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Frequently Asked
PCA Questions
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Q. When are Safety and Quality Reviews due?
Q. Should I wait until the investigation of a Safety and Quality issue is complete before filing a report?
Q. If no Safety and Quality issues occur in a particular calendar quarter,
do I have to submit some kind of report stating so?
Q. What if I am not sure whether an event meets the requirements for reporting?
Q. There is a new PCA Coordinator at our health care facility.
Do we have to do anything?
Q. When are my facility's PCA Semi-Annual and Annual reports
due? Are there formats or forms for these reports?
Q. I am confused about PCA Annual reporting - is it the same
as the Annual Disciplinary Action Summary report? Please clarify.
Q. How long should I keep the credentialing files for our physicians?
PCA Questions
Q. When are Safety and Quality Reviews due?
A. Technically, a health care facility has 30 days following the
end of the calendar quarter in which the Safety and Quality issue occurred to submit
a report to the PCA Unit. The intention of this "quarterly
reporting" is to give facilities approximately three months
to investigate an issue before filing the Safety and Quality Review
with the Board.
Q. Should I wait until the investigation of an incident
is complete before filing a report?
A. If the investigation will take (approximately) three months or
less, yes, you may wait until the investigation is complete before
submitting a report. If the investigation is likely to take more
than three months, you should file an initial report with as much
information as possible and then submit a follow-up report when
the investigation is completed. If you do submit an initial report,
you must be sure to submit a follow-up report when the investigation
is closed.
Q. If no major Safety and Quality issues occur in a particular calendar quarter,
do I have to submit some kind of report stating so?
A. Although some hospitals do submit a written statement that no
major issues have occurred in the most recent quarter, it is
not necessary to do so.
Q. What if I am not sure whether an event meets the definition
of a Safety and Quality issue?
A. Call the PCA Unit for guidance and assistance.
Q. There is a new PCA Coordinator at our health care facility.
Do we have to do anything?
A. The PCA regulations require (at 243 CMR 3.06(2)) that the health
care facility report the name of the PCA Coordinator to the PCA
Unit within ten days of designation or replacement.
Q. When are my facility's PCA Semi-Annual and Annual reports
due? Are there formats or forms for these reports?
A. There is no form but there is a recommended format for PCA Semi-Annual reports. There is no form per se for the PCA Annual report, however,
the information that must be contained in the report can be found
at 243 CMR 3.12(4). Please call the PCA Unit or see the PCA section
of the Board's website for: (1) the recommended format for the PCA
Semi-Annual report; (2) the information that must be included in
the PCA Annual report; and (3) a reporting schedule for PCA Semi-Annual
and Annual reporting.
Q. I am confused about PCA Annual reporting - is it the same
as the Annual Disciplinary Action Summary report? Please clarify.
A. Please see the above question for information on PCA Annual
reporting. The PCA Annual report is DIFFERENT from the Board's Annual
Disciplinary Action Summary report. The latter report, which asks
for information about the physicians who were disciplined by the
health care facility in the previous year, go to a completely different
unit in the Board: the Data Repository Unit.
Q. How long should I keep the credentialing files for our physicians?
A. The PCA regulations (at 243 CMR 3.12(1)(d)) state that the health
care facility must maintain personnel records regarding its health
care providers for a minimum of ten years. This regulation deals
only with the Board's requirements - there may be other state laws
and regulations that require organizations to maintain personnel
files for a longer period of time.
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