# COMAR Title 10 — Maryland Department of Health

## Subtitle 07 — Hospitals

### Chapter 17 — Limited Service Hospital

#### Regulation .06 Quality Assurance.

*COMAR 10.07.17.06*

A. The facility shall plan and implement a quality assurance program which includes:

  (1) Monitoring and evaluation of the quality of patient care;

  (2) Identification, evaluation, and resolution of care problems; and

  (3) A peer review process.

B. The facility shall conduct ongoing quality assurance activities and document the activities on a continuous basis, but not less than quarterly.

C. Peer Review. The facility shall establish a peer review process that includes:

  (1) A mechanism to evaluate the clinical performance of each health care practitioner on a continuous basis, but not less than annually;

  (2) Procedures, approved by a supervising physician, to identify and minimize risks to the patient; and

  (3) Documentation of each health care practitioner's annual evaluation.

D. Equipment Quality Control.

  (1) The facility shall develop and implement a quality control procedure to monitor the safety and performance of all biomedical equipment.

  (2) In developing its procedures, the facility shall consider:

    (a) FDA recommendations; and

    (b) The equipment manufacturer's recommendations.

E. Quality Assurance Records. The facility shall document the following information for all quality assurance activities:

  (1) A description of identified problems;

  (2) Findings;

  (3) Conclusions;

  (4) Recommendations;

  (5) Actions taken;

  (6) Results; and

  (7) Follow-up.