105 CMR 140.306
Serious Complaint Procedure
Each clinic shall develop a written procedure that ensuring prompt and complete
investigations of all serious complaints filed against the clinic, employees of the clinic or
members of its professional staff. The procedure shall include, at a minimum, the following
provisions:
(A) Designation of a senior member of the clinic administration as the person responsible for
overseeing the investigation of serious complaints lodged against the clinic, an employee or
member of the professional staff;
140.306: continued
(B) Establishment of a reporting procedure ensuring the designated administrator will receive
from clinical staff written reports of serious complaints within one day of the clinic’s receipt of
the serious complaint;
(C) Development by the designated administrator of a written process of investigation, which
shall include the following:
(1) A process of fact-gathering, including provision for interviewing of the complainant,
patient, and relevant witnesses;
(2) Creation of a complaint file that includes the original report of complaint, progress
reports as investigation is carried out and outcome of investigation including action taken,
if any;
(3) Notification of the complainant of the outcome of the investigation.
(D) The complaint files shall be available for inspection by agents of the Department.