The Patient Care Assessment Coordinator's Semi-Annual Report to the health care facility's governing body must be prepared every six months, consistent with the Reporting Schedule set forth below. Note that, once a year, the PCA Coordinator's PCA Program Annual Report (required by 243 CMR 3.12(4)) is to be included with one of the Semi-Annual Reports. See the schedule for details.
The Semi-Annual Report is required by 243 CMR 3.07(3)(g). It must be submitted to your health care facility's governing body (its Board of Trustees or Board of Directors, for example), with a copy filed with the Board of Registration in Medicine, 560 Harrison Avenue, G-4, Boston, MA 02118, not later than 30 days after the end of the applicable six-month period. The Board has developed the attached guidelines under authority of G. L. c. 112, § 5I, 243 CMR 3.07(3)(g) and 243 CMR 3.07(3)(k).
Semi-Annual Reports acceptable to the Board follow the guidelines on the next two pages and evidence diligent effort on the part of the PCA Coordinator to apprise the governing body of the operation of the facility's qualified Patient Care Assessment program.
In the interest of uniform and complete reporting, the Board requires that Semi-Annual Reports be organized according to the attached outline. Responses should correspond to outline format numbers, but otherwise may be organized in the fashion most suitable to the particular facility.
With respect to focused occurrence reporting and occurrence screening, the facility's report should state the number of reportable events by criterion -- either for all or for a sizable sampling of criteria (or at minimum explain why this was not possible). For occurrence screening, the report should state the number and type of charts eligible for review, the number actually reviewed, and the number of occurrences found -- by each criterion or a sizable sampling of criteria.
Safety and Quality issues, as defined in 243 CMR 3.08, continue to be separately reportable to the Board on the basis of calendar quarters, with reports due within 30 days after the end of each quarter. Forms for this purpose have already been mailed to all affected facilities and are also available from the Board. The Semi-Annual Report should not be used for reporting Safety and Quality issues to the Board. However, Section III of the report -- to the extent applicable -- should include summary information on Safety and Quality issues.
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