Requirements for the Annual PCA Report

There are six elements that must be included. They are as follows [243 CMR 3.12(4)]:

A summary analysis of patient complaints and their disposition.

In this summary, you should discuss the number and types of complaints patients have made to your facility and the system through which your facility addresses complaints. Please also summarize respective resolutions of complaints received.

The names of all full licensees (physicians only) who have terminated their relationship with the health care facility.

Please list any physician who has terminated his/her relationship with your facility during the reporting period. It is helpful, but not required, to indicate the reason for termination, for example, relocation, retirement, etc.

Any amendments to the Patient Care Assessment Plan and any proposed amendments thereto, pursuant to 243 CMR 3.03(1).

If you have amended your PCA plan during the reporting period, please submit those amendments with your annual report. Please also include proposed amendments. (If you submit your entire PCA plan, please highlight proposed and actual amendments. If there have been no amendments, do not submit an additional copy of your plan; simply indicate that there have been no changes.)

The number of Safety and Quality issues filed pursuant to 243 CMR 3.08.

In your report, please indicate the number of Safety and Quality issues submitted to the Board during the past twelve months. (You do not need to include descriptions or copies of previously submitted report.)

The written instructions for the Patient Care Assessment Plan, pursuant to 243 CMR 3.06(3).

If there have been no changes in your facility's instructions during the past twelve months, it is not necessary to resubmit them. Merely indicate in your report that there have been no changes.

Summary information on the handling of impaired physicians.

In this summary, please discuss your facility's mechanism for addressing reports of physician impairment internally, or through referral to one or more external entities.