H1N1 Influenza - 9/14/2009 (PDF) | RTF 

  • Guidelines (PDF) | RTF

• #09-08-518 Emergency Regulation - Influenza Vaccination of Hospital Employees - 8/27/2009 (PDF) | RTF

  • Proposed Amendments to 105 CMR 130.000: Hospital Licensure (PDF) | RTF

  • Sample Influenza Vaccine Declination Form (PDF) | RTF

  • Sample Vaccination Declination Tracking Form (PDF) | RTF

  • Partial List of Seasonal Flu Vaccine Distributors (PDF) | RTF

• #09-07-515 Notification of Destruction of Medical Records - 7/22/2009 (PDF) | RTF 

  • Records Destruction Fax Notification Form (PDF) | RTF

• #09-07-514 Patient and Family Advisory Councils - 7/8/2009 (PDF) | RTF

• #09-07-513 Boarding of Emergency Department (ED) Patients Awaiting a Bed - 7/8/200 (PDF) | RTF 

• #09-01-504 Hospital Fire Safety and Evacuation Plans: Surges in Patient Volume/Boarding - 1/14/2009 (PDF) | RTF

• • Memorandum to Heads of Fire Departments (PDF) | Word

  • Commissioner’s Letter (PDF) | Word

• #08-12-501 Discrete Substance Abuse Treatment Programs Operating under Hospital Licenses - 12/2/2008 (PDF) | RTF

• #08-10-500 Influenza Vaccination Data Collection - 10/17/2008 (PDF) | RTF

• #08-09-499 Feasibility of Collecting Data on Restraint Use - 9/24/2008 (PDF) | RTF

• #08-07-495 Forced Removal of Clothing of Patients in Hospital Emergency Departments - 7/8/2008

• #08-03-484 Use of Cameras During the Survey Process - 3/25/2008 (PDF) | RTF

  • CMS Memorandum S&C-06-33 (provided by CMS) 

  • Consent to Photograph Form (PDF) | RTF

  • Survey Photo Log (PDF) | RTF

• #04-6-442 New Consent Requirements for Autopsy - 6/2004 (PDF) | RTF

• #01-10-420 Governing the Discontinuance of Essential Health Services - 5/9/2001 (PDF) | RTF

• #01-01-409 Temporary Placement of Medical/Surgical Patients into TCU Beds/Relicensure of Previously Licensed Space - 1/19/2001 (PDF) | RTF

• #5-98-381 Unlicensed Assistive Personnel - 5/1998 (PDF) | RTF

  • Appropriate Use of of Unlicensed Assistive Personnel in Acute Care Institutions (PDF) | RTF

• #8-94-348 Definition of Emergency Services - 8/2/1994

Emergency Department

• #09-09-522 Reducing Need for Boarding Patients and Alternate Space for Patients with Influenza-like Illness - 9/25/2009 (PDF) | RTF

  • Attachement B - EMTALA Fact Sheet (PDF) | RTF

• #09-01-505 Emergency Department Data Collection - 1/23/2009 (PDF) | RTF

  • Data Reporting Instructions

• #08-07-494 Changes to Ambulance Diversion Policies - 7/3/2008 (PDF) | RTF

Healthcare Associated Infections

• #09-09-516 Healthcare Associated Infections – Betsy Lehman Center Data - 8/19/2009 (PDF) | RTF

• #09-02-507 Healthcare Associated Infections – Public Reporting - 2/13/2009 (PDF) | RTF

• #09-01-506 Public Health Hospital Reporting Requirements - 1/26/2009 (PDF) | RTF

• #08-12-502 Additional Reporting Guidelines - 12/12/2008 (PDF) | RTF

• #08-08-498 The Infection Prevention and Control Program - MRSA Point Prevalence Survey - 8/26/2008 (PDF) | RTF

  • MRSA Point Prevalence Survey Data Collection Form (PDF) | RTF

  • Survey Instructions

• #08-06-490 Reminder: Healthcare Associated Infections Reporting Requirement in Acute Care - 6/112008 (PDF) | RTF

• #08-02-482 HAI Reporting Requirement in Acute Care Hospitals - 2/22/2008 (PDF) | RTF

  • Overview of HAI Reporting Requirement

  • Recommendations for Reporting of Healthcare-Associated Infection Measures

  • National Healthcare Safety Network (NHSN) Information

Influenza Speciality Care Unit

• #06-7-463 Influenza Speciality Care Unit - 7/2006 (PDF) | RTF

  • Pandemic Planning (PDF) | RTF

  • Emergency Site Data Form (PDF) | RTF

  • Application for DPH Licensure Approval (PDF) | RTF

  • Preparation Checklist (PDF) | RTF

MASS COMM Trial

• Revised MASS COMM Trial Protocol - 2/20/2009 (PDF) | RTF

  • Summary of Changes (PDF) | RTF

• #06-8-465 Elective Percutaneous Coronary Intervention (PCI) - 8/21/2006 (PDF) | RTF

  • Application (PDF) | RTF

  • Guidelines for Agreement (PDF) | RTF

  • Protocol (PDF) | RTF

Maternal and Newborn Services

• #06-12-469 Maternal and Newborn Service Designation 12/6/2006 (PDF) | RTF

  • Application for Designation (PDF) | RTF

  • Pre-Survey Questonnaire (PDF) | RTF

  • Licensed Bed Capacity Form (PDF) | RTF

  • Service Level Definitions (PDF) | RTF

• #06-6-461 Amendments to Hospital Licensure Governing Maternal and Newborn Services - 6/20/2006 (PDF) | RTF

  • Attachment (PDF) |  RTF

Medical Control Service

• #07-06-476 Medical Service Control Update - 6/22/2007 (PDF) | RTF

• #07-02-472 Medical Control Service Regulations - 2/7/2007 (PDF) | RTF

  • Addendum A (PDF) | RTF

  • Application for Licensure (PDF) | RTF

Primary Angioplasty

• #08-05-486 Implementation of Statewide STEMI Triage (Point-of-Entry) Criteria - 5/5/2008 (PDF) | RTF

• #6-00-405 Approval Process for Primary Angioplasty in the Treatment of Acute Myocardial Infarction (AMI) - 6/15/2000 (PDF) | RTF

  • Guidelines (PDF) | RTF

  • Revised Section VII of the Guidelines - 10/24/01 (PDF) | RTF

  • A. Letter of Application (PDF) | RTF

  • B. Guidelines for Development of Collaboration Agreement (PDF) | RTF

  • C. Application Supporting Documentation: 8 Week Log of Patients Presenting in Emergency Department with Symptoms of AMI (PDF) | RTF

  • D. CDAC's Recommended Guidelines for Clinical Care (Not Available Online)

  • E. Hospital Reporting Procedures (PDF) | RTF

  • F. CDAC Case Report Forms/Definitions (Not Available Online)

  • G. Log of Patients Presenting in Emergency Department with Symptoms of AMI (PDF) | RTF

  • H. Special Project Procedure Volume Report (PDF) | RTF

Reporting Cardiac Surgery and Angioplasty

• #02-06-426 Reporting Requirements for Cardiac Surgery and Angioplasty - 6/2002 (PDF) | RTF

• #02-01-421 Proposed Reporting Requirements for Cardiac Surgery and Angioplasty - 1/4/2002 (PDF) | RTF

Reporting Serious Incidents

• 09-06-510 Hospital Reporting of Serious Incidents (SREs) Updated Instructions - 06/22/2009 (PDF) | RTF

  • Hospital Fax Reporting Form with Directions (PDF) | RTF

• #08-07-496 Hospital Reporting of Serious Incidents (SREs) - 07/24/2008 (PDF) | RTF

  • Updated Reporting Form and Instructions (PDF) | RTF

• #08-06-489 Hospital Reporting of Serious Incidents (SREs) - 6/4/2008 (PDF) | RTF

  • List of Serious Reportable Events and Criteria for Inclusion 
    Provided by the National Quality Forum

  • Definition of Serious Disability (PDF) | RTF

• #07-12-478 Hospital Reporting of Serious Incidents - 12/13/2007 (PDF) | RTF

• #07-42-474 Hospital Reporting Requirement - 2/15/07 (PDF) | RTF

• #04-03-439 Hospital Reporting of Serious Incidents - 3/3/2004 (PDF) | RTF

• #12-98-385 Hospital Reporting of Serious Incidents - 12/12/1998 (PDF) | RTF

Stroke Services

• #09-06-512 Public Release of Aggregate Data on PSS and PSS Updates - 6/29/2009 (PDF) | RTF 

  • Draft Narrative of Web Reporting (PDF) | RTF

  • AHA/ASA Journal Article

  • Time Target Recommendations (PDF) | RTF

• #08-07-493 Primary Stroke Services Attestation - 7/16/2008 (PDF) | RTF

• #06-5-460 Information Update Regarding Designated Primary Stroke Services (PDF) | RTF

• #05-06-450 Update to Primary Stroke Services Regulation - 6/2005 (PDF) | RTF

• #04-04-440 Designation as a Provider of Primary Stroke Services - 4/13/2004 (PDF) | RTF

Trauma Centers

• #08-03-483 Requirement for the Submission of Trauma Data (Revised) - 4/30/2008 (PDF) | RTF

• #08-03-483 Requirement for the Submission of Trauma Data (Original) - 3/12/2008 (PDF) | RTF

• #05-11-454 Trauma Center Designation - 12/22/2005 (PDF) | RTF

• #08-04-443 Advisory Bulletin: Trauma Service - 8/17/2004 (PDF) | RTF

Treatment of Victims of Sexual Assault

• #08-06-492 - Emergency Contraception and Attachments A-C 06/27/2008 (PDF) | RTF

• #08-06-491 - Emergency Contraception and Attachments A-C 06/27/2008 (Revised) (PDF) | RTF

• #08-06-491 - Emergency Contraception and Attachments A-C 06/27/2008 (Original) (PDF) | RTF

  • Updated Provider Sexual Crime Report

  • Updated Comprehensive Rape Crisis Centers List (PDF) | RTF

  • Medical Eligibility Criteria for Contraceptive Use, Full Text

  • ACOG Practice Bulletins

• #08-01-481 - Updates regarding payment options and Treatment of patients following Sexual Assault - 1/18/2008 (PDF) | RTF

  • Forensic Sexual Assault Exam Expense Application (PDF) | RTF

  • Sexual Assault Evidence Collection Kit

  • Provider Sexual Crime Report

  • Comprehensive Rape Crisis Centers List (PDF) | RTF

• #07-04-475 - Emergency Contraception Reminder - 4/19/2007 (PDF) | RTF

  • Hospital Affirmations (PDF) | RTF

• #06-6-462 - Emergency Contraception Update - 7/1/2006 (PDF) | RTF

• #05-12-456 - Notice to Acute Care Hospitals re: Emergency Contraception - 12/2005 (PDF) | RTF