Section 3.06 - Qualified Patient Care Assessment Program - Structure(1) The health care facility shall establish a medical peer review committee, within the meaning of M.G.L. c. 111, § 1, with responsibility for patient care assessment at the governing body level, to be known as the Patient Care Assessment Committee. (a) The governing body shall assure the adequacy of resources and support systems for the Patient Care Assessment Committee functions. In lieu of establishing a single Patient Care Assessment Committee, the governing body may elect to establish or maintain separate board level medical peer review committees to carry out the Patient Care Assessment Committee functions required by 243 CMR 3.00. A governing board level committee shall include at least one member of the governing body.(b) The health care facility may have any other peer review committees as it deems appropriate.(c) The Patient Care Assessment Committee or the committees carrying out patient care assessment committee functions may: 1. be comprised of persons not only from the medical staff; and2. consistent with the definition of Medical Peer Review Committee under M.G.L. c. 111, § 1, carry out all or some of the following functions: the evaluation or improvement of the quality of health care rendered by providers of health care services, the determination whether health care services were performed in compliance with the applicable standards of care, determination whether the cost of health care services rendered was considered reasonable by the providers of health services in the area, the determination of whether a health care provider's actions call into question such health care provider's fitness to provide health care services, or the evaluation and assistance of health care providers impaired or allegedly impaired by reason of alcohol, drugs, physical disability, mental instability or otherwise.(2) The governing body shall designate a Patient Care Assessment Coordinator, who shall be charged by the governing body with responsibility for implementing, by delegation, oversight, facilitating, coordinating, or otherwise, the health care facility's Qualified Patient Care Assessment Program and with ensuring compliance with 243 CMR 3.00. In lieu of appointing a single Patient Care Assessment Coordinator, the governing body of a health care facility may designate a committee to carry out the Patient Care Assessment Coordinator's functions as enumerated in 243 CMR 3.00. Thus, upon election of the health care facility's governing body, all references herein to Patient Care Assessment Coordinator may include the Patient Care Assessment Committee. The Patient Care Assessment Coordinator shall be responsible to the Patient Care Assessment Committee or shall be the formal administrative link amongst any separate committees which carry out the patient care assessment functions required by 243 CMR 3.00. The health care facility shall report the name of the Patient Care Assessment Coordinator to the Board within ten days of designation or replacement. The Patient Care Assessment Coordinator may be a qualified physician or a qualified non-physician.(3) The Patient Care Assessment Coordinator shall prepare and distribute detailed written instructions regarding operational procedures relevant to patient care assessment and compliance with 243 CMR 3.00. The Patient Care Assessment Coordinator shall distribute such written instructions as are relevant to each health care provider at the health care facility. As part of the annual report under 243 CMR 3.12(4), the health care facility shall file the written instructions with the Board.(4) The Patient Care Assessment Coordinator shall have unrestricted access to all records and information related to the Patient Care Assessment Coordinator's functions as per 243 CMR 3.00.