• General
• Emergency Department
• Healthcare Associated Infections
• MASS COMM Trial
• Maternal and Newborn Services
• Medical Control Service
• MOLST (Medical Orders for Life-Sustaining Treatment)
• Primary Angioplasty
• Reporting Cardiac Surgery and Angioplasty
• Reporting Serious Incidents
• Stroke Services
• Trauma Centers
• Treatment of Victims of Sexual Assault

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General

• #12-05-562 Clarification of Out-of-Hospital Dialysis Unit Regulations - 5/7/2012 
• #11-11-553 Data Submission Instructions for Seasonal Influenza Vaccination of Employees at Massachusetts Health Facilities for the 2011-2012 Influenza Season - 12/14/2011 
• #11-02-546 Updated Data Submission Instructions for Seasonal Influenza Vaccination of Employees - 2/25/2011 

• #11-01-545 Care Transitions and Universal Transfer - 1/18/2011 

  • Universal Transfer Form and Instructions  file size 25MB
• #11-01-544 Hospital Obligations under (EMTALA) related to Behavioral Health Patients - 1/14/2011 
• #10-12-541 Condition of Licensure: Immunization of Healthcare Personnel Against Influenza - 12/6/2010 
• #10-11-540 Infection Prevention during Blood Glucose Monitoring and Insulin Administration - 11/24/2010 
• #10-10-536 Clarification Regarding Authorized Vaccinators for the 2010 - 2011 Influenza Season - 10/5/2010 
• #10-09-535 Reporting and Data Collection Guidelines for Seasonal Influenza Vaccination of Employees at Massachusetts Health Facilities for the 2010-2011 Influenza Season 9/22/2010 
• #10-05-534 Changes in Procedures for Distributing Circular Letters - Request for Email Contact Information - 5/14/2010 

• #09-12-526 Reporting and Data Collection Guidelines for Seasonal Influenza Vaccination of Personnel for the 2009-2010 Influenza Season - 12/10/2009 

  • Amendments to Guidelines 

• #09-12-525 Update on Regulations Regarding Influenza Vaccination of Employees and Annual December 15th Deadline - 12/4/2009 

  • Amendments to Regulations 

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

  • Attachment A - waiver or modification of requirements 
  • Attachment B - Fact Sheet 
  • Attachment C - Requesting an 1135 Waiver 
• #09-10-523 Compliance with Regulations Regarding Influenza Vaccination of Employees when Vaccine is Unavailable - 10/21/2009 

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

  • Guidelines 

• #09-08-518 Emergency Regulation - Influenza Vaccination of Hospital Employees - 8/27/2009 

  • Proposed Amendments to 105 CMR 130.000: Hospital Licensure 
  • Sample Influenza Vaccine Declination Form 
  • Sample Vaccination Declination Tracking Form 
  • Partial List of Seasonal Flu Vaccine Distributors 

• #09-07-515 Notification of Destruction of Medical Records - 7/22/2009 

  • Records Destruction Fax Notification Form 
• #09-07-514 Patient and Family Advisory Councils - 7/8/2009 
• #09-07-513 Boarding of Emergency Department (ED) Patients Awaiting a Bed - 7/8/200 

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

  • Memorandum to Heads of Fire Departments 
  • Commissioner's Letter 
• #08-12-501 Discrete Substance Abuse Treatment Programs Operating under Hospital Licenses - 12/2/2008 
• #08-10-500 Influenza Vaccination Data Collection - 10/17/2008 
• #08-09-499 Feasibility of Collecting Data on Restraint Use - 9/24/2008 
• #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 

  • CMS Memorandum S&C-06-33 (provided by CMS)
  • Consent to Photograph Form 
  • Survey Photo Log 
• #04-6-442 New Consent Requirements for Autopsy - 6/2004 
• #01-10-420 Governing the Discontinuance of Essential Health Services - 5/9/2001 
• #01-01-409 Temporary Placement of Medical/Surgical Patients into TCU Beds/Relicensure of Previously Licensed Space - 1/19/2001 

• #5-98-381 Unlicensed Assistive Personnel - 5/1998 

  • Appropriate Use of of Unlicensed Assistive Personnel in Acute Care Institutions 

 

Emergency Department

• #12-01-555 Emergency Department Data Collection Update - 2/3/2012 
  • Clarification to Circular Letter DHCQ 12-01-555 - 2/3/2012 
  • Data Reporting Instructions
• #10-02-531 Reducing Emergency Department Patient Boarding and Submitting Code Help Policies to DPH - 2/25/2010 

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

  • Attachement B - EMTALA Fact Sheet 
• #09-01-505 Emergency Department Data Collection - 1/23/2009 
• #08-07-494 Changes to Ambulance Diversion Policies - 7/3/2008 

 

Healthcare Associated Infections

• #10-11-539 High Level Disinfection - 11/10/2010 

• #10-02-528 Acute Care Hospital Survey Visits - Infection Prevention and Control - 2/4/2010 

  • Regulations, Interpretive Guidelines and Procedures 
• #09-09-516 Healthcare Associated Infections - Betsy Lehman Center Data - 8/19/2009 
• #09-02-507 Healthcare Associated Infections - Public Reporting - 2/13/2009 
• #09-01-506 Public Health Hospital Reporting Requirements - 1/26/2009 
• #08-12-502 Additional Reporting Guidelines - 12/12/2008 

• #08-08-498 The Infection Prevention and Control Program - MRSA Point Prevalence Survey - 8/26/2008 

  • MRSA Point Prevalence Survey Data Collection Form 
  • Survey Instructions
• #08-06-490 Reminder: Healthcare Associated Infections Reporting Requirement in Acute Care - 6/112008 

• #08-02-482 HAI Reporting Requirement in Acute Care Hospitals - 2/22/2008 

  • Overview of HAI Reporting Requirement
  • Recommendations for Reporting of Healthcare-Associated Infection Measures
  • National Healthcare Safety Network (NHSN) Information

 

MASS COMM Trial

• MASS COMM Trial, Latest Protocol Revision - 1/12/2010 

  • Summary of Changes

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

  • Application 
  • Guidelines for Agreement 
  • Protocol 

 

Maternal and Newborn Services

• #11-07-548 Maternal and Newborn Service Guidelines and Updates - 7/14/2011 

  • Attachment A - The Development of Hospital Protocols for Use of Hydrotherapy for Low Risk Patients in Labor 
  • Attachment B - Transfer of Infants to Level IB Community-based Maternal and Newborn Services with a Continuing Care Nursery 

• #06-12-469 Maternal and Newborn Service Designation 12/6/2006 

  • Application for Designation 
  • Pre-Survey Questonnaire 
  • Licensed Bed Capacity Form 
  • Service Level Definitions 

• #06-6-461 Amendments to Hospital Licensure Governing Maternal and Newborn Services - 6/20/2006 

  • Attachment 

 

Medical Control Service

• #07-06-476 Medical Service Control Update - 6/22/2007 

• #07-02-472 Medical Control Service Regulations - 2/7/2007 

  • Addendum A 
  • Application for Licensure 

 

Primary Angioplasty

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

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

  • Guidelines 
  • Revised Section VII of the Guidelines - 10/24/01 
  • A. Letter of Application 
  • B. Guidelines for Development of Collaboration Agreement 
  • C. Application Supporting Documentation: 8 Week Log of Patients Presenting in Emergency Department with Symptoms of AMI 
  • D. CDAC's Recommended Guidelines for Clinical Care (Not Available Online)
  • E. Hospital Reporting Procedures 
  • F. CDAC Case Report Forms/Definitions (Not Available Online)
  • G. Log of Patients Presenting in Emergency Department with Symptoms of AMI 
  • H. Special Project Procedure Volume Report 

 

Reporting Cardiac Surgery and Angioplasty

• #02-06-426 Reporting Requirements for Cardiac Surgery and Angioplasty - 6/2002 
• #02-01-421 Proposed Reporting Requirements for Cardiac Surgery and Angioplasty - 1/4/2002 

 

Reporting Serious Incidents

• 09-06-510 Hospital Reporting of Serious Incidents (SREs) Updated Instructions - 06/22/2009 
  • Hospital Fax Reporting Form with Directions 

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

  • Updated Reporting Form and Instructions 

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

  • List of Serious Reportable Events and Criteria for Inclusion
    Provided by the National Quality Forum
  • Definition of Serious Disability 
• #07-12-478 Hospital Reporting of Serious Incidents - 12/13/2007 
• #07-42-474 Hospital Reporting Requirement - 2/15/07 
• #04-03-439 Hospital Reporting of Serious Incidents - 3/3/2004 
• #12-98-385 Hospital Reporting of Serious Incidents - 12/12/1998 

 

Stroke Services

• #10-12-542 Public Release of Hospital-Specific Data on Primary Stroke Services, 2008-2009 - 12/29/2010 
• #10-4-533 Public Release of Hospital-Specific Data on Primary Stroke Services - 4/8/2010 

• #09-06-512 Public Release of Aggregate Data on PSS and PSS Updates - 6/29/2009 

  • Draft Narrative of Web Reporting 
  • AHA/ASA Journal Article
  • Time Target Recommendations 
• #08-07-493 Primary Stroke Services Attestation - 7/16/2008 
• #06-5-460 Information Update Regarding Designated Primary Stroke Services 
• #05-06-450 Update to Primary Stroke Services Regulation - 6/2005 
• #04-04-440 Designation as a Provider of Primary Stroke Services - 4/13/2004 

 

Trauma Centers

• #10-03-532 Update to Trauma Field Triage Criteria and Point of Entry Plan for Trauma Patients Transported by Air Medical Ambulance Services - 3/4/2010 

  • Trauma Field Triage Criteria and Point-of-Entry Plan - Corrected 4/8/2010 
  • Attached Trauma Field Triage Criteria and Point-of-Entry Plan
• #08-03-483 Requirement for the Submission of Trauma Data (Revised) - 4/30/2008 
• #08-03-483 Requirement for the Submission of Trauma Data (Original) - 3/12/2008 
• #05-11-454 Trauma Center Designation - 12/22/2005  file size 1MB
• #08-04-443 Advisory Bulletin: Trauma Service - 8/17/2004 

 

Treatment of Victims of Sexual Assault

• #11-10-551 Emergency Contraception Update - 10/5/2011 

• #10-10-537 Emergency Contraception Update - 10/8/2010 

  • EC Provider Fact Sheet 
  • EC Patient Fact Sheet 
  • Provider Sexual Crime Report Form
  • Updated Comprehensive Rape Crisis Centers List 
  • Rape Crisis Counselors Can Benefit You 
• #08-06-492 - Emergency Contraception and Attachments A-C 06/27/2008 
• #08-06-491 - Emergency Contraception and Attachments A-C 06/27/2008 (Revised) 

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

  • Updated Provider Sexual Crime Report
  • Updated Comprehensive Rape Crisis Centers List - June, 2008 
  • Medical Eligibility Criteria for Contraceptive Use, Full Text
  • ACOG Practice Bulletin (no longer available)

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

  • Forensic Sexual Assault Exam Expense Application 
  • Sexual Assault Evidence Collection Kit
  • Provider Sexual Crime Report
  • Comprehensive Rape Crisis Centers List - December, 2007 

• #07-04-475 - Emergency Contraception Reminder - 4/19/2007 

  • Hospital Affirmations 
• #06-6-462 - Emergency Contraception Update - 7/1/2006 
• #05-12-456 - Notice to Acute Care Hospitals re: Emergency Contraception - 12/2005 

 

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This information is provided by the Division of Health Care Quality within the Department of Public Health.