# COMAR Title 10 — Maryland Department of Health

## Subtitle 07 — Hospitals

### Chapter 03 — Health Care Staff Agencies

#### Regulation .08 Administration.

*COMAR 10.07.03.08*

A. The agency shall develop, document, and implement policies and procedures.

B. Policies and procedures shall include, but are not limited to:

  (1) Selecting and verifying the credentials of a health care practitioner referred by the agency;

  (2) Validating the experience of a health care practitioner prior to referral by the agency;

  (3) Tracking and acting on serious or life-threatening complaints received by a client, facility, or the client facility's agent;

  (4) Reporting of an action or condition performed by a health care practitioner as required under Regulation .09C of this chapter;

  (5) Verifying the following:

    (a) A health care practitioner referred by the agency is of satisfactory health status and has received the necessary testing and immunization as required or requested by the client facility;

    (b) Drug screening of a health care practitioner is performed before referral by the agency, if the client facility requires drug screening for facility employees;

    (c) Drug testing of a health care practitioner referred by the agency is performed, if there is probable cause to perform a drug test or if a client facility requests a drug test;

    (d) Criminal background checks of a health care practitioner are performed before referral by the agency, if the client facility requires criminal background checks for facility employees;

    (e) The references of a health care practitioner referred by the agency;

    (f) A health care practitioner referred by the agency has I-9 status that permits them to legally work in the United States; and

    (g) A health care practitioner has active licensure or certification with the Board; and

  (6) Investigating a complaint or grievance presented to an agency by the client facility, an individual receiving services, a representative of the individual receiving services, or any concerned individual that includes a:

    (a) Description of how and to whom to file a complaint within the agency;

    (b) Description of how and to whom to file a complaint with the Office;

    (c) Commitment to conduct a thorough investigation into any allegation against individuals referred by the agency; and

    (d) Mechanism for making completed investigation reports available to the Department immediately upon request during inspections.