Mandated Reporting

(1) Scope of 243 CMR 2.13 and 2.14. 243 CMR 2.13 and 2.14 are mandated reporting sections. A mandated report is also referred to as a “statutory report” throughout 243 CMR 2.00. 243 CMR 2.14 contains a nonexclusive list of mandated reports. Some mandated reports are not listed within 243 CMR 2.13 and 2.14. (2) Mandated Report, Defined. A mandated report is a written filing, made to the Board of Registration in Medicine, by a reporter required to make the report pursuant to a state or federal law or regulation. The subject of a mandated report shall be a physician, registered with the Board as qualified to practice medicine in the commonwealth, including any person licensed pursuant to M.G.L. c. 112, §§ 2 through 9B. Mandated reports received in the Data Repository are confidential, unless otherwise required by law. A mandated reporter is any entity or individual that is required, by state or federal law or regulation, to make a report to the Board of Registration in Medicine, except for reports filed with the Board pursuant to M.G.L. c. 111, § 205. Reports filed with the Quality and Patient Safety Division are not mandated reports as defined in 243 CMR 2.14(2). (3) Filing a Mandated Report. Mandated reports shall be filed with the Data Repository Unit, except for licensing materials filed with the Board pursuant to M.G.L. c. 112, § 2 through 9B, which shall be filed with the Licensing Division at the Board's mailing address. Unless otherwise provided by law or regulation, a mandated report shall be filed with the Board no later than 30 days after the date of the incident being reported. A licensee's failure to timely file a mandated report may be a ground for a disciplinary action by the Board. (4) Mandated Reports Made by a Physician. (a) Peer Reports. A doctor of medicine or osteopathy, an intern, resident, fellow or medical officer licensed under M.G.L. c. 112, § 9, must report to the Board when he or she has a reasonable basis to believe that a physician may have violated the provisions of M.G.L. c. 112, § 5 or any regulation of the Board. This report is filed under M.G.L. c. 112, § 5F and is referred to as a “peer report”, or a “5F report”. A reporter may be exempt from this reporting requirement when the limited exemption provisions of M.G.L. c. 112, § 5F, and 243 CMR 2.07(23) apply. (b) Certain Licensing Materials. Licensing materials filed under M.G.L. c. 112, §§ 2 through 9B, and signed and sworn to by the applicant, are mandated reports, portions of which are confidential as provided in M.G.L. c. 112, § 2, and 243 CMR 2.01(5). The mandated reporter is the applicant or licensee. Additional responses or documentation provided by the applicant or licensee and submitted as part of an initial or renewal application may be mandated reports. (c) Action against Health Care Facility Privileges. A licensee shall notify the Board of any restriction, termination, revocation, suspension or resignation of his or her health care facility privileges in accordance with 243 CMR 1.03(5). A licensee's report of an action against his or her privileges is a mandated report. The licensee shall report the action taken against his or her privileges within 30 days of the health care facility's action, notwithstanding any appeal that may be pending. (d) Report on Certain Adverse Events Occurring in a Licensee's Office. A licensee must report to the Board the following events, if precipitated by a treatment administered or a procedure performed in a licensee's office setting: 1. an unplanned patient transfer to a hospital; 2. a patient death, when this death was unexpected and not related to the natural course of the patient's illness or underlying condition; or 3. a serious injury. The report shall be filed by the licensee as soon as possible, but in no event later than 30 days following the event. (e) Dissolution or Disassociation from a Professional Practice for Reasons of Competence. A licensee shall report a dissolution of, or disassociation from, a professional corporation, partnership or other professional practice group, however legally organized, when the dissolution is for cause. A licensee shall report to the Board when such dissolution or disassociation is related, directly or indirectly, to: 1. A licensee's competence to practice medicine, or 2. A complaint or allegation regarding any violation of law or regulation, or bylaws of a health care facility, medical staff, group practice, or professional medical association whether or not the complaint or allegation specifically cites violation of a specific law, regulation or bylaw. (f) Settlement by a Self-insured Physician. A licensee without professional liability insurance at the time when a malpractice action occurs must report to the Board any settlement or arbitration award for damages for death or personal injury. The licensee shall report a settlement or award against him or her caused by the licensee's negligence, error or omission in practice, or for an unauthorized rendering of professional services, as provided in M.G.L. c. 112, § 5E. (5) Mandated Reports Made by Health Care Facilities or Other Reporters. (a) Disciplinary Action by Health Care Facility. A health care facility disciplinary action report filed under M.G.L. c. 111, § 53B is a mandated report. The mandated reporter is any person or entity licensed under M.G.L. c. 111, § 51. The reporting entity shall use the definition of Disciplinary Action set forth at 243 CMR 1.01(2). 1. Notice of Termination or Suspension. If the disciplinary action taken is a suspension or termination of privileges, notice must be filed with the Board within two business days of the occurrence of the reportable action. The health care facility giving notice of a suspension or termination to the Board may do so initially by telephone or by facsimile transmission, to be followed by a written report within 30 days of the occurrence of the reportable action. 2. Initial Reports. Whenever a report is required pursuant to M.G.L. c. 111, § 53B, the person or entity reporting shall use Form HCFD-1, the Board's form prescribed for that purpose. The report shall be filed within 30 days of actual imposition of the disciplinary action, regardless of whether further appellate remedies are available to the licensee. However, at any time after making an initial report, if the reporting entity reverses its disciplinaryaction, the reportingentityshall notifythe Board and file a subsequent report on Form HCFD-2 within 30 days of the reversal of action. 3. Subsequent Reports. The disciplinary action reporting requirement under M.G.L. c. 111, § 53B does not end until the disciplinary action upon which the report was based is complete. The reporting entity shall submit to the Board a status report at the end of every 60-day period about the ongoing disciplinary action. When the health care facility has completed its disciplinary action, it shall file a Subsequent HCFD-2 Report within 30 days of the date of the final action. 4. Annual Summaryof DisciplinaryActions. Under M.G.L. c. 111, § 53B, a health care facility shall file an annual disciplinary summary, no later than January 31st for each previous calendar year, on a Form HCFD-3. The cumulative,de-identified data compiled by the Data Repository Unit from the total Annual Summary of Disciplinary Actions reports filed in a calendar year shall be a public record, except that information that is deemed confidential pursuant to M.G.L. c. 111, § 53B or M.G.L. c. 112, § 5 shall not be disclosed by the Board. (b) Nursing Homes. A report of a disciplinary action taken by a convalescent home or nursing home and filed under M.G.L. c. 111, § 203 is a mandated report. The mandated reporter is a nursing home or other entity licensed by the Department of Public Health under M.G.L. c. 111, § 71. A copy of a report sent to the Department of Public Health under M.G.L. c. 111, § 72, that indicates physician incompetency or other physician conduct that seriously affects a nursing home patient's health and safety, is a mandated report under M.G.L. c. 111, § 203. In determining what constitutes a disciplinary action, the nursing home shall rely on the Board's definition of Disciplinary Action set forth in 243 CMR 1.01(2): Definitions. 1. Notice of Termination or Suspension. If the disciplinaryaction taken is a suspension or termination of privileges, notice must be filed with the Board within two business days of the occurrence of the reportable action. The nursing home giving notice of a suspension or termination to the Board may do so initially by telephone or by facsimile transmission, to be followed by a written report within 30 days of the occurrence of the reportable action. 2. Initial Reports. Whenever a report is required pursuant to M.G.L. c. 111, § 203, the person or entity reporting shall use the Board's form prescribed for that purpose, Form HCFD-1. The report shall be filed within 30 days of actual imposition of the disciplinary action, regardless of whether further appellate remedies are available to the licensee. However, at any time after making an initial report, if the reporting entity reverses its disciplinary action, the reporting entity shall notify the board and file a subsequent Form HCFD-2 report within 30 days. 3. Subsequent Reports. The disciplinary action reporting requirement under M.G.L. c. 111, § 203 does not end until the disciplinary action upon which it is based is complete. The reporting entity shall submit to the Board a status report at the end of every 60-day period about the ongoing disciplinary action. When the nursing home has completed its disciplinary action, it shall file a Subsequent HCFD-2 Report within 30 days of the date of the final action. 4. Annual Summary of Disciplinary Actions. Under M.G.L. c. 111, § 203(e), a nursing home shall file an annual disciplinary summary, no later than January 31st for each previouscalendar year, on a Form HCFD-3. The cumulative, de-identified data compiled by the Data Repository Unit from the total Annual Summary of Disciplinary Actions filed in a calendar year shall be a public record, except that information that is deemed confidential pursuant to M.G.L. c. 112, § 5 shall not be disclosed by the Board. (c) Professional Organizations. A professional medical association disciplinary action report filed under M.G.L. c. 112, § 5B is a mandated report. The reporting entity shall use the definition of Disciplinary Action set forth in 243 CMR 1.01(2): Definitions. The mandated reporter is a professional medical association, society,body,professionalstandards review organization, or similarly constituted professional organization, whether local, regional, state, national, or international in scope. This mandated report shall be filed within 30 days of the disciplinary action. (d) Healthcare Agency Employee. When an officer or employee of a state agency, engaged in the provision or oversight of medical or health services, has a reasonable basis to believe that a physician may have violated the provisions of M.G.L. c. 112, § 5 or any Board regulation, he or she shall report this to the Board under M.G.L. c. 112, § 5D as a mandated report. Mandated reporters are officers or employees of an agency, executive office, department, board, commission, bureau, division or authority of the Commonwealth or, of, any political subdivision thereof, that provides medical or health services, or oversees the delivery of healthcare services. (e) Peer Reports. A health care provider, as defined in M.G.L. c. 111, § 1, must report to the Board when he or she has a reasonable basis to believe that a physician mayhave violated the provisions of M.G.L. c. 112, § 5 or anyregulation of the Board. This report is filed under M.G.L. c. 112, § 5F and is sometimes referred to as a “peer report”, although the health care provider need not be a peer of the licensee. A health care provider may be exempt from this reporting requirement when the limited exemption provisions of M.G.L. c. 112, § 5F, and 243 CMR 2.07(23) apply. (f) Secondary Remedial Action by Insurer. A report of a secondary remedial action, as defined in M.G.L. c. 175A, § 5C(a)(3)(vi) and (vii), and imposed by the experience review committee, as defined in M.G.L. c.175A, § 5C(a)(6), is a mandated report. The mandated reporter is the medical professional mutual insurance company approved by the commissioner of insurance in M.G.L. c. 175A. (g) Insurer's Disposition of a Malpractice Claim. A report of the final judgment, settlement, or disposition of a medical malpractice claim or action, filed under M.G.L. c. 112, § 5C, is a mandated report. The mandated reporters are insurers or risk management organizations providing professional liability insurance to a licensee. The report shall be filed with the Board within 30 days of the date of the final judgment, settlement or disposition. (h) Criminal Conviction. A clerk of courts shall report a physician's conviction of a crime, or a physician's plea of nolo contendere or admission to sufficient facts to a crime, within one week of the date of conviction or plea. This report, filed under M.G.L. c. 221, § 26, is a mandated report. (i) Medical Malpractice Tribunal Findings. The clerk of the Superior Court shall report the findings of a medical malpractice tribunal, as defined in M.G.L. c. 231, § 60B. This mandated report shall be filed with the Board within 15 days of the date of the finding. (j) Final Disposition by Court of Malpractice Claim. A clerk of the superior court shall file with the Board a report of a final judgment, settlement or disposition of a medical malpractice claim or action. This mandated report, filed under M.G.L. c. 231, § 60B, shall be filed within 15 days of the date of the final judgment, settlement or disposition. (k) Report from the Health Care Services Board. A report by the Worker's Compensation Health Care Services Board (HCSB) filed under M.G.L. c. 152, § 13(3), and received from an employee, an employer or an insurer, regarding licensees serving as health care providers under the Worker's Compensation Law is a mandated report. The HCSB shall report to the Board when the HCSB finds that a licensee may have engaged in a pattern of abuse such as: 1. Discrimination against compensation claimants; 2. Overutilization of procedures; 3. Unnecessary surgery or other procedures; or 4. Other inappropriate treatment of compensation recipients. (l) Additional Reporting Requirements. A report made to the Board of Registration in Medicine about a licensee, filed pursuant to a state or federal statute or regulation or filed under 243 CMR 2.07(8), 2.13 or 2.14, shall be a mandated report, unless otherwise specifically required by law. Statutes or regulations requiring a mandated report to the Board should be read as consistent with 243 CMR 2.07(8), 2.13 and 2.14.