# COMAR Title 10 — Maryland Department of Health ## Subtitle 27 — Board of Nursing ### Chapter 01 — Examination and Licensure **Authority:** Health Occupations Article, §§1-213, 1–230, 8-101, 8-201, 8-205, 8-206, 8-301—8-315, 8-6A-05(a), 8-701, 8-7A-01, Article 1116(b)(2), and 8-703; Tax-General Article, §§10-738 and 10-739(b)(1); Annotated Code of Maryland; Ch. 486, Acts of 2012; Chs. 281 and 282, Acts of 2013; Chs. 385 and 386, Acts of 2016; and Chs. 234 and 234, Acts of 2017 **Administrative History:** Effective date: **Administrative History:** Regulation .01B, C amended effective May 5, 1978 (5:9 Md. R. 684) **Administrative History:** Regulation .02A amended effective January 7, 1976 (3:1 Md. R. 40) **Administrative History:** Regulation .02B, F amended effective October 13, 1976 (13:21 Md. R. 1206) **Administrative History:** Regulation .02G amended effective May 14, 1975 (2:10 Md. R. 752) **Administrative History:** Regulation .05 amended effective January 7, 1976 (3:1 Md. R. 40) **Administrative History:** Regulation .08 repealed effective March 23, 1979 (6:6 Md. R. 512) **Administrative History:** Regulations .01—.07 renumbered as Regulations .02, .03, .04, .05, .07, .08, and .09, respectively **Administrative History:** Regulation .01 adopted effective March 23, 1979 (6:6 Md. R. 512) **Administrative History:** Regulation .02A, C, E, G, H amended effective March 23, 1979 (6:6 Md. R. 512) **Administrative History:** Regulation .02B, C amended effective June 29, 1979 (6:13 Md. R. 1128) **Administrative History:** Regulations .03A—F, H and .05A amended effective March 23, 1979 (6:6 Md. R. 512) **Administrative History:** Regulation .06 adopted effective March 23, 1979 (6:6 Md. R. 512) **Administrative History:** Regulations .08A, C and .09 amended effective March 23, 1979 (6:6 Md. R. 512) **Administrative History:** Regulations .01—.09 repealed effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulations .01—.11 adopted effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulations .01—.06 amended as an emergency provision effective April 11, 1994 (21:9 Md. R. 744); amended permanently effective August 15, 1994 (21:16 Md. R. 1384) **Administrative History:** Regulation .01B amended effective December 11, 1989 (16:24 Md. R. 2620); May 10, 1993 (20:9 Md. R. 779) **Administrative History:** Regulation .02A amended effective December 11, 1989 (16:24 Md. R. 2620); October 1, 1990 (17:19 Md. R. 2321); May 10, 1993 (20:9 Md. R. 779) **Administrative History:** Regulation .02A amended as an emergency provision effective July 1, 1991 (18:14 Md. R. 1606); adopted permanently effective January 2, 1992 (18:25 Md. R. 2751) **Administrative History:** Regulation .02A amended as an emergency provision effective October 27, 1995 (22:23 Md. R. 1795); amended permanently effective February 12, 1996 (23:3 Md. R. 169) **Administrative History:** Regulation .02A amended as an emergency provision effective November 14, 1997 (24:25 Md. R. 1717); amended permanently effective March 9, 1998 (25:5 Md. R. 369) **Administrative History:** Regulation .02A amended as an emergency provision effective August 2, 1999 (26:17 Md. R. 1314); amended permanently effective November 15, 1999 (26:23 Md. R. 1777) **Administrative History:** Regulation .04D adopted effective November 8, 1993 (20:22 Md. R. 1707) **Administrative History:** Regulation .06G amended as an emergency provision effective November 1, 1987 (14:23 Md. R. 2412); adopted permanently effective March 1, 1988 (15:3 Md. R. 304) **Administrative History:** Regulation .06G amended effective May 10, 1993 (20:9 Md. R. 779) **Administrative History:** Regulation .07 amended effective October 1, 1990 (17:19 Md. R. 2321); May 10, 1993 (20:9 Md. R. 779) **Administrative History:** Regulation .07A amended effective December 11, 1989 (16:24 Md. R. 2620); November 8, 1993 (20:22 Md. R. 1707) **Administrative History:** Regulation .08E adopted effective October 1, 1990 (17:19 Md. R. 2321) **Administrative History:** Regulation .09 amended as an emergency provision effective October 27, 1995 (22:23 Md. R. 1795); amended permanently effective February 12, 1996 (23:3 Md. R. 169) **Administrative History:** Regulation .09C amended effective May 10, 1993 (20:9 Md. R. 779) **Administrative History:** Regulation .10 amended effective December 11, 1989 (16:24 Md. R. 2620) **Administrative History:** Regulation .10D amended and H adopted effective October 1, 1990 (17:19 Md. R. 2321) **Administrative History:** Regulation .10I adopted effective May 10, 1993 (20:9 Md. R. 779) **Administrative History:** Regulation .11 recodified to Regulation .12 and new Regulation .11 adopted effective December 11, 1989 (16:24 Md. R. 2620) **Administrative History:** Regulation .13 adopted effective December 11, 1989 (16:24 Md. R. 2620) **Administrative History:** Regulations .14 and .15 adopted effective May 10, 1993 (20:9 Md. R. 779) **Administrative History:** Chapter revised effective April 30, 2001 (28:8 Md. R. 760) **Administrative History:** Regulation .01B amended effective March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Regulation .01B amended as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .01B amended effective September 22, 2008 (35:19 Md. R. 1717) **Administrative History:** Regulation .01C adopted effective September 22, 2008 (35:19 Md. R. 1717) **Administrative History:** Regulation .02 repealed and new Regulation .02 adopted effective April 1, 2013 (40:6 Md. R. 474) **Administrative History:** Regulation .02A amended effective September 3, 2001 (28:17 Md. R. 1556); August 27, 2007 (34:17 Md. R. 1508) **Administrative History:** Regulation .03 amended effective March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Regulation .03A amended effective September 22, 2008 (35:19 Md. R. 1717) **Administrative History:** Regulation .04 amended effective September 22, 2008 (35:19 Md. R. 1717) **Administrative History:** Regulation .04B amended effective September 3, 2001 (28:17 Md. R. 1556) **Administrative History:** Regulation .05 amended effective March 1, 2004 (31:4 Md. R. 316); September 27, 2004 (31:19 Md. R. 1433) **Administrative History:** Regulation .05A amended as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .05D amended effective September 22, 2008 (35:19 Md. R. 1717) **Administrative History:** Regulation .05I adopted as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .09A amended as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .09A amended effective January 6, 2014 (40:26 Md. R. 2164) **Administrative History:** Regulation .09D adopted as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .11 amended as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .11 amended effective April 19, 2010 (37:8 Md. R. 617) **Administrative History:** Regulation .12 amended effective April 1, 2013 (40:6 Md. R. 474) **Administrative History:** Regulation .12F, G amended effective April 24, 2006 (33:8 Md. R. 733) **Administrative History:** Regulation .12H adopted effective October 11, 2004 (31:20 Md. R. 1485) **Administrative History:** Regulation .12I, J, K adopted as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .12I amended effective April 19, 2010 (37:8 Md. R. 617) **Administrative History:** Regulation .12I-1, I-2, J-1 adopted effective April 19, 2010 (37:8 Md. R. 617) **Administrative History:** Regulation .12I-1 amended effective June 13, 2011 (38:12 Md. R. 705) **Administrative History:** Regulation .13 amended as an emergency provision effective January 2, 2007 (34:4 Md. R. 397); amended permanently effective May 7, 2007 (34:9 Md. R. 825) **Administrative History:** Regulation .13A amended effective April 24, 2006 (33:8 Md. R. 733) **Administrative History:** Regulation .13C amended effective January 6, 2014 (40:26 Md. R. 2164) **Administrative History:** Regulation .15 amended effective April 24, 2006 (33:8 Md. R. 733) **Administrative History:** Regulation .16 amended effective April 19, 2010 (37:8 Md. R. 617) **Administrative History:** Regulation .17C amended effective March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Chapter revised effective February 13, 2017 (44:3 Md. R. 189) **Administrative History:** Regulation .01B amended effective July 2, 2018 (45:13 Md. R. 667); June 17, 2019 (46:12 Md. R. 544); August 23, 2021 (48:17 Md. R. 669); Regulation .01B amended as an emergency provision effective January 4, 2022 (49:4 Md. R. 297); emergency status expired effective July 3, 2022 **Administrative History:** Regulation .01B amended as an emergency provision effective September 7, 2022 (49:21 Md. R. 940); emergency status expired effective March 5, 2023 **Administrative History:** Regulation .01B amended as an emergency provision effective May 4, 2023 (50:10 Md. R. 405); emergency status expired effective October 31, 2023 **Administrative History:** Regulation .01B amended as an emergency provision effective August 26, 2025 (52:20 Md. R. 999); amended permanently effective October 13, 2025 (52:20 Md. R. 1001) **Administrative History:** Regulation .01B amended effective April 27, 2026 (53:8 Md. R. 356 **Administrative History:** Regulation .01D adopted effective August 23, 2021 (48:17 Md. R. 669) **Administrative History:** Regulation .02 amended effective January 29, 2018 (45:2 Md. R. 69); July 1, 2025 (52:10 Md. R. 436) **Administrative History:** Regulation .03 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03A, C amended as an emergency provision effective January 4, 2022 (49:4 Md. R. 297); emergency status expired effective July 3, 2022 **Administrative History:** Regulation .03C amended as an emergency provision effective September 7, 2022 (49:21 Md. R. 940); emergency status expired effective March 5, 2023; Regulation .03C amended as an emergency provision effective May 4, 2023 (50:10 Md. R. 405); emergency status expired effective October 31, 2023 **Administrative History:** Regulation .03C amended as an emergency provision effective August 26, 2025 (52:20 Md. R. 999); amended permanently effective October 13, 2025 (52:20 Md. R. 1001) **Administrative History:** Regulation .05 amended effective July 2, 2018 (45:13 Md. R. 667); April 27, 2026 (53:8 Md. R. 356) **Administrative History:** Regulation .05C amended effective August 23, 2021 (48:17 Md. R. 669) **Administrative History:** Regulation .05C amended as an emergency provision effective October 6, 2023 (50:22 Md. R. 972); emergency status expired effective April 3, 2024 **Administrative History:** Regulation .05C amended effective June 24, 2024 (51:12 Md. R. 619) **Administrative History:** Regulation .06F repealed effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .09D, F amended effective July 2, 2018 (45:13 Md. RR. 667) **Administrative History:** Regulation .10 amended effective August 28, 2017 (44:17 Md. R. 835); July 2, 2018 (45:13 Md. R. 667); August 23, 2021 (48:17 Md. R. 669); April 27, 2026 (53:8 Md. R. 356) **Administrative History:** Regulation .11 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .12 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .13 amended effective July 2, 2018 (45:13 Md. R. 667); June 17, 2019 (46:12 Md. R. 544) **Administrative History:** Regulation .13N amended as an emergency provision effective June 24, 2025 (52:15 Md. R. 810); amended permanently effective August 18, 2025 (52:16 Md. R. 846) **Administrative History:** Regulation .14 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .15B amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .16E amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .17C adopted as an emergency provision effective January 4, 2022 (49:4 Md. R. 297); emergency status expired effective July 3, 2022 **Administrative History:** Regulation .17C adopted as an emergency provision effective September 7, 2022 (49:21 Md. R. 940); emergency status expired effective March 5, 2023 **Administrative History:** Regulation .17C amended as an emergency provision effective May 4, 2023 (50:10 Md. R. 405); emergency status expired effective October 31, 2023 **Administrative History:** Regulation .17C adopted as an emergency provision effective August 26, 2025 (52:20 Md. R. 999); adopted permanently effective October 13, 2025 (52:20 Md. R. 1001) #### Regulation .01 Definitions. *COMAR 10.27.01.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Active nursing practice” as used in Health Occupations Article, §8-312, Annotated Code of Maryland, means: (a) The practice of registered nursing or licensed practical nursing as defined in Health Occupations Article, §8-101, Annotated Code of Maryland; (b) Related nursing activities approved by the Board, including but not limited to a generic nursing education program, degree completion programs, or graduate programs within the last 5 years; and (c) Completion of a generic nursing education program, degree completion program, or a graduate program within the last 5 years. (2) “Advanced practice registered nurse” has the meaning stated in Health Occupations Article, §8-101, Annotated Code of Maryland. (3) “Biennial renewal” means renewal of a license every 2 years in the licensee’s birth month. (4) “Board” means the Maryland Board of Nursing. (5) “Central Repository” means the Maryland Criminal Justice Information System Central Repository of the Department of Public Safety and Correctional Services. (6) “Certified nursing assistant (CNA)” has the meaning stated in Health Occupations Article, §8-6A-01, Annotated Code of Maryland. (7) “Continuing education” means planned, organized learning experiences designed to augment the knowledge, skill, and ability to enhance nursing practice and therefore improve health care delivered to the public. (8) “Continuing education unit (CEU)” means 1 contact hour of 50—60 minutes. (9) “Cosign” means a registered nurse verifies that: (a) An activity was performed safely and accurately by the nursing graduate; and (b) The documentation is complete and accurate. (10) “Criminal history records check” means the performance of both a State criminal history check by the Central Repository, and a national criminal history check by the Federal Bureau of Investigation (FBI). (11) “Criminal history records information” means information provided by the criminal history records check regarding an applicant's criminal arrests, charges, and convictions, and other dispositions of criminal charges. (12) “Direct patient care” means healthcare activities that involve direct interaction between a healthcare professional and a patient. (13) “Endorsement” means, for qualified applicants who have an unencumbered license from another state or country to practice registered nursing or licensed practical nursing, a waiver of the initial licensure requirement to take the national licensure examination in accordance with Health Occupations Article, §8-307, Annotated Code of Maryland. (14) “English language competency examination” means an examination that tests an individual’s written and oral competency in the English language. (15) Entry-level Registered Nursing Education Program. (a) “Entry-level registered nursing education program” means a registered nursing education program that is the initial entry point for formal registered nursing education that, upon successful completion, qualifies an individual with no prior registered nursing education to obtain licensure as a registered nurse. (b) “Entry-level registered nursing education program” does not include degree completion programs, including but not limited to: (i) Associate of Applied Science Degree in Nursing to Baccalaureate of Science Degree in Nursing (AAS-BSN); (ii) Associate of Degree in Nursing to Baccalaureate of Science Degree in Nursing (ADN-BSN); (iii) Associate of Applied Science Degree in Nursing to Masters of Science Degree in Nursing (AAS-MSN); (iv) Associate Degree in Nursing to Masters of Science Degree in Nursing (ADN-MSN); (v) Baccalaureate of Science Degree in Nursing to Masters of Science Degree in Nursing (BSN-MSN); (vi) Baccalaureate of Science Degree in Nursing to Doctor of Philosophy (BSN-PHD); (vii) Baccalaureate of Science Degree in Nursing to Doctor of Education (BSN-EDD); (viii) Baccalaureate of Science Degree in Nursing to Doctor of Nursing Practice (BSN-DNP); (ix) Masters of Science Degree in Nursing to Doctor of Philosophy (MSN-PHD); (x) Masters of Science Degree in Nursing to Doctor of Education (MSN-EDD); (xi) Masters of Science Degree in Nursing to Doctor of Nursing Practice (MSN-DNP); or (xii) Masters of Science Degree in Nursing to Post Masters Certificate/Post Graduate Certificate. (16) “Former licensee” means an individual who once had an active license with the Board who is no longer active. (17) “Multistate licensure privilege” means an authorization to practice registered nursing or licensed practical nursing in Maryland that is granted to a registered nurse or licensed practical nurse who has an active multistate license issued by another state in accordance with the Nurse Licensure Compact. (18) “NCLEX” means the National Council Licensure Examination for initial licensure as a registered nurse or licensed practical nurse. (19) “Nursing assistant” means an individual certified by the Board as a certified nursing assistant. (20) “Preceptor” means a registered nurse who meets the qualifications of faculty as described in Regulation .16 of this chapter. (21) “Preceptorship” means an individualized refresher course approved by the Board and offered by an institution employing nurses which complies with Regulation .16 of this chapter. (22) “Student” means a registered nurse or licensed practical nurse who is required to complete a refresher course in order to maintain or reestablish an active license. (23) “Substantially equivalent” has the meaning stated in §§C and D of this regulation. (24) “Volunteer” means a licensee who, at the time of licensure renewal, elects to receive a license which only allows the licensee to provide professional services without remuneration. (25) “Written and oral competency in the English language” means the ability to demonstrate proficiency in listening, reading, speaking, and writing the English language. C. “Substantially equivalent” means a registered nursing or licensed practical nursing education program that: (1) Contains theoretical learning experiences and related clinical learning experiences that include direct patient care within various settings consistent with program objectives, outcomes, or competencies conducted either concurrently with or after the theoretical learning experience; and (2) Meets the curriculum requirements for Maryland schools of nursing at the time of the applicant’s graduation, including, but not limited to: (a) The appropriate level of the graduate's intended scope of practice; (b) Didactic and clinical learning experiences that are diverse and consistent with program objectives, outcomes, or competencies; (c) Didactic and clinical instruction in nursing care of families and clients throughout the life span in a variety of care settings requiring nursing measures appropriate for: (i) The maintenance or restoration of mental and physical health; (ii) Preventive, rehabilitative, and curative aspects of health care; (iii) Biophysical, psychosocial, cultural, and spiritual components of health and illness; and (iv) Professional issues content; and (d) Didactic and clinical instructional content that includes, but is not limited to, the areas of: (i) Medical and surgical nursing; (ii) Maternal and child health; (iii) Psychiatric nursing; and (iv) Geriatric nursing. D. “Substantially equivalent” does not mean a registered nurse or licensed practical nursing education program in another state or country that does not have a supervised clinical learning experience requirement. #### Regulation .02 Fees. *COMAR 10.27.01.02* A. The fees listed in this regulation are not refundable. B. Licensure by examination fees are as follows: (1) Registered nurse licensure — $187; (2) Licensed practical nurse licensure — $187; and (3) An examination fee for registered nurse and licensed practical nurse licensure shall be paid by the candidate directly to the testing service. C. Licensure by endorsement fees are as follows: (1) Registered nurse licensure — $230; and (2) Licensed practical nurse licensure — $230. D. Temporary registered nurse or licensed practical nurse licensure fee —$70. E. Advanced practice registered nurse certification fees are as follows: (1) Initial advanced practice certification — $50; and (2) Each additional initial advanced practice certification — $25. F. Specialty nursing practice certification fees are as follows: (1) Initial forensic nurse examiner certification — $25; and (2) Initial workers’ compensation medical case manager certification — $25. G. Biennial renewal fees are as follows: (1) Renewal of a registered nurse license — $165; (2) Renewal of a licensed practical nurse license — $165; (3) Renewal of a registered nurse or licensed practical nurse volunteer license — $73; (4) Renewal of an inactive license for a registered nurse or licensed practical nurse — $60; (5) Renewal of each advanced practice registered nurse certification is in addition to the registered nurse license renewal fee and is — $10; and (6) Renewal of certification for specialty nursing practices regulated by the Board is in addition to the registered nurse license renewal fee and is as follows: (a) Forensic nurse examiner certification — $10; and (b) Workers’ compensation medical case manager certification — $10. H. Health Care Practitioner User Fee. (1) In addition to a license fee, each registered nurse shall pay a non-refundable health care practitioner user fee assessed by the Maryland Health Care Commission in accordance with Health-General Article, §19-111(b)(4), Annotated Code of Maryland. (2) The health care practitioner user fee shall be: (a) Included in the licensing fee paid to the Board; and (b) Collected with the application for an initial or renewal license. (3) The amount of the assessed health care practitioner user fee shall be double the amount of the annual health care practitioner user fee for biennial licensure. (4) The Board shall: (a) Account for the user fees; and (b) Transfer the fees to the Maryland Health Care Commission on a quarterly basis. I. Nurse Practitioner Preceptorship Tax Credit Fund. (1) This fee applies only to nurse practitioners. (2) The Board shall assess a separate $15 fee for the renewal of a nurse practitioner, regardless of the number of certifications held by the nurse practitioner. (3) The Board shall: (a) Account for the fees collected under this section; and (b) Transfer the fee to the Nurse Practitioner Preceptorship Tax Credit Fund. J. Other fees are as follows: (1) Verification of licensure — $45; (2) Copies of transcripts — $25; and (3) Returned check fee —$30. #### Regulation .03 Licensure Exceptions. *COMAR 10.27.01.03* A. Registered nurses or licensed practical nurses who hold a current active license in any other state or jurisdiction may render nursing care: (1) For not more than 30 days, to an individual who is visiting the State for medical, educational, or personal reasons; (2) For the purpose of the interstate transport and care of patients traveling to and from Maryland; and (3) During an emergency situation. B. A registered nurse or licensed practical nurse who holds a multistate licensure privilege under the Nurse Licensure Compact may practice nursing in this State in accordance with the laws of this State. C. Nursing Graduate. (1) A nursing graduate is a graduate of: (a) A Board-approved registered nursing or licensed practical nursing education program; or (b) An out-of-state nursing education program determined to be equivalent by the Board. (2) A nursing graduate may practice as set forth in §C(5)—(7) of this regulation if: (a) The nursing graduate has an application for a license pending before the Board; and (b) One of the following circumstances exists: (i) The nursing graduate has not taken the NCLEX examination; (ii) The nursing graduate has taken the NCLEX examination, but the results of the NCLEX examination are not yet known; (iii) The nursing graduate has taken and passed the NCLEX examination but is waiting for the completion of the criminal history records check; or (iv) The nursing graduate has taken and failed the NCLEX examination but has not failed the NCLEX examination more than one time within the 120 day period immediately following the submission of the application to the Board. (3) A nursing graduate shall cease practice as a nursing graduate: (a) No later than 120 days after the date the nursing graduate submitted an application to the Board; or (b) Immediately if the nursing graduate fails the second NCLEX examination. (4) If the nursing graduate fails the NCLEX examination, the nursing graduate may practice as a nursing assistant provided the individual obtains certification as a nursing assistant and practices according to COMAR 10.39.01. (5) A nursing graduate shall: (a) Practice only under the direct supervision of a registered nurse who is physically present on the unit to: (i) Cosign medication transcription, medication administration, and nursing documentation; and (ii) Continually observe, assist, coordinate, evaluate, and monitor the nursing graduate; and (b) Use the initials “NG” after the nursing graduate's name as credentials. (6) After successful completion of an organized staff development program which includes an evaluation that the nursing graduate is competent and in compliance with §C(5) of this regulation, the nursing graduate may: (a) Transcribe medication orders if: (i) Written policies and procedures are available on the unit of care; and (ii) An organized staff development program which includes skill validation has been successfully completed by the nursing graduate; (b) After competency has been validated by the facility: (i) Administer medications and controlled substances; and (ii) Sign controlled substances sheets; (c) Document in the medical record with the abbreviation “NG”; (d) Perform patient assessments after the initial assessment or after the first assessment of the shift performed by the registered nurse; and (e) Perform and document routine procedures taught within the nursing graduate's generic nursing program, including but not limited to: (i) Placing nasal gastric tubes; (ii) Performing urinary catheterizations; (iii) Applying sterile dressings; (iv) Performing blood sugar checks; and (v) Obtaining specimens. (7) A nursing graduate may not: (a) Work without the physical presence of and direct supervision by a registered nurse; (b) Refer to oneself or practice as a registered nurse (RN) or licensed practical nurse (LPN); (c) Be considered a staff person for purposes of a staffing pattern; (d) Accept charge responsibilities; or (e) Perform initial patient assessment or the first patient assessment of a shift, develop patient plans of care, evaluate or document patient discharge, or independently administer medications or intravenous therapy. #### Regulation .04 General Provisions for Applications. *COMAR 10.27.01.04* A. An applicant shall submit: (1) A completed application to the Board on the form that the Board requires; (2) To a criminal history records check (CHRC) in accordance with Health Occupations Article, §8–303, Annotated Code of Maryland; (3) Written evidence satisfactory to the Board that the applicant has submitted to a CHRC as required by §A(2) of this regulation by submitting: (a) Two sets of fingerprints, as required by the Central Repository and the FBI; and (b) All fees required by the Central Repository and the FBI; (4) Any documentation requested from the applicant by the Board including, but not limited to, official certified or true test court documents and a signed, dated explanation written by the applicant, regarding the facts and circumstances, outcome, and current status of any criminal history record information received by the Board: (a) Under Health Occupations Article, §8-303, Annotated Code of Maryland; (b) In an answer to a question on the Board’s application form; or (c) From any other source; and (5) Any additional documentation requested by the Board if the documentation received from the applicant under §A(4) this regulation is incomplete or insufficient. B. If an application is not complete when initially submitted to the Board by the applicant, the applicant shall have no longer than 12 months from the date the application is received by the Board to: (1) Complete the application; and (2) Provide all information and documents required in §A of this regulation. C. If an applicant fails to provide to the Board a complete application and any additional documentation requested by the Board in §A of this regulation within 12 months from the date the application is received by the Board, then the application: (1) Shall be considered abandoned; and (2) May be destroyed. D. Once an application is deemed abandoned under §C of this regulation, an individual seeking licensure shall: (1) Submit a new application; (2) Meet all of the requirements for licensure; and (3) Pay the required fees that are in effect at the time of re-application. #### Regulation .05 Qualifications of Applicants for Examination. *COMAR 10.27.01.05* A. An applicant for the registered nurse licensure examination shall: (1) Complete satisfactorily and meet all requirements for a diploma or degree from an entry-level registered nursing education program approved by the Board (2) Have a diploma or degree from an entry-level registered nursing education program in another state, territory, or country determined by the Board to be substantially equivalent to the registered nursing education program approved in this State at the time of the applicant's graduation. B. An applicant for the licensed practical nurse licensure examination shall: (1) Meet all requirements for a high school diploma or its equivalent and complete satisfactorily and meet all requirements for a diploma from: (a) A licensed practical nursing education program approved by the Board; or (b) A licensed practical nursing education program in any other state, territory, or country determined by the Board to be substantially equivalent to the licensed practical nursing education programs approved in this State at the time of the applicant's graduation; or (2) Meet the requirements of §A of this regulation. C. Applicants for registered nurse licensure and licensed practical nurse licensure who take an English proficiency examination approved by the U.S. Department of Health and Human Services in order to demonstrate English language proficiency under Health Occupations Article, § 8-302(e), Annotated Code of Maryland, shall obtain the minimum passing scores for registered nurses and licensed practical nurses set by the Health Resources and Services Administration of the U.S. Department of Health and Human Services. D. An applicant whose entry-level registered nursing education program or licensed practical nursing education program was completed in another country shall have the applicant's transcript evaluated by the Commission on Graduates of Foreign Nursing Schools or a successor organization. #### Regulation .06 Application for Licensure by Examination. *COMAR 10.27.01.06* A. An applicant shall: (1) Comply with all of the requirements in Regulation .04A of this chapter; (2) File and submit a completed application to the National Council of State Boards of Nursing on the form required; and (3) Pay any required fees. B. Each application shall be signed by the nurse administrator of the school or program or an officer of the school to whom this responsibility has been designated. C. Applications may be signed before graduation and it shall be the responsibility of the person signing the application to submit written verification of program completion before the licensure examination. D. Applicants whose applications are complete and who, for any reason, fail to take the examination within 6 months shall be required to reapply and pay all fees. E. The authorization to test card shall be valid for a period of 6 months. If the applicant fails to complete the examination within that time frame the applicant is required to re-register and pay the NCLEX testing fee. #### Regulation .07 Examination Procedures. *COMAR 10.27.01.07* A. Examinations shall be held at least once per year. B. The Board will participate with the National Council of State Boards of Nursing, Inc., in preparing and administering the National Council Licensure Examination for registered nurse and practical nurse licensure. C. The results of the NCLEX shall be reported as pass or fail. D. An authorization to test card shall be sent to each candidate that the Board determines to be eligible for the examination. E. Examination scores shall be released only to the candidate and to the school of nursing from which the candidate graduated, except on written authorization of the candidate. F. Candidates for Maryland licensure may write the licensure examination in any jurisdiction. G. Candidates applying for licensure in other jurisdictions may write the licensure examination in Maryland. #### Regulation .08 Applicants Requiring Special Accommodation. *COMAR 10.27.01.08* A. An applicant with a disability may request modifications in examination materials or procedures. The applicant shall: (1) Make the request for modifications in writing; (2) Include in the request the following: (a) The candidate's name; (b) The date of the examination to be modified; (c) A letter from the appropriate medical professional which: (i) Confirms the disability; and (ii) Provides information describing the accommodations required; and (d) A letter from the candidate's education program, indicating what modifications, if any, were granted by the program. B. Requests for modification and supporting documentation shall be received by the application deadline. #### Regulation .09 Speech-Impaired Applicants. *COMAR 10.27.01.09* A. An applicant who claims a speech impairment shall fulfill all requirements for application, and shall submit to the Board documentation of the applicant's impairment, from: (1) An otolaryngologist who has current certification from the American Board of Otolaryngology; and (2) A speech-language pathologist who has current certification from the American Speech-Language-Hearing Association. B. The Board shall require a speech-impaired applicant to prove the applicant's ability to communicate adequately with patients and other health care professionals by: (1) Submitting letters from instructors in a nursing program, attesting to the applicant's ability to communicate in a professionally competent manner; and (2) Meeting with the Board to demonstrate the manner in which communication with patients will occur. C. A speech-language pathologist or otolaryngologist may be asked to attend the meeting in an advisory capacity to the Board to aid in assessing an applicant's ability to communicate. D. A foreign-educated, speech-impaired applicant shall notify the Board before taking a Board-approved standardized test for competency in the English language. E. The Board shall attempt to locate a speech-language pathologist fluent in the applicant's native language to assess the impairment. F. A foreign-educated applicant who is in need of foreign accent reduction, but who has competency in the applicant’s native language, may obtain assistance from a bilingual speech-language pathologist before attempting to pass a test for competency in the English language. #### Regulation .10 Licensure by Endorsement. *COMAR 10.27.01.10* A. An applicant who holds an active, unencumbered license to practice registered nursing or practical nursing in another state, territory, or country is eligible for licensure without examination if the applicant: (1) Complies with all of the requirements under Regulation .04A of this chapter; (2) Pays the required fee; (3) Meets one of the conditions in §B of this regulation; and (4) Presents evidence of 1,000 hours of active nursing practice within the last 5 years or successful completion of a Board-approved refresher course or preceptor program. B. An applicant for licensure as a registered nurse by endorsement shall either: (1) Hold a valid, unencumbered multistate license under the Nurse Licensure Compact; or (2) Submit the following evidence directly to the Board from the appropriate authority: (a) Verification that, at the time that applicant graduated from the nursing education program, the nursing education program was: (i) Approved as a registered nursing or licensed practical nursing education program in that state, territory, or country; and (ii) Substantially equivalent to the education program approved in this State; (b) Verification that the applicant passed one of the following licensure examinations under the laws of another state, territory, or country: (i) If completed from 1952 to 1982, the “State Board Test Pool Examination — Registered Nurse or Practical Nurse”; (ii) If completed from 1982 to present, the “National Council Licensure Examination — Registered Nurse or Practical Nurse”; (iii) If completed before, 1952, the “National League for Nursing State-Constructed Board Examination, Registered Nurse or Practical Nurse”; or (iv) If completed before 1982, “Canadian Nurses Association Test Service Examination for Registered Nurses”; (c) For applicants whose entry-level registered nursing education program or licensed practical nursing education program was completed in another country, a copy of an evaluation of the applicant's transcript by the Commission on Graduates of Foreign Nursing Schools or successor organization; and (d) Except as provided in §D(1) of this regulation, proof of written and oral competency in the English language, in accordance with Health Occupations Article, § 8-302(e), Annotated Code of Maryland. C. An applicant for licensure as a registered nurse by endorsement who cannot provide the evidence required under §B(2) of this regulation may qualify for licensure if the applicant submits evidence, as required by the Board, that the applicant has: (1) Completed satisfactorily and met all requirements for an associate or a baccalaureate degree in registered nursing from a college or university that, at the time of the applicant’s graduation, is: (a) Accredited by a national or regional nursing accreditation agency that is recognized by the Secretary of the U.S. Department of Education or the Council for Higher Education Accreditation; and (b) Approved by the board of nursing or other applicable state regulator in the state in which the program is located; and (2) Completed a minimum of 1,000 hours of practice in direct patient care. D. English Language Competency Requirements for Endorsement. (1) An applicant is not required to submit proof of English language competency if the applicant demonstrates that the applicant holds or has held a license to practice registered nursing or licensed practical nursing in another state if that state has an English language competency component for licensure or examination. (2) Applicants for registered nurse licensure and licensed practical nurse licensure who take an English proficiency examination approved by the U.S. Department of Health and Human Services in order to demonstrate English language proficiency under Health Occupations Article, § 8-302(e), Annotated Code of Maryland, shall obtain the minimum passing scores for registered nurses and licensed practical nurses set by the Health Resources and Services Administration of the U.S. Department of Health and Human Services. E. Those applicants who cannot present evidence of 1,000 hours of active nursing practice within the last 5 years, or successful completion of a Board-approved refresher course or preceptor program, may apply for inactive license. #### Regulation .11 Issuance of Licenses. *COMAR 10.27.01.11* A. An initial license shall be issued to each applicant passing the licensure examination or qualifying for licensure by endorsement provided that: (1) The applicant meets all the requirements of this chapter; and (2) The Board has: (a) Received and reviewed the criminal history record information; and (b) Approved the application. B. An initial license may not be issued for less than 90 days. C. An incorrect license issued as a result of a Board error will be corrected in the Board’s data base at no charge to the licensee. D. A licensee who requests a change of name for a license shall: (1) Make the request in writing on the form required by the Board; and (2) Provide appropriate legal documentation supporting the change. #### Regulation .12 Temporary Licensure. *COMAR 10.27.01.12* A. The Board may issue a temporary license to an applicant who passed the licensure examination and is waiting for the criminal history records check to be completed or who is licensed as a registered nurse or licensed practical nurse in any other state provided that the applicant: (1) Completes the required application; (2) If licensed in another state, presents a copy of a current, active license in another state; (3) Presents positive personal identification; (4) Pays the required fee; and (5) Provides written, verified evidence that the applicant has submitted to a criminal history records check in accordance with Health Occupations Article, §8-303, Annotated Code of Maryland. B. Except as provided in §§C and E of this regulation, temporary licenses expire 90 days after date of issuance and are not renewable. C. A temporary license may be extended for an additional 90 days if the applicant is waiting for the completion of the criminal history record information. D. The Board shall revoke a temporary license if the criminal history records check reveals that the applicant has been convicted of or pled guilty or nolo contendere to an act that would be cause for discipline under Health Occupations Article, §8-316(a), Annotated Code of Maryland. E. If an applicant does not meet the practice requirement in Regulation .10A(5) of this chapter, a temporary license may be extended every 90 days: (1) Pending completion of the practice requirement; and (2) Provided that the total length of the temporary license does not exceed 12 months from the original date of issuance. #### Regulation .13 Renewal of License. *COMAR 10.27.01.13* A. The Board shall renew the license of a licensee who meets all the requirements of Health Occupations Article, §8-312, Annotated Code of Maryland and of this chapter. B. The Board shall renew licenses biennially according to the following schedule: (1) A registered nurse or licensed practical nurse with an odd-numbered birth year shall always renew in an odd-numbered year not later than the 28th day of the licensee’s birth month; and (2) A registered nurse or licensed practical nurse with an even-numbered birth year shall always renew in an even-numbered year not later than the 28th day of the licensee’s birth month. C. At least 3 months before a license expires, the Board shall send the licensee a renewal notice by: (1) First-class mail to the last known address of the licensee; or (2) Electronic means to the last known electronic address of the licensee. D. It shall be the responsibility of the licensee to notify the Board if a renewal notice is not received. E. The Board cannot guarantee that renewal applications received later than 30 days before the expiration date will be processed before the expiration date. F. The Board shall issue a volunteer license to any registered nurse or licensed practical nurse who meets the licensure renewal requirements provided the licensee: (1) Certifies to the Board that the licensee provides professional services only as a volunteer; (2) Completes the required application; and (3) Pays the required fee. G. Active Licensure Renewal. (1) An individual applying for active licensure renewal shall show evidence of: (a) 1,000 hours of active nursing practice within the 5 years immediately preceding the date of the renewal application; (b) Satisfactory completion of all requirements for a diploma or degree from a Board-approved nursing education program within the 5 years immediately preceding the date of the renewal application; or (c) Completion of 30 continuing education units (CEUs) within the 2 years immediately preceding the date of the renewal application. (2) College or University Coursework. (a) A renewal applicant may submit qualifying college or university coursework to fulfill the requirement under §G(1)(c) of this regulation. (b) 15 CEUs shall be awarded for each semester hour completed of a qualifying college or university course. (c) For the coursework to qualify: (i) The college or university course shall be related to the renewal applicant’s nursing practice; and (ii) The renewal applicant shall receive a grade of C or higher, or the numeric equivalent in the course. (d) An official transcript shall be acceptable as proof of completion of a qualifying college or university course. H. Continuing Education. (1) Except as provided in §G(2) of this regulation, CEUs shall be approved by an entity listed in §H(5) of this regulation. (2) CEUs used for the purpose of renewing a license are subject to random audits by the Board or the Board’s designee. (3) CEUs that are used for the purpose of renewing a license shall be earned within the 2 years immediately preceding the date of the renewal application. (4) The renewal applicant shall be responsible for: (a) Ensuring that a CEU course, forum, or meeting has been approved for CEUs by one of the entities listed in §H(5) of this regulation; (b) Retaining evidence of completed CEUs that are submitted for the purpose of renewing a license for 6 years after the license is renewed; and (c) Producing evidence of completed CEUs for an audit by the Board or the board’s designee within 30 days of the request. (5) The Board shall accept CEUs awarded or approved by: (a) Area Health Education Centers (AHEC), including all local, state, and national centers; (b) The American Nurses Association (ANA); (c) The American Nurses Credentialing Center (ANCC); (d) Professional organizations offering CEUs for the purpose of renewing a national certification for advanced practice registered nursing; (e) A local, state, or national professional nursing association that provides educational programs; (f) The Maryland Nurses Association (MNA); (g) The National Council of State Boards of Nursing; and (h) The National League for Nursing. (6) CEUs may not be carried forward into the next renewal period. I. An individual applying for active licensure renewal who do not meet the requirements of §G of this regulation shall be required to successfully complete a Board-approved refresher program or Board-approved preceptorship program prior to renewal of the license. J. Tax Deficiencies. (1) On a monthly basis, the Board shall notify the Office of the Comptroller of any licensee or certificate-holder: (a) Whose license expires within the next 4-month period; and (b) Whose identity has not previously been provided to the Office of the Comptroller. (2) Upon notification by the Office of the Comptroller of any licensee or certificate-holder who is delinquent in the payment of undisputed taxes or unemployment insurance contributions, the Board shall notify the licensee or certificate-holder that renewal processing shall be delayed until the Office of the Comptroller verifies that the licensee or certificate-holder has made arrangements for payment of the undisputed taxes or unemployment insurance contributions that are satisfactory to the unit responsible for collection. (3) Upon notification by the Office of the Comptroller that the licensee or certificate-holder has made satisfactory arrangements for payment of the undisputed taxes or unemployment insurance contributions, and where the licensee or certificate-holder is otherwise qualified for licensure, the Board shall renew the license or certificate. K. Along with the renewal notice in accordance with §C of this regulation, the Board shall: (1) Notify every renewal applicant who is required to have a criminal history records check in the selected birth month; and (2) Send the renewal applicant instructions for downloading and completing the documents needed to submit to a criminal history records check. L. If a renewal applicant is out of the state, the Board shall mail a packet to the applicant with the required documents and instructions for completing the documents. M. Upon notification by the Board that a criminal history records check is required before a license can be renewed, a renewal applicant shall comply with all of the requirements under Regulation .04A of this chapter. N. Criminal history record checks for renewal applicants shall be scheduled according to the licensee's birth month as follows: (1) In 2025 — all applicants with an August or September birth month; (2) In 2026 — all applicants with a September or October birth month; (3) In 2027 — all applicants with an October or November birth month; (4) In 2028 — all applicants with a November or December birth month; (5) In 2029 — all applicants with a December or January birth month; (6) In 2030 — all applicants with a January or February birth month; (7) In 2031 — all applicants with a February or March birth month; (8) In 2032 — all applicants with a March or April birth month; (9) In 2033 — all applicants with an April or May birth month; (10) In 2034 — all applicants with a May or June birth month; (11) In 2035 — all applicants with a June or July birth month; and (12) In 2036 — all applicants with a July or August birth month. O. For renewal applicants who are required to submit to a criminal history records check, the Board may not renew a license without written documentation that the applicant has submitted to a criminal history record check in accordance with Health Occupations Article, §8-303, Annotated Code of Maryland. #### Regulation .14 Inactive Status. *COMAR 10.27.01.14* A. The Board shall place the license of any registered nurse or licensed practical nurse on inactive status if the licensee: (1) Has not satisfactorily completed 1,000 hours of active nursing practice or graduated from an approved nursing program within the 5-year period immediately preceding the date of anticipated renewal or chooses inactive status; (2) Completes the biennial application for inactive status; and (3) Pays all fees. B. A licensee on inactive status may not practice nursing in this State. However, a registered nurse on inactive status may use the title “registered nurse”, and a practical nurse on inactive status may use the title “licensed practical nurse”. C. A licensee on inactive status may apply for an active status license provided that the licensee: (1) Meets the renewal requirements of Health Occupations Article, §8-312, Annotated Code of Maryland; and (2) Submits to the Board: (a) The required application; and (b) Written, verified evidence that the licensee has submitted to a criminal history records check in accordance with Regulation .13 of this chapter by: (i) Submitting two sets of fingerprints required by the Central Repository and the FBI; and (ii) Paying all fees required by the Central Repository and the FBI. D. An additional fee may not be charged to change from inactive to active status. #### Regulation .15 Expiration of License. *COMAR 10.27.01.15* A. A license expires on the 28th day of the licensee's birth month. B. A licensee has a 30-day grace period beyond the expiration date of a license to renew a license. #### Regulation .16 Refresher Course and Preceptorship Requirements. *COMAR 10.27.01.16* A. Refresher courses and preceptor programs, as defined in Regulation .01B of this chapter, shall be approved by the Board before their implementation and at least every 5 years after that. B. The registered nurse curriculum shall: (1) Have a minimum of 80 theory hours, 60 clinical hours, and 8 hours of a classroom laboratory training before the on-site clinical experience; (2) Include the following content areas: (a) The nursing process; (b) Management and delegation of patient care; (c) Documentation and information management; (d) Pharmacology, including calculation; (e) Nursing care of patients with alterations in body systems; (f) Emergency procedures; (g) Disaster response; and (h) Professional responsibilities, which include, but are not limited to, the following: (i) Trends in nursing and the health care system; (ii) Legal aspects of nursing; and (iii) Development and initiation of patient and community health education. C. The practical nurse curriculum shall: (1) Have a minimum of 60 theory hours, 60 on-site clinical hours, and 8 hours of a classroom laboratory training before the on-site clinical experience; (2) Include the following content areas: (a) The nursing process with the licensed practical nurse as a contributor; (b) Provision and delegation of patient care under the supervision of a registered nurse; (c) Documentation and information management; (d) Pharmacology, including calculations; (e) Nursing care of patients with common health problems; (f) Emergency procedures; (g) Disaster response; and (h) Professional responsibilities, which include, but are not limited to, the following: (i) Trends in nursing; (ii) Legal aspects of nursing; and (iii) Contribution to patient health teaching. D. The organization and utilization of curriculum materials shall be based on accepted educational principles. E. Faculty Qualifications. (1) Faculty shall: (a) Be a registered nurse as defined in Health Occupations Article, §8-101, Annotated Code of Maryland; and (b) Have a baccalaureate degree in nursing. (2) A minimum of 3 years of clinical and teaching experience is recommended. F. Faculty shall: (1) Plan, implement, evaluate, and revise the educational program. (2) Select and evaluate clinical facilities used to achieve program objectives. (3) Develop and utilize: (a) Written examinations to measure achievement of program objectives. (b) An evaluation tool to measure achievement of clinical competencies. The clinical competencies shall be based upon the registered nurse and licensed practical nurse standards of practice. (c) A mechanism for student evaluation of the course. G. Students shall complete theoretical instruction either before or concurrent with clinical instruction. H. All program requirements including required clinical hours shall be completed within 12 months of the starting date of the refresher course. I. Clinical facilities shall provide sufficient opportunities to meet the learning objectives of the refresher course. J. The faculty/student ratio may not exceed 1:10 in the clinical area. #### Regulation .17 Reinstatement. *COMAR 10.27.01.17* A. The Board shall reinstate the license of a former licensee who has failed to renew the license for any reason if the former licensee meets the renewal requirements. B. After January 1, 2010, an applicant for reinstatement who has failed to renew the applicant's license for a period of 1 year or more shall submit to a criminal history records check before the license is reinstated. C. Temporary License. (1) The Board shall issue a temporary license to a former licensee who: (a) Applies for reinstatement in accordance with Health Occupations Article, §8-313, Annotated Code of Maryland; (b) Meets the renewal requirements of Health Occupations Article, §8-312, Annotated Code of Maryland; and (c) Is awaiting the completion of the criminal history records check. (2) The temporary license issued pursuant to §C(1) of this regulation is effective until the earlier of 90 days after the date of issue or the date the Board issues an active license. #### Regulation .18 Violation of Regulations. *COMAR 10.27.01.18* A. If a program is thought to be in violation of this chapter, the following steps shall be taken: (1) The Board shall notify the program of the regulations it is violating; (2) The program shall submit a plan with a proposed time frame for correcting the violations; (3) The plan shall be due within 30 days of receipt of notification of the violations; (4) The Board's professional staff may, at the request of the Board, visit the program; (5) After receipt of the plan, the Board shall provide the program with a reasonable time frame within which to correct the violations; and (6) Upon expiration of the time period for correcting violations, a member of the Board's staff shall visit the program to determine if the school is in compliance with the regulations, and report to the Board. B. If the program does not correct the violations within the time frame established by the Board, the Board: (1) Shall notify the program that it has not corrected violations in a reasonable time and schedule a hearing in accordance with the Administrative Procedure Act; and (2) If, after a hearing, determines that the program or preceptorship is in violation of the regulations, may place a program on either conditional approval or remove it from the approved list of programs. If the Board places the program on conditional approval, the Board may request that a program suspend admission of students. A program placed on conditional approval shall remain in that status until the Board determines it has complied with the regulations. C. Unless authorized to practice as a nursing graduate under this chapter, an individual may not use the words “nursing graduate”, the abbreviation “NG”, or any other title, symbol, abbreviation, sign, card, device, or other representation with the intent to represent that the individual practices as a nursing graduate. ### Chapter 02 — Hearing Procedures **Authority:** Health Occupations Article, §§8-205(a)(1), and 8-317, Annotated Code of Maryland **Administrative History:** Effective date: September 30, 1973 **Administrative History:** Regulation .01-1 adopted effective November 23, 1981 (8:23 Md. R. 1857) **Administrative History:** Regulations .01 and .01-1 recodified to .01-1 and .01-2, respectively, and Preface recodified to Regulation .01 Scope, July 1991 **Administrative History:** Regulation .01 amended effective July 3, 1995 (22:13 Md. R. 967); March 14, 2005 (32:5 Md. R. 580) **Administrative History:** Regulation .01-1 repealed and new Regulation .01-1 adopted effective July 3, 1995 (22:13 Md. R. 967) **Administrative History:** Regulation .01-3 adopted effective April 30, 2001 (28:8 Md. R. 760) **Administrative History:** Regulation .02 amended effective July 3, 1995 (22:13 Md. R. 967) **Administrative History:** Regulation .04 amended effective July 3, 1995 (22:13 Md. R. 967) **Administrative History:** Regulation .06A amended effective July 3, 1995 (22:13 Md. R. 967) **Administrative History:** Regulation .06C amended effective March 14, 2005 (32:5 Md. R. 580) **Administrative History:** Regulation .08 amended effective July 3, 1995 (22:13 Md. R. 967) **Administrative History:** Regulation .09 amended effective July 3, 1995 (22:13 Md. R. 967) **Administrative History:** Regulation .10 repealed effective July 3, 1995 (22:13 Md. R. 967) #### Regulation .01 Scope. *COMAR 10.27.02.01* These regulations apply only to formal hearings before the Board based on charges or notices of proposed action issued pursuant to Health Occupations Article, §§8-316, 8-404, 8-6A-10, 8-6B-18, 8-6C-20 or 8–6D–10, Annotated Code of Maryland. #### Regulation .01-1 Notice of Hearing. *COMAR 10.27.02.01-1* A. The Board shall send written notice of the hearing to all interested parties at least 30 days before the hearing. B. The Board shall notify the parties of: (1) The date, time, and place of the hearing; (2) A clear and concise statement of the facts asserted; and (3) The charges alleged. C. If the facts cannot be stated in detail when the notice is given, the Board shall state the issues involved. #### Regulation .01-2 Prehearing Conferences. *COMAR 10.27.02.01-2* The Board may set prehearing conferences as it considers appropriate. #### Regulation .01-3 Discovery. *COMAR 10.27.02.01-3* A. Discovery on Request. By written request served on other parties and filed with this Board, a party may require another party to produce, within 15 calendar days: (1) A list of witnesses to be called; and (2) Copies of documents intended to be produced at the hearing. B. Mandatory Discovery. (1) Each party shall provide to the other party the name and curriculum vitae of any expert witness who will testify at the hearing not later than 15 days before the scheduled hearing date. (2) The designation of an expert witness shall be accompanied by a detailed written report summarizing the expert's testimony, which includes the opinion offered and the factual basis and reasons underlying the opinion. (3) If the Board finds that the report is not sufficiently specific, or otherwise fails to comply with the requirements of this section, the Board shall exclude from the hearing the testimony and any report of the expert. (4) At the hearing, the Board shall consider arguments regarding the sufficiency of the report. (5) If an expert adopts a sufficiently specific charging document as the expert's report, the report satisfies the requirements set forth in this regulation. C. Parties are not entitled to discovery of items other than as listed in §§A and B of this regulation. D. Ongoing Duty of Disclosure. (1) All parties have a continuing duty to supplement their disclosures of witnesses and documents. (2) If witnesses or documents are later added to the list provided under §A of this regulation, each party shall provide notice of these witnesses or documents to the opposing party during business hours at least 1 day before the hearing. (3) The notice requirement referred to in §D(2) of this regulation applies only to witnesses or documents to be used in the party's case-in-chief and not to witnesses or documents to be used for impeachment or rebuttal purposes. #### Regulation .02 Representation. *COMAR 10.27.02.02* A. A party appearing at a formal hearing has the right to appear in proper person or by or with counsel. A party has the right to be accompanied, represented, and advised by counsel. B. Unless authorized to practice law in this State, a counsel may not represent a party before the Board. #### Regulation .03 Records and Transcript. *COMAR 10.27.02.03* A. The Board shall prepare an official record, which shall include all pleadings, testimony, exhibits, and other memoranda or material filed in the proceeding. B. Unless waived by all parties, a stenographic record of the proceedings shall be made at the expense of the Board. This record need not be transcribed, however, unless requested by a party, or by the Board. The cost of any typewritten transcripts of any proceeding, or part of a proceeding, shall be paid by the party requesting the transcript. #### Regulation .04 Presiding Officer Duties. *COMAR 10.27.02.04* A quorum of the Board shall be present for each formal hearing. The president, or the president's designee, is the presiding officer, and has complete charge of the hearing, permitting the examination of witnesses, admitting evidence, ruling on the admissibility of evidence, and adjourning or recessing the hearing from time to time. #### Regulation .05 Order of Procedure. *COMAR 10.27.02.05* The order in which the parties shall present their case shall be determined by the presiding officer. #### Regulation .06 Examination of Witnesses and Introduction of Evidence. *COMAR 10.27.02.06* A. The rules of evidence in all hearings under these bylaws are as set forth in State Government Article, §§10-213 and 10-214, Annotated Code of Maryland. B. Any party may submit evidence, examine and cross-examine witnesses, and file objections, exceptions, and motions. However, when a party is represented by counsel, all submission of evidence, examination and cross-examination of witnesses, and filing of objections, exceptions, and motions shall be done and presented solely by the counsel. C. The presiding officer, or any person designated by the presiding officer for the purpose, may examine any witness called by any party. The presiding officer may call as a witness any person in attendance at the hearing. Any member of the Board may examine any witness called by any party. #### Regulation .07 Briefs. *COMAR 10.27.02.07* Any party may submit briefs of the issues of fact and law involved in the hearing. The briefs shall be filed in the form, with the number of copies, and at the time that the presiding officer designates. #### Regulation .08 Request for Office of the Attorney General Counsel. *COMAR 10.27.02.08* The Board may request the Office of the Attorney General to participate in any hearing as counsel for the Board. Upon that request, the counsel is entitled to submit evidence and question witnesses on behalf of the Board as permitted by State Government Article, §10-213, Annotated Code of Maryland. #### Regulation .09 Decision and Order. *COMAR 10.27.02.09* The Board shall render every decision and order in writing, which shall be accompanied by findings of fact and conclusions of law. A copy of the decision and order and accompanying findings and conclusions shall be delivered or mailed promptly to each party or the party's attorney of record. ### Chapter 03 — Nursing Education Programs **Authority:** Health Occupations Article, §§8-205, 8-401, and 8-404, Annotated Code of Maryland **Administrative History:** Effective date: April 16, 1975 (2:8 Md. R. 566) **Administrative History:** Chapter revised effective August 30, 1982 (9:17 Md. R. 1708) **Administrative History:** Regulation .01 amended effective November 21, 1983 (10:23 Md. R. 2064); August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulation .03 amended effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulation .04 amended effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulation .05 amended effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulation .06 amended effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulation .08 repealed and new Regulation .08 adopted effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulation .09 amended effective November 21, 1983 (10:23 Md. R. 2064) **Administrative History:** Regulation .09 repealed and new Regulation .09 adopted effective August 11, 1986 (13:16 Md. R. 1827) **Administrative History:** Regulation .10 amended effective November 21, 1983 (10:23 Md. R. 2064) **Administrative History:** Regulation .13 adopted effective November 21, 1983 (10:23 Md. R. 2064) **Administrative History:** Regulations .01—.13 repealed and new Regulations .01—.20 adopted effective September 30, 1991 (18:19 Md. R. 2100) **Administrative History:** Regulations .01, .06, .07, .09, and .11 amended as an emergency provision effective April 11, 1994 (21:9 Md. R. 745) **Administrative History:** Regulation .01B amended effective August 1, 1994 (21:15 Md. R. 1305) **Administrative History:** Regulation .06 amended effective August 1, 1994 (21:15 Md. R. 1305); February 12, 1996 (23:3 Md. R. 169) **Administrative History:** Regulation .06A, B amended effective February 15, 1993 (20:3 Md. R. 259) **Administrative History:** Regulation .07 amended effective August 1, 1994 (21:15 Md. R. 1305) **Administrative History:** Regulation .09 amended effective August 1, 1994 (21:15 Md. R. 1305) **Administrative History:** Regulation .11D amended effective August 1, 1994 (21:15 Md. R. 1305) **Administrative History:** Regulations .01—.20, Registered Nursing Education Programs, repealed and new Regulations .01—.19, Nursing Education Programs, adopted effective August 10, 1998 (25:16 Md. R. 1274) **Administrative History:** Chapter revised effective March 5, 2001 (28:4 Md. R. 418) **Administrative History:** Regulation .02G amended effective July 18, 2005 (32:14 Md. R. 1276) **Administrative History:** Regulation .02I amended effective February 18, 2002 (29:3 Md. R. 220) **Administrative History:** Regulation .03A amended effective February 18, 2002 (29:3 Md. R. 220); July 18, 2005 (32:14 Md. R. 1276) **Administrative History:** Regulation .08 amended as an emergency provision effective August 1, 2003 (30:19 Md. R. 1327); amended permanently effective January 5, 2004 (30:26 Md. R. 1915) **Administrative History:** Regulation .08B amended as an emergency provision effective May 23, 2008 (35:13 Md. R. 1178); amended permanently effective August 25, 2008 (35:17 Md. R. 1489) **Administrative History:** Chapter revised as an emergency provision effective November 3, 2008 (35:24 Md. R. 2069); revised permanently effective January 26, 2009 (36:2 Md. R. 101) **Administrative History:** Regulation .01B amended effective July 2, 2018 (45:13 Md. R. 667); February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .02 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .03B amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .05 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .07A amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .08 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .08A, C amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .09A amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .11 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .12D, E amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .13 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .14 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .15 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .16 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .17 amended effective February 22, 2021 (48:4 Md. R. 177) **Administrative History:** Regulation .18 amended effective February 22, 2021 (48:4 Md. R. 177) #### Regulation .01 Definitions. *COMAR 10.27.03.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Approval” means the status granted to a nursing education program that: (a) Is in compliance with the regulations of the Board; and (b) Holds a certificate of approval from the Board of Nursing. (2) “Articulation” means the process by which a registered nurse or licensed practical nurse who is enrolled in a nursing education program is given credit for previous nursing education. (3) “Board” means the Board of Nursing. (4) “Board-recognized nursing accreditation agency (BRNAA)” means a national or regional nursing education accreditation agency recognized by the: (a) Secretary of the United States Department of Education (USDOE); and (b) Board. (5) Clinical Learning Experience. (a) “Clinical learning experience” means faculty planned and guided learning activities designed to assist students to meet the course objectives and apply nursing knowledge and skills in the direct care of patients. (b) “Clinical learning experience” includes: (i) Direct care of patients within the relevant practice setting; (ii) Clinical support activities such as clinical conferences; and (iii) Simulation laboratories. (6) “Clinical nurse faculty” means an individual with at least a baccalaureate degree in nursing who is employed by the program solely for clinical learning of nursing students. (7) “Clinical preceptor” means a registered nurse employee of a cooperating clinical agency acting to facilitate and supervise student learning in a manner specified in a signed written agreement between the cooperating clinical agency and the educational institution. (8) “Clinical preceptorship” means an organized system of clinical experience that allows a nursing student to be paired with a clinical preceptor for the purpose of attaining specific learning objectives. (9) “Conditional approval” means a limited-time status that: (a) Is imposed by the Board if the Board finds evidence that the program has failed to meet or maintain the regulations or requirements, or both, set by the Board; and (b) Allows the program to continue to operate subject to the program conforming to the Board’s requirements and recommendations within a time period set by the Board. (10) “Controlling institution” means an organization that offers a nursing education program. (11) “Cooperating clinical agency” means an agency that provides the facilities and clinical resources for clinical learning experiences in nursing, with the nurse faculty or the clinical nurse faculty of the program responsible for the planning, implementation, and evaluation of these experiences. (12) “Curriculum changes” means changes in course offerings that will alter the curriculum, philosophy, objectives, outcomes, competencies, or conceptual framework of the program. (13) “Full time nurse faculty equivalent” means nursing faculty who are designated as full time employees by their institution. (14) “Generic student” means one who enters at the beginning of the nursing education program and plans to complete the entire curriculum. (15) “Initial approval” means the approval period from the first admission of nursing students to the program through the first full implementation of the curriculum and graduation. (16) “Informatics” means the use of technology in nursing practice. (17) “Licensed practical nurse” means an individual who: (a) Is licensed by the Board to practice licensed practical nursing; or (b) Has a multistate licensure privilege to practice licensed practical nursing. (18) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (19) “MHEC” means Maryland Higher Education Commission. (20) “Nurse faculty” means an individual with a graduate degree in nursing who is employed to teach full-time or part-time in a nursing education program. (21) Program. (a) “Program” means a registered nursing or licensed practical nursing educational program. (b) “Program” includes any of the following: (i) A college; (ii) A school; (iii) A division; (iv) A department; (v) An academic unit; or (vi) A program. (22) “Regional nursing education accrediting agency” means an accrediting agency that operates in a specific geographic region of the United States and accredits post-secondary institutions and primary and secondary schools. (23) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (24) “Requirement” means a mandatory condition that a program meets: (a) For the program to be approved; and (b) To ensure that graduates of the program are eligible to take the NCLEX-RN® and NCLEX-PN®. (25) “Simulation” means instructional activities and strategies that mimic the reality of a clinical environment and complement other clinical learning experiences. (26) “Transfer student” means a student who is permitted to apply nursing courses completed at another institution to a nursing education program of study. (27) “USDOE” means the United States Department of Education. #### Regulation .02 Approval of Programs Accredited by a Board-Recognized Nursing Accreditation Agency. *COMAR 10.27.03.02* A. The Board shall place on its list of approved programs any nursing education program in Maryland granted accreditation by a BRNAA, provided the program meets all requirements of this chapter. B. A program approved by the Board and accredited by a BRNAA agency shall submit to the Board within 30 days of receipt: (1) Evidence of current accreditation; (2) Accreditation reports; and (3) Any correspondence related to the status of the program's accreditation. C. The Board shall continue to grant approval to programs in Maryland filing evidence of continuing accreditation by the BRNAA, provided those programs continue to meet all requirements of this chapter. D. The Board shall be notified in writing within 10 business days of any change in accreditation status by the nursing program. E. Withdrawal of accreditation, accreditation with warning, or failure to meet the requirements of this chapter or the standard for performance on the licensing examination shall be cause for Board review of the program in accordance with Regulations .16B and C and .17 of this chapter. F. A program on which the Board has taken action under Regulations .16B and C and .17 of this chapter shall be reported to MHEC. G. On a periodic basis, the Board shall compare its regulations to those of the BRNAA and the USDOE to ensure that the Board standards for programs are being met. H. The Board and MHEC shall inform one another in a timely manner of proposed changes to regulations that may affect nursing education programs. #### Regulation .03 Board Approval of Nonaccredited Programs. *COMAR 10.27.03.03* A. A Board-approved nursing education program that is not accredited by a BRNAA shall meet the requirements stated in Regulations .04—.16 of this chapter. B. In institutions having both a licensed practical nursing education program and a registered nursing education program and when only one of the programs is accredited by a BRNAA: (1) Except as otherwise provided in Regulation .18 of this chapter, the Board and the BRNAA shall conduct concurrent visits; and (2) The program shall submit an addendum to the accredited program's self-study describing the unique components of the nonaccredited program. C. A program on which the Board has taken action shall be reported to MHEC. #### Regulation .04 Philosophy and Objectives, Outcomes, or Competencies. *COMAR 10.27.03.04* A. The philosophy and program objectives, outcomes, or competencies shall be: (1) Developed by the nursing faculty and represent a consensus of that faculty; (2) Consistent with the characteristics of the specific type of nursing education program; (3) Communicated to those responsible for and participating in the program; and (4) Periodically evaluated. B. The philosophy of the program shall: (1) Be consistent with that of the controlling institution and governing body; (2) Articulate beliefs about individuals and their health, environment, nursing, adult education, and learning; and (3) Serve as a foundation for developing, implementing, and evaluating the educational program. C. The program objectives, outcomes, or competencies shall: (1) Evolve from the philosophy of the program; (2) Be clearly stated, measurable, and attainable; (3) Serve as a foundation for planning, implementing, and evaluating the program; and (4) Identify the expected competencies of the graduate. #### Regulation .05 Administration and Organization. *COMAR 10.27.03.05* A. The controlling institution shall: (1) Be accredited by the appropriate national or regional accrediting agency; and (2) Have a statement of equal educational opportunity. B. The organizational chart shall: (1) Demonstrate the relationship of the nursing program to the controlling institution; (2) Indicate lines of responsibility and authority; and (3) Indicate channels of communication. C. The program shall have comparable status with other academic units within the controlling institution. D. The controlling institution shall provide the financial support and resources needed to operate a program which: (1) Meets the requirements of the Board; and (2) Fosters achievement of program goals. E. The financial resources shall support: (1) Adequate educational facilities and equipment; and (2) Qualified administrative, clerical, and instructional personnel. F. The program shall be administered by a registered nurse who meets the qualifications stated in Regulation .07 of this chapter. G. When the nursing program administrator changes, the administrative officer of the controlling institution shall submit written notification to the Board of the change indicating that the new program administrator meets the Board’s requirements. #### Regulation .06 Records and Reports. *COMAR 10.27.03.06* A. Accurate and appropriate records shall be maintained that include, but are not limited to: (1) Current records of students; (2) Transcripts of graduates; (3) Faculty records; (4) Administrative records, which include: (a) Minutes of faculty meetings; (b) Annual reports of the program; and (c) School bulletins; (5) The current curriculum, including: (a) Philosophy; (b) Objectives or outcomes; and (c) Course outlines; (6) Agreements with cooperating agencies; and (7) A master plan of evaluation. B. Records shall be safely stored to prevent loss, destruction, or unauthorized use. C. The nursing program administrator shall submit an annual report to the Board on forms provided by the Board. #### Regulation .07 Nursing Program Administrator. *COMAR 10.27.03.07* A. Qualifications. (1) Qualifications of the nursing program administrator include: (a) Current licensure as a registered nurse in Maryland or possession of a multistate licensure privilege to practice registered nursing; (b) A graduate degree in nursing; and (c) Academic preparation or experience in administration. (2) A doctorate in nursing or a related field is recommended for the nursing program administrator. B. Responsibilities. The nursing program administrator, with the participation of the faculty, is responsible for: (1) Recommendations for faculty appointment and review; (2) The educational program or programs; (3) Preparing and administering the budget; (4) Formulating and implementing policies pertinent to the program, which include but are not limited to: (a) Admission and progression; (b) Advanced standing; (c) Transfer and articulation; (d) Withdrawal; (e) Reinstatement; (f) Evaluation; (g) Graduation requirements; and (h) Competency in oral and written communication of the English language; (5) Determining the student/teacher ratio based on the objectives of the course, method of instruction used, and the requirements of the faculty; (6) Determining the number of faculty, including clinical faculty, needed based on the: (a) Number and academic level of enrolled students; (b) Curriculum; (c) Activities and responsibilities required of the faculty; and (d) Number and geographic locations of the clinical facilities; (7) Developing, maintaining, complying with, and periodically reviewing written agreements with cooperating agencies; (8) Implementing a faculty orientation and development program; (9) Implementing the entire program in accordance with Board regulations; (10) Assuring that all publications pertaining to the nursing program are clear, accurate, and current; (11) Developing and implementing a written plan that provides that all students participating in clinical practice settings are physically and mentally competent at all times to provide safe client care; and (12) Developing appropriate clinical learning experiences that reflect an understanding of the program's philosophy, objectives, outcomes or competencies, and curriculum. #### Regulation .08 Nurse Faculty and Clinical Nurse Faculty. *COMAR 10.27.03.08* A. Qualifications of Nurse Faculty. (1) Nurse faculty shall: (a) Be currently licensed as a registered nurse in Maryland or have a multistate licensure privilege to practice registered nursing; (b) Be academically and professionally qualified; (c) Maintain expertise appropriate to their teaching responsibilities; and (d) Have a minimum of 2 years of clinical experience as a registered nurse. (2) Except as provided under §B of this regulation, nurse faculty shall have a graduate degree in nursing. (3) Non-nurse faculty, or nurses not meeting the requirements for nurse faculty, may teach selected portions of the nursing curriculum that relate to their areas of expertise. B. Waiver of Graduate Degree in Nursing Requirement for Nursing Faculty. (1) A program experiencing a faculty shortage may petition the Board for a waiver of the graduate degree in nursing required by §A(2) of this regulation. (2) The petition for a waiver of the graduate degree in nursing shall include documentation that the institution has attempted to hire nurse faculty with graduate degrees and a summary of those efforts. (3) The petition in §B(1) of this regulation shall include documentation verifying that the nurse faculty applicant for whom the waiver is requested has: (a) A baccalaureate degree in nursing and a graduate degree in another field; or (b) A baccalaureate degree in nursing and: (i) Is enrolled as a student in an approved graduate study program in nursing; and (ii) Will complete the graduate study program in nursing within 36 months. (4) If the graduate degree in nursing is waived by the Board: (a) The nurse faculty member for whom a waiver has been granted shall complete a minimum of 9 graduate credits in nursing within 24 months of the issuance of the waiver; and (b) The program shall submit documentation to the Board of completion of the required credits by the nurse faculty member within 24 months of the date when the waiver was granted. (5) If the nurse faculty member fails to complete the 9 graduate credits required in nursing within 24 months of the granting of the waiver, the Board may withdraw the waiver. (6) If the waiver has been withdrawn, the program shall require that the nurse faculty member cease functioning as nurse faculty. If the program fails to do so, the Board may take action under Regulation .17 of this chapter. (7) Once the nurse faculty member for whom the waiver was granted has met the 9 graduate credit waiver requirements, that nurse faculty member is considered to have met the educational requirements of §A(2) of this regulation. (8) The Board shall grant a waiver for a nurse faculty member: (a) With experience in teaching; and (b) Who is within a semester of graduation with a graduate degree in nursing. C. Qualifications of Clinical Nurse Faculty. (1) A clinical nurse faculty member shall: (a) Be currently licensed as a registered nurse in Maryland or have a multistate licensure privilege to practice registered nursing; (b) Have a degree in nursing at or above the baccalaureate level; (c) Have a minimum of 2 years of clinical experience as a registered nurse; and (d) Have the clinical experience necessary to function effectively and safely in the clinical nurse faculty's area of responsibility. (2) A program may not, in any academic year, fill more than 25 percent of the program’s full-time nurse faculty equivalent positions with clinical nurse faculty whose highest nursing degree is at the baccalaureate level. D. Responsibilities of Nurse Faculty and Clinical Nurse Faculty. (1) Responsibilities of the nurse faculty include participation in the planning, implementation, evaluation, and revision of the educational program. (2) Nurse faculty shall: (a) Develop and implement standards for admission, progression, and graduation of students; (b) Participate in academic advisement and guidance of students; (c) Evaluate student performance; (d) Maintain clinical skills in the nurse faculty’s area of responsibility; (e) Develop and implement a plan to assure that all instructional materials are accessible, current, and relevant to the curriculum; (f) Participate in the recruitment, selection, and promotion of nurse faculty and the recruitment and selection of clinical nurse faculty; (g) Participate in peer evaluation of nurse faculty and clinical nurse faculty performance; and (h) Elicit student evaluation of teaching effectiveness. (3) Clinical nurse faculty shall: (a) Provide clinical instruction and supervision of students; and (b) Evaluate student performance in clinical learning experiences. #### Regulation .09 Faculty Policies. *COMAR 10.27.03.09* A. There shall be written personnel policies for nurse faculty and clinical nurse faculty that conform to accepted educational standards. B. Policies concerning the teaching load for faculty and the nursing program administrator shall be in writing. Sufficient time shall be provided for faculty to accomplish those activities related to the teaching-learning process. If the program administrator is required to teach, the program administrator shall carry only a minimum teaching load. #### Regulation .10 Faculty Organization. *COMAR 10.27.03.10* A. The faculty shall be organized with written policies and procedures to guide its activities. B. The faculty shall meet regularly and function in such a manner that all members participate in planning, implementing, and evaluating the nursing program. C. Committees necessary to carry out the functions of the program shall be established with the duties and membership of each committee clearly defined. D. As appropriate, students shall participate on faculty committees. E. Minutes of faculty organization and committee meetings shall: (1) Document actions and decisions of the faculty; and (2) Be available for reference. #### Regulation .11 Faculty Development and Evaluation. *COMAR 10.27.03.11* A. There shall be a formal plan for orientation of new nurse faculty and clinical nurse faculty. B. A program of faculty development shall be offered to encourage and assist nurse faculty members and clinical nurse faculty in their professional growth and development. C. A variety of means shall be used to evaluate nurse faculty and clinical nurse faculty’s effectiveness of teaching within the classroom and clinical setting. #### Regulation .12 Resources, Facilities, and Services. *COMAR 10.27.03.12* A. Physical Facilities. The physical facilities shall be adequate to meet the needs of the nursing program and include the following: (1) Office for the administrator, faculty members, and staff; (2) Adequate space for privacy of faculty-student conferences; (3) Classroom, laboratories, simulation laboratories, and conference rooms; (4) Space for equipment and instructional materials; and (5) Space for noninstructional activities of nursing faculty and students. B. Learning resources shall be developed with faculty input and shall be: (1) Accessible to faculty and students; (2) Comprehensive; and (3) Current. C. Educational support services that facilitate students' abilities to achieve the program's objectives, outcomes, or competencies shall be available. D. Cooperating Clinical Agencies. (1) The appropriate authorities shall approve cooperating clinical agencies and all facilities used for clinical learning experiences. (2) Facilities with conditional or provisional approval status may not be used for student learning experiences. (3) Cooperating clinical agencies shall meet the following requirements: (a) Accreditation or approval by the appropriate authority; (b) A sufficient number and variety of clients to provide learning experiences for all students to achieve the stated objectives, outcomes, or competencies; (c) A sufficient number of registered nurses and other nursing personnel to ensure safe and continuous care of clients; and (d) Conformance with accepted standards of nursing care and practice. E. Written Agreements. (1) Written agreements between the program and the cooperating clinical agencies shall specify the responsibility of the program to the cooperating clinical agency and the responsibility of the cooperating clinical agency to the program. (2) Written agreements shall: (a) Be developed jointly with the cooperating clinical agency; (b) Be reviewed periodically; and (c) Include provision for adequate notice of termination. #### Regulation .13 Curriculum. *COMAR 10.27.03.13* A. The curriculum shall be: (1) Planned, implemented, and evaluated by the faculty; (2) Based on the philosophy and program objectives, outcomes, or competencies; (3) Organized logically and sequenced appropriately; and (4) Based on sound educational principles. B. The curriculum plan shall: (1) Serve as the foundation for curriculum development; (2) Define and organize philosophical beliefs, values, and concepts; (3) Operationalize the program objectives or outcomes; (4) Structure concepts and theories to enhance the teaching-learning process; and (5) Provide a model for progressive learning. C. The curriculum objectives, outcomes, or competencies shall: (1) Flow from the curriculum plan; (2) Measure the intended objectives, outcomes, or competencies for program graduates; and (3) Serve as a foundation for: (a) Sequencing of the program; (b) Course objectives; (c) Sequential arrangement of courses; and (d) Distribution of class and clinical hours. D. The curriculum of all programs shall: (1) Be appropriate to the level of the graduate's intended scope of practice; (2) Provide didactic and clinical learning experiences that are diverse and consistent with program objectives, outcomes, or competencies; and (3) Include: (a) Content in the arts and humanities, social and behavioral sciences, and biological and physical sciences; (b) The nursing process; (c) Didactic and clinical instruction which includes, but is not limited to, the following areas: (i) Nursing care of families and clients throughout the life span in a variety of care settings requiring nursing measures appropriate for either the maintenance or restoration of mental and physical health; (ii) Preventive, rehabilitative, and curative aspects of health care; and (iii) Biophysical, psychosocial, cultural, and spiritual components of health and illness; (d) Professional issues content including, but not limited to: (i) The historical development of nursing; (ii) Current issues and trends in nursing; and (iii) Ethical, legal, and professional aspects of nursing; (e) Multidisciplinary communication; (f) Evidence based practice; (g) Patient centered care; (h) Quality improvement; and (i) Informatics. E. The curriculum of baccalaureate degree programs in nursing shall also include: (1) Didactic and clinical experiences in community health nursing; (2) Study of nursing research and its application to nursing; and (3) Study and practice of leadership and management. F. Course objectives, outcomes, or competencies shall serve as: (1) Selection criteria for the location and type of clinical learning experiences; and (2) A basis for evaluation of student performance. G. Changes in course offerings that will alter the curriculum, philosophy, objectives, outcomes, competencies, or conceptual framework of the program shall: (1) Be reported to the Board in the annual report; and (2) Include the following information: (a) The rationale for changes; and (b) The methods of evaluation to be used to determine the effect of the change. H. Students shall be provided didactic instruction either before or concurrent with the related clinical learning experiences. I. Clinical learning experiences shall be sufficient in quantity and quality to provide opportunities for students to achieve the stated objectives, outcomes, or competencies. J. Students shall have sufficient opportunities to develop the knowledge, skills, and abilities essential for a safe and effective nursing practice. K. Evaluation methods and tools used for measuring students’ knowledge, skills, and abilities shall be developed and implemented in order to ensure satisfactory progression of students. L. There shall be a rationale for the ratio of classroom to clinical hours for each clinical nursing course. M. Clinical Preceptorships. (1) When clinical preceptors are used, the following conditions shall be met: (a) Written agreements between the cooperating agency and the nursing program shall delineate the functions and responsibilities of the parties involved; (b) There shall be written criteria for selecting clinical preceptors; (c) The clinical preceptor shall have the following minimum qualifications: (i) Current licensure as a registered nurse, (ii) 2 years of experience as a registered nurse and clinical expertise in the area of nursing required for the experience; and (iii) A philosophy of health care congruent with that of the nursing program; (d) Written clinical objectives, outcomes, or competencies shall be specified and shared with the clinical preceptor before the preceptorship experience begins; and (2) The designated faculty member shall: (a) Be responsible for a student's learning experiences, and (b) Meet regularly with the clinical preceptor and the student for the purpose of monitoring and evaluating learning experiences. (3) A bachelor’s degree in nursing is recommended. (4) Nothing in this section shall be construed to prohibit any cooperating clinical agency’s registered nurses from assisting with clinical activities selected by the program’s nurse faculty or clinical nurse faculty. (5) The program’s nurse faculty or clinical nurse faculty may not be required to be in the cooperating clinical agency’s facilities but shall be immediately available by telephone. #### Regulation .14 Students. *COMAR 10.27.03.14* A. The following shall be available to students: (1) A written statement of students' rights and responsibilities; (2) The opportunity to participate in program development and evaluation; (3) A written grievance mechanism; and (4) Guidance and advisement services. B. Students shall have: (1) Membership on selected faculty committees, as appropriate; and (2) The opportunity to participate in an organization of self-governance. C. Exercise of the right and responsibility to discuss, inquire, and express opinion is encouraged. D. Each program shall have clearly defined written policies for the following: (1) Admission of: (a) Generic students; (b) Transfer students; and (c) Articulation; (2) Oral and written English proficiency in reference to Health Occupations Article, §8-302(e), Annotated Code of Maryland, and COMAR 10.27.01.05; (3) Withdrawals; (4) Readmissions; (5) Progression; (6) Counseling and guidance; (7) Representation on faculty governance; (8) Graduation; (9) Refund policies governing all fees and tuition paid by students; and (10) Ethical practices for the performance of activities, including recruitment, admission, and advertising. E. Each program shall have a written policy providing information to any student who may be subject to licensure denial under Health Occupations Article, §§-308(c) and 8-316(a), Annotated Code of Maryland, and amendments applying to that citation. The information shall be provided before admission to the nursing education program. #### Regulation .15 Program Evaluation. *COMAR 10.27.03.15* A. The faculty shall develop and implement a Board-approved evaluation plan for evaluating the total nursing education program not less than: (1) Every 10 years for programs that are accredited by a BRNAA; and (2) 5 years for programs without BRNAA accreditation. B. The evaluation plan shall include: (1) All components of the program; (2) Evaluation time intervals; (3) Student, graduate, faculty, cooperating clinical agencies, and administration participation; (4) Instruments or methods used; and (5) Evidence that prior recommendations from the Board have been acted upon. C. The evaluation process shall provide evidence that the program is meeting its objectives or outcomes as well as the changing needs of nursing and society. D. The outcome of evaluation includes: (1) Recommendations for necessary program revisions; and (2) Direction for future action. #### Regulation .16 Annual Review. *COMAR 10.27.03.16* A. Annually, a program shall submit the following to the Board: (1) An annual report on the form that the Board requires; (2) A program catalog; (3) Any annual reports to the BRNAA; (4) Any correspondence related to the status of the program's accreditation; (5) A summary of practices followed in safeguarding the health and well-being of students; (6) An audited fiscal report covering the previous 2 years, including a statement of income and expenditures; and (7) Accurate and complete data including, but not limited to, number of enrollments, admissions, graduates, and faculty. B. Annually, the Board shall: (1) Review each program’s annual report, supporting documentation, and the licensure examination performance of first-time candidates from each program; (2) Notify each program achieving less than 90 percent of the national success rate; and (3) If necessary, conduct a survey or site visit, issue recommendations, place a program on conditional approval, or issue a formal notice of violation and withdraw approval in accordance with Regulation .17 of this chapter. C. Approval may be reduced to conditional status for the following reasons: (1) Noncompliance with this chapter; (2) Failure to hire faculty who meet the qualifications as stated in Regulation .08 of this chapter; (3) Noncompliance with the school’s stated philosophy, program design, objectives, or policies; (4) Failure to submit records and reports to the Board in a timely manner; (5) Failure to implement the approved curriculum; (6) In accordance with §D of this regulation, failure to maintain the required passing rate on the licensing examination by first-time candidates; (7) Failure to annually document that all faculty have current licenses; and (8) Other activities or situations, as determined by the Board, that indicate a program is in jeopardy of violating statutory and regulatory requirements and standards. D. Unacceptable Performance on Licensure Examination. (1) The Board shall issue a warning to a program when the pass rate of first-time candidates does not comply with §B(2) of this regulation. (2) For the first year a program does not meet the requirements of §B(2) of this regulation and following the warning in §D(1) of this regulation, the program shall, within 30 calendar days, provide to the Board: (a) A report that identifies the factors believed to have contributed to the unacceptable performance; and (b) An action plan to be approved by the Board. (3) Second Successive Year Not in Compliance. (a) For the second successive year that a program is not in compliance with §B(2) of this regulation, the program shall be placed on conditional approval and shall: (i) Provide the Board with a report analyzing all aspects of the educational program and identifying areas that may be contributing to the unacceptable performance; and (ii) Obtain the services of a Board-approved outside consultant with expertise in nursing education congruent with program needs. (b) The Board’s professional staff shall conduct a survey visit to the school and provide a report to the Board. (4) If compliance with the minimum licensure examination performance standard for first-time candidates is not made by the program within 1 examination year from the date of conditional approval, approval may be withdrawn. #### Regulation .17 Removal from Approved List. *COMAR 10.27.03.17* A. Pursuant to Health Occupations Article, §8-404, Annotated Code of Maryland, at least 30 days before issuing a formal notice of violation of regulations to a program, the Board shall notify the chief administrator of the controlling institution and the chief administrator of the nursing education program that the Board is considering issuing a formal notice of violation. B. During the 30-day period, the Board shall provide the chief administrator of the controlling institution and the nursing education program with an opportunity to meet with representatives of the Board to discuss the Board’s proposed action against the program. C. The program shall notify the Board within the 30-day period if it is interested in meeting with the Board. If the program requests a meeting, the Board shall set up the meeting. D. At the meeting, the program shall submit to the Board a plan with a proposed time frame for correcting the violations. E. The Board shall: (1) Evaluate the plan; (2) Approve or modify the plan; and (3) Have discretion to make changes to the time frames for correcting violations or other components of the plan. F. The program shall correct the violations within the time frames approved by the Board. G. Approval may be withdrawn for the following reasons: (1) Noncompliance with any of the regulations in this chapter; (2) Failure to hire faculty who meet the qualifications as stated in Regulation .08 of this chapter; (3) Noncompliance with the school's stated philosophy, program design, objectives, or policies; (4) Failure to submit records and reports to the Board in a timely manner; (5) Failure to implement the approved curriculum; (6) Failure to comply with the Board’s requirements within the specified time frames; (7) Failure to maintain the required passing rate on the licensing examination by first-time writers; (8) Failure to annually document that all faculty have current licenses; and (9) Other activities or situations, as determined by the Board, that indicate a program is not meeting statutory and regulatory requirements and standards. H. Withdrawal of Approval. If the program does not correct the violations within the approved time frames, the Board shall begin proceedings to remove the program from its list of institutions that offer approved nursing education programs in Maryland pursuant to Health Occupations Article, §§8-316—8-318, and 8-404, Annotated Code of Maryland. #### Regulation .18 New Programs and Continuing Approval Requirements. *COMAR 10.27.03.18* A. New Program Requirements. (1) An institution wishing to establish a nursing program shall submit to the Board: (a) A letter of intent; (b) Proof that the institution is accredited by the appropriate national or regional accrediting agency; (c) A copy of the prospectus and program proposal submitted to MHEC; (d) An addendum that describes in detail the: (i) Type and length of nursing program; (ii) Curriculum plan; (iii) Program objectives, outcomes, or competencies; and (iv) Description of available clinical resources; (e) Evidence that the proposed nursing program is based upon sound educational principles; and (f) Materials validating that the educational institution is prepared to meet the requirements specified in this chapter. (2) A nursing program providing on-site didactic or clinical instruction in Maryland shall comply with this chapter and receive Board approval of the on-site program before the commencement of instruction. (3) Both MHEC and the Board shall collaborate on program review. (4) Following review of the materials submitted, the Board shall notify the institution as to whether further clarifications or revisions are necessary. B. New Program Review. (1) The proposed nursing education program shall be reviewed at a regularly scheduled Board meeting. (2) The Board may: (a) Deny further consideration of the proposal; (b) Defer action on the proposal; or (c) Authorize a site visit by the Board’s professional staff and, following a report of the site visit by the Board’s professional staff, grant initial approval, defer action, or deny the request. (3) If deferred or denied, the institution shall be notified in writing of the reasons for the action. C. Initial Approval. Initial approval: (1) Is required before the admission of students; (2) Requires concurrence of the Maryland Higher Education Commission; and (3) Extends until the school or program has graduated its first class. D. Approval. (1) Following graduation of the first class, the Board shall evaluate the program for approval, considering the: (a) Report of a survey of the program by the Board’s professional staff, scheduled before graduation of the first class; (b) Results of the performance of the graduates on the National Council Licensure Examination; and (c) Program’s demonstrated continued ability to provide an educational program that meets the standards set by the Board. (2) Upon review of the survey report, the results of graduate performance on the National Council Licensure Examination, and an assessment of the program’s continued ability to meet the standards set forth in this chapter, the Board may: (a) Grant approval; (b) Place the program on conditional approval; or (c) Withdraw initial approval in accordance with Regulation .17 of this chapter. (3) Approval, if granted, shall be valid for not more than: (a) 10 years for a program accredited by a BRNAA; and (b) 5 years for a program without BRNAA accreditation. E. Reapproval Requirements. (1) The Board shall evaluate a program for reapproval: (a) Every 5 years if the program is without BRNAA accreditation; and (b) Not more than 10 years after approval is granted if the program has BRNAA accreditation. (2) Evaluation of continuing compliance shall include the submission of a self-study report by the program and a survey visit by the Board’s professional staff. The self-study report shall be submitted to the Board no less than one month prior to the survey visit. (3) If the program is accredited by a BRNAA, the reapproval survey visit may be made in coordination with a BRNAA visit. (4) Unscheduled survey or site visits may be conducted at the discretion of the Board. (5) A program that is accredited by a BRNAA and is subsequently placed on warning or whose accreditation by the BRNAA is withdrawn shall be scheduled immediately for a survey visit. (6) During each survey or site visit, the nurse administrator of the program shall make the following information available: (a) Data about the program, including the following: (i) The number of students; (ii) The legal body responsible for policy and support of the program; (iii) The organizational chart; and (iv) An audited fiscal report covering the previous 2 years, including a statement of income and expenditures; (b) The nurse administrator’s job description; (c) For each faculty member and clinical preceptor, the following: (i) Job descriptions; (ii) Selection policies; (iii) Orientation plan; (iv) Faculty organization by-laws; (v) Number of full-time and part-time faculty and non-nursing faculty with academic credentials and assignments; and (vi) Faculty-student clinical ratio; (d) Degree plan; (e) A copy of the current curriculum and course catalog with the date of last revision; (f) The testing process with test analysis and the written test procedure; (g) A description of education facilities, including classrooms, offices, libraries, and computers; (h) A list of clinical facilities and cooperating clinical agencies; (i) The number of students by classes; and (j) The policies for students as listed in Regulation .14D of this chapter. (7) During each survey or site visit, the nurse administrator shall make available the following: (a) The program’s administrators, faculty, support services personnel, and students; (b) Staff members of selected cooperating clinical agencies; (c) Faculty minutes for at least the previous 3 years; (d) Faculty and student handbooks; (e) Student records; (f) Policies and procedures; (g) Curriculum materials; (h) Cooperating clinical agency contractual agreements; (i) Program evaluation plan and evidence of program effectiveness; and (j) The program’s current catalog. (8) Upon review of the survey report and the results of graduate performance on the National Council Licensure Exam, and an assessment of the program’s continued ability to meet the standards set forth in this chapter, the Board may: (a) Grant reapproval; (b) Place the program on conditional approval; or (c) Withdraw approval in accordance with Regulation .17 of this chapter. (9) Reapproval, if granted, shall be valid for not more than: (a) 10 years for a program accredited by a BRNAA; and (b) 5 years for a program without BRNAA accreditation. #### Regulation .19 Closure of Programs. *COMAR 10.27.03.19* A. Upon request, the Board shall provide consultation concerning closing of a program. B. Upon the decision by a program to close, and at least 90 days before closing, the nurse administrator shall notify the Board of its intent, giving the following information: (1) Date and reason for closing; (2) Plans for phasing out the program; (3) Disposition of the records of students, graduates, and faculty; and (4) Title of the position of the individual to be responsible for the records and the name of the agency in which the records will be located. ### Chapter 04 — Methadone Dispensing **Authority:** Health Occupations Article, §§8-205(a)(1) and 8-511, Annotated Code of Maryland **Administrative History:** Effective date: February 9, 2009 (36:3 Md. R. 209) #### Regulation .01 Dispensing Methadone. *COMAR 10.27.04.01* A. A registered nurse or licensed practical nurse working in a methadone clinic licensed by the Maryland Department of Health may dispense methadone in accordance with: (1) The patient's standing medication order; (2) The methadone clinic's policies and procedures for dispensing methadone; and (3) State and federal laws and regulations for labeling. B. A registered nurse or licensed practical nurse working in a methadone clinic licensed by the Maryland Department of Health shall dispense methadone: (1) In tamper evident containers; (2) In child resistant containers; and (3) With any required patient information documents. C. A registered nurse or licensed practical nurse working in a methadone clinic licensed by the Maryland Department of Health shall maintain records of methadone dispensed in accordance with the provisions of Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland. D. A registered nurse or licensed practical nurse may not delegate the dispensing of methadone. ### Chapter 05 — Practice of Nurse Midwifery **Authority:** Health Occupations Article, §§8-101, 8-205, and 8-601—8-603, Annotated Code of Maryland **Administrative History:** Effective date: **Administrative History:** Regulations .01—.10 adopted as an emergency provision effective March 14, 1983 (10:11 Md. R. 970); emergency status expired July 13, 1983; adopted permanently effective October 10, 1983 (10:20 Md. R. 1787) **Administrative History:** Regulation .01 amended effective September 2, 1991 (18:17 Md. R. 1919); April 10, 1995 (22:7 Md. R. 536); June 26, 2000 (27:12 Md. R. 1140) **Administrative History:** Regulation .01B amended effective March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Regulation .02 amended effective April 10, 1995 (22:7 Md. R. 536); June 26, 2000 (27:12 Md. R. 1140) **Administrative History:** Regulation .02B amended effective September 2, 1991 (18:17 Md. R. 1919) **Administrative History:** Regulation .02 repealed and new Regulation .02 adopted effective March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Regulation .03 repealed effective February 15, 1993 (20:3 Md. R. 259) **Administrative History:** Regulation .04 repealed effective April 10, 1995 (22:7 Md. R. 536) **Administrative History:** Regulation .05 amended effective February 15, 1993 (20:3 Md. R. 259); April 10, 1995 (22:7 Md. R. 536); June 26, 2000 (27:12 Md. R. 1140) **Administrative History:** Regulation .06 amended effective April 10, 1995 (22:7 Md. R. 536) **Administrative History:** Regulation .06C amended effective March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Regulation .07 amended effective April 10, 1995 (22:7 Md. R. 536); March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Regulation .07B amended effective February 15, 1993 (20:3 Md. R. 259) **Administrative History:** Regulation .08 amended effective February 15, 1993 (20:3 Md. R. 259); April 10, 1995 (22:7 Md. R. 536) **Administrative History:** Regulation .09 amended effective February 15, 1993 (20:3 Md. R. 259); April 10, 1995 (22:7 Md. R. 536); June 26, 2000 (27:12 Md. R. 1140) **Administrative History:** Regulation .10 amended effective April 10, 1995 (22:7 Md. R. 536) **Administrative History:** Regulation .11 adopted effective September 2, 1991 (18:17 Md. R. 1919) **Administrative History:** Regulation .11 amended effective April 10, 1995 (22:7 Md. R. 536); March 1, 2004 (31:4 Md. R. 316) **Administrative History:** Chapter revised as an emergency provision effective January 1, 2010 (37:6 Md. R. 474); revised permanently effective June 28, 2010 (37:13 Md. R. 852) **Administrative History:** Chapter revised effective September 29, 2014 (41:19 Md. R. 1079) **Administrative History:** Regulation .01B amended effective July 2, 2018 (45:13 Md. R. 667); October 13, 2025 (Md. R. 1001) **Administrative History:** Regulation .02 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .06B amended effective October 13, 2025 (Md. R. 1001) **Administrative History:** Regulation .06D adopted effective October 13, 2025 (Md. R. 1001) **Administrative History:** Regulation .07 repealed effective February 22, 2026 (52:17 Md. R. 875) **Administrative History:** Regulation .08 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .09 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .10 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .11 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Annotation: COMAR 10.11 Midwifery was replaced by COMAR 10.27.05 Practice of Nurse Midwifery **Administrative History:** Annotation: COMAR 10.11 Midwifery adopted effective February 1, 1957; repealed effective July 12, 1987 (14:14 Md. R. 1572) #### Regulation .01 Definitions. *COMAR 10.27.05.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “ACME” means the Accreditation Commission for Midwifery Education. (2) “ACNM” means the American College of Nurse Midwives. (3) “Advanced practice registered nurse (APRN)” means a registered nurse who is certified by the Board as: (a) A certified nurse midwife (CNM); (b) A certified registered nurse anesthetist (CRNA); (c) A certified nurse practitioner (CRNP); or (d) A clinical nurse specialist (CNS). (4) “AMCB” means the American Midwifery Certification Board. (5) “Board” means the Board of Nursing. (6) “Certification” means the permission to practice nurse midwifery granted by the Board to a registered nurse who has: (a) Met all the specified requirements of a national certifying body recognized by the Board; and (b) Complied with the requirements of this chapter. (7) “Certified nurse midwife” means an advanced practice registered nurse who is certified by the Board to practice nurse midwifery in this State. (8) “Clinical practice guidelines” standards for practice of midwifery using current guidelines established by ACNM in Standards for the Practice of Midwifery. (9) “Delegated medical functions” means those functions that come within the definition of “practice medicine” in the Health Occupations Article, §14-101, Annotated Code of Maryland, that have been delegated to a certified nurse midwife to perform. (10) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (11) “Newborn” means an infant in the first 28 days after birth. (12) “Nurse midwifery” means the health care management of newborns and clients throughout their reproductive life cycle. (13) “Physician” means an individual licensed to practice medicine in this State. (14) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. #### Regulation .02 Certification. *COMAR 10.27.05.02* A. An applicant for certification as a nurse midwife shall: (1) Hold a current Maryland license in good standing to practice registered nursing or a multistate licensure privilege to practice registered nursing; (2) Have graduated from a Board-approved graduate level program for nurse midwives at the Masters’ level or higher that is accredited by: (a) The National League for Nursing Accreditation Commission (NLNAC); (b) The Commission on Nursing Education (CCNE); (c) ACME; or (d) Any other accrediting body recognized by the Board; (3) Hold a current national certification as a nurse midwife from the AMCB or any other national certifying body recognized by the Board; (4) Submit to the Board a completed application for certification as a nurse midwife; (5) Submit an affidavit that the applicant agrees to comply at all times with the clinical practice guidelines in accordance with Regulation .01B(8) of this chapter when providing clinical midwifery services; (6) Comply with all the requirement set forth in COMAR 10.27.01.04; (7) Demonstrate written and oral competency in the English language; and (8) Pay all fees. B. If the applicant’s nurse midwifery program was completed before July 1, 2014, and was not at a Master’s degree or higher level, but the applicant otherwise qualifies for certification, the applicant shall provide the Board with: (1) Verification of completion of a nurse midwifery program recognized by AMCB; and (2) Current national certification by AMCB or any other national certifying body recognized by the Board. #### Regulation .03 Duties of the Board. *COMAR 10.27.05.03* The Board shall: A. Maintain an up-to-date list of all certified nurse midwives in this State; and B. Include on the nurse midwife's registered nursing license an indication that the licensee is certified as a nurse midwife. #### Regulation .04 Required Documentation. *COMAR 10.27.05.04* A. A certified nurse midwife who provides clinical midwifery services across the reproductive lifespan shall: (1) Maintain a medical record for each client; and (2) In the case of a transfer of care to another provider or a facility, transfer the client’s medical records with the client. B. A certified nurse midwife who provides clinical midwifery services shall have available at all times for examination by the Board, written clinical practice guidelines that cover all aspects of care, practice, and quality assurance, including but not limited to: (1) A plan for emergency consultation; (2) A plan for transfer of care; and (3) If needed, a plan for admission of the client or newborn to a hospital within the client’s geographic area. #### Regulation .05 Practice Before Certification. *COMAR 10.27.05.05* A. A registered nurse who meets the qualifications to sit for the AMCB national certifying examination or any other certifying examination approved by the Board who has taken that examination and is waiting for the results of it may practice as a nurse midwife graduate before certification if the: (1) Practice is under the supervision of a certified nurse midwife who shall be physically available to the nurse midwife graduate; (2) Supervising certified nurse midwife signs a written supervision agreement on the required form to provide the supervision; and (3) Nurse midwife graduate files with the Board a copy of the admission slip to the Board-approved certifying examination and a copy of the signed supervision agreement. B. A nurse midwife graduate who has entered into a supervision agreement under this regulation shall immediately notify the Board and the supervising certified nurse midwife of the results of the Board-approved certifying examination. C. A nurse midwife graduate may not continue to practice under a supervision agreement under this regulation for more than 1 year from the filing of all documents required under §A of this regulation, or after the denial of AMCB or other Board-approved certification, whichever occurs first. #### Regulation .06 Scope of Practice. *COMAR 10.27.05.06* A. A certified nurse midwife who meets the requirements of Regulation .02 of this chapter may perform the following functions: (1) Independent management of clients appropriate to the skill and educational preparation of the certified nurse midwife and the nurse midwife's clinical practice guidelines; (2) Consult or collaborate with a physician or other health care provider as needed; and (3) Refer clients with complications beyond the scope of practice of the certified nurse midwife to a licensed physician. B. A certified nurse midwife shall keep a record of all cases attended and maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. C. A certified nurse midwife has the right and obligation to refuse to perform any delegated medical act, oral or written, if, in the certified nurse midwife’s judgment, it is unsafe or an invalidly prescribed medical act or beyond the competence of the certified nurse midwife, in which case the nurse midwife shall notify the delegating physician at once. D. A certified nurse midwife shall comply with applicable State and federal law. #### Regulation .07 Nurse Midwife Peer Review Advisory Committee. — Repealed. *COMAR 10.27.05.07* #### Regulation .08 Renewal of Certification. *COMAR 10.27.05.08* A. Certification as a nurse midwife expires at the same time as the nurse midwife's registered nursing license unless the certification is renewed. B. Before a nurse midwife’s certification expires, the nurse midwife may renew the certification biennially if the nurse midwife: (1) Is otherwise entitled to be certified; (2) Submits to the Board: (a) Documentation of a current national certification as a nurse midwife from AMCB or another national certifying body recognized by the Board; and (b) A completed renewal application on the form that the Board requires; and (3) Pays all fees. C. Certified nurse midwife renewal applicants who are authorized to practice registered nursing in this State under a multistate licensure privilege shall be periodically required to submit to a criminal history records check in accordance with the schedule and requirements set forth in COMAR 10.27.01.13J — N. D. The certified nurse midwife shall ensure that the Board has a record of the renewed national certification if the national certification expires before the registered nurse license renewal date. E. Certification as a nurse midwife shall be deemed to have lapsed if the Board does not have a record of a current active national certification. F. Practicing on an expired national certification is prohibited and subject to discipline under Health Occupations Article, §8-316(a), Annotated Code of Maryland. #### Regulation .09 Compliance. *COMAR 10.27.05.09* The certified nurse midwife shall develop and comply with clinical practice guidelines as defined in Regulation .01B of this chapter. #### Regulation .10 Unlawful Practices. *COMAR 10.27.05.10* Pursuant to Health Occupations Article, Title 8, Subtitle 7, Annotated Code of Maryland, an individual may not: A. Practice nurse midwifery unless certified under these regulations or otherwise permitted by law to engage in those activities; B. Use the title nurse midwife, certified nurse midwife, or any other similar designation unless certified by the AMCB, or other certifying body approved by the Board; or C. Use the title certified nurse midwife unless certified by the Board. #### Regulation .11 Prescribing of Substances by a Certified Nurse Midwife. *COMAR 10.27.05.11* Pursuant to Health Occupations Article, §8-601, Annotated Code of Maryland, a certified nurse midwife may prescribe: A. Substances commonly used in the practice of nurse midwifery; and B. Controlled substances on Schedules II-V under Criminal Law Article, §§5-403 — 5-406, Annotated Code of Maryland, commonly used in the practice of nurse midwifery; and C. Dispense substances prescribed in accordance with §§A and B of this regulation in the course of treating a client at a: (1) Nonprofit medical facility or clinic; (2) Health center operating on the campus of an institution of higher learning; (3) Public health facility; (4) Medical facility under contract with a State or local health department; or (5) Facility funded with public funds. ### Chapter 06 — Practice of Nurse Anesthetist **Authority:** Health Occupations Article, §§8-205(a)(1), (3), (4), and (5), and 8-513; Annotated Code of Maryland **Administrative History:** Effective date: December 1, 1979 (6:21 Md. R. 1709) **Administrative History:** Regulations .01—.09 repealed and new Regulations .01—.08 adopted effective April 3, 2000 (27:6 Md. R. 642) **Administrative History:** Regulation .01B amended effective June 17, 2019 (46:12 Md. R. 544) **Administrative History:** Regulation .02 amended effective November 23, 2006 (33:23 Md. R. 1796); June 17, 2019 (46:12 Md. R. 544) **Administrative History:** Regulation .02B amended effective June 18, 2007 (34:12 Md. R. 1067) **Administrative History:** Regulation .03 amended effective June 17, 2019 (46:12 Md. R. 544) **Administrative History:** Regulation .04B amended effective June 17, 2019 (46:12 Md. R. 544) **Administrative History:** Regulation .04C—E adopted effective June 17, 2019 (46:12 Md. R. 544) **Administrative History:** Regulation .05 amended effective June 17, 2019 (46:12 Md. R. 544) **Administrative History:** Regulation .05A amended effective January 19, 2026 (53:1 Md. R. 20) **Administrative History:** Regulation .05D adopted effective January 19, 2026 (53:1 Md. R. 20) **Administrative History:** Regulation .06A, C amended effective June 17, 2019 (46:12 Md. R. 544); October 13, 2025 (52:20 Md. R. 1002) #### Regulation .01 Definitions. *COMAR 10.27.06.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “A.A.N.A.” means the American Association of Nurse Anesthetists. (2) “Advanced practice registered nurse (APRN)” means a registered nurse who is certified by the Board as: (a) A certified nurse midwife (CNM); (b) A certified registered nurse anesthetist (CRNA); (c) A certified nurse practitioner (CRNP); or (d) A clinical nurse specialist (CNS). (3) “Anesthesiologist” means a Maryland-licensed physician who: (a) Has had special training in the field of anesthesiology; (b) Administers anesthesia on a regular basis; and (c) Devotes a substantial portion of the physician's medical practice to the practice of anesthesiology. (4) “Board” means the Board of Nursing. (5) “Certification” means the permission to practice nurse anesthesia granted by the Board to a registered nurse who has: (a) Met all the specified requirements of a national certifying body recognized by the Board; and (b) Complied with the requirements of this chapter. (6) “Certified registered nurse anesthetist (CRNA)” means an advanced practice registered nurse who is certified by the Board to practice as a nurse anesthetist in this State. (7) “Licensed physician or dentist” means a Maryland-licensed physician or dentist who has knowledge and experience in resuscitation, anesthetic drugs, and their reactions. (8) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (9) “Perioperative assessment and management” means the assessment and management of the patient preoperatively, intraoperatively, and postoperatively. (10) “Practice of nurse anesthesia” means the performance of acts in collaboration with an anesthesiologist, licensed physician, or dentist, which require substantial specialized knowledge, judgment, and skill related to the administration of anesthesia, including: (a) Perioperative assessment and management of patients requiring anesthesia services; (b) Administering anesthetics; (c) Management of fluid in intravenous therapy; and (d) Respiratory care. (11) “Qualified anesthesia provider” means a physician, dentist, or certified registered nurse anesthetist trained and duly authorized under the respective provisions of the Health Occupations Article to administer local, regional, and general anesthesia. (12) “Registered Nurse” means an individual who is licensed by the Board to practice registered nursing or has a multistate licensure privilege to practice registered nursing in this State under the Nurse Licensure Compact. #### Regulation .02 Certification. *COMAR 10.27.06.02* A. An applicant for certification as a CRNA shall: (1) Hold a current Maryland license in good standing or a multistate licensure privilege to practice registered nursing in this State under the Nurse Licensure Compact; (2) Have graduated from an education program in nurse anesthesia approved by the Board; (3) Hold current national certification from the Council on Certification of Nurse Anesthetists or from another national certifying body recognized by the Board; (4) Submit to the Board a completed application for certification as a nurse anesthetist; (5) Comply with all the requirements set forth in COMAR 10.27.01.04; (6) Demonstrate oral and written competency in the English language; and (7) Pay all fees. B. If the applicant’s nurse anesthetist program was completed after January 1, 2008, the applicant for certification as a CRNA shall also provide to the Board documentation that the applicant graduated from a graduate level accredited nurse anesthetist program with a master’s degree or higher. #### Regulation .03 Practice Before Certification. *COMAR 10.27.06.03* A. A registered nurse who has completed a program for preparation of nurse anesthetists and who has applied to take a national certifying examination acceptable to the Board may practice as a nurse anesthetist graduate before certification in the State, on approval of the Board, if the nurse: (1) Has a current license or multistate privilege to practice registered nursing in the State; (2) Submitted in full the application for State certification as a CRNA; (3) Paid all fees established by the Board; (4) Completed a nurse anesthetist program approved by the Board; (5) Practices under the supervision of an anesthesiologist or CRNA and the supervisor is on site and immediately available to the nurse anesthetist graduate; (6) Provides the Board a copy of the admission document to the national certification examination which must be taken not later than 6 months after program completion; and (7) Immediately notifies the Board and the supervising anesthesiologist or CRNA of the results of the certification examination. B. A nurse anesthetist graduate who fails the national certification examination shall immediately cease practice as a nurse anesthetist graduate. #### Regulation .04 Renewal of Certification. *COMAR 10.27.06.04* A. Certification as a nurse anesthetist expires at the same time as the nurse anesthetist's registered nursing license unless the certification is renewed. B. Before a nurse anesthetist’s certification expires, the nurse anesthetist may renew the certification biennially, if the nurse anesthetist: (1) Is otherwise entitled to be certified; (2) Pays all appropriate renewal fees set by the Board; and (3) Submits to the Board: (a) A completed renewal application on the form required by the Board; and (b) Documentation of a current national certification as a nurse anesthetist from the Council on Certification of Nurse Anesthetists or some other national certifying body recognized by the Board. C. Nurse anesthetist renewal applicants who are authorized to practice registered nursing in this State under a multistate privilege shall be periodically required to submit to a criminal history records check in accordance with the schedule and requirements set forth in COMAR 10.27.01.13J—N. D. The nurse anesthetist shall ensure that the Board has a record of the renewed national certification if the national certification expires before the renewal date. E. Practicing on an expired national certification is prohibited and subject to disciplinary action under Health Occupations Article, §8-316, Annotated Code of Maryland. #### Regulation .05 Scope of Practice. *COMAR 10.27.06.05* A. A nurse anesthetist may perform the following functions: (1) Perioperative assessment and management of patients requiring anesthesia services; (2) Administration of anesthetic agents; (3) Management of fluids in intravenous therapy; (4) Respiratory care; and (5) In accordance with §D of this regulation, prescribe, order, and administer drugs, including a drug that is classified as a controlled dangerous substance under Criminal Law Article, Title 5, Subtitle 4, Annotated Code of Maryland. B. A nurse anesthetist has the right and obligation to refuse to perform a delegated act if, in the nurse anesthetist’s judgment, the act is: (1) Unsafe; (2) An invalidly prescribed medical act; or (3) Beyond the clinical skills of the nurse anesthetist. C. Section A of this regulation may not be construed to authorize a nurse anesthetist to: (1) Diagnose a medical condition; (2) Provide care that is not consistent with the scope of practice of nurse anesthetists; or (3) Provide care for which the nurse anesthetist does not have proper education and experience. D. A nurse anesthetist may prescribe drugs in accordance with §A of this regulation: (1) Only in an amount that does not exceed a 10-day supply; (2) Only for an individual with whom the nurse anesthetist has, at the time of prescription, established a client or patient record; and (3) Only in connection with the delivery of anesthesia services. #### Regulation .06 Standards of Practice. *COMAR 10.27.06.06* A. A nurse anesthetist shall collaborate with an anesthesiologist, licensed physician, or dentist in the following manner: (1) An anesthesiologist, licensed physician, or dentist shall be physically available to the nurse anesthetist for consultation at all times during the administration of, and recovery from, anesthesia; (2) An anesthesiologist shall be available for consultation to the nurse anesthetist for other aspects of the practice of nurse anesthesia; and (3) If an anesthesiologist is not available, a licensed physician or dentist shall be available to provide this type of consultation. B. The nurse anesthetist shall assure that a qualified anesthesia provider: (1) Performs a thorough and complete preanesthetic assessment; (2) Obtains informed consent for the planned anesthetic intervention from the patient or responsible other; and (3) Formulates a patient-specific plan for anesthesia care. C. The nurse anesthetist as part of the standards of practice shall: (1) Implement and adjust the anesthesia care plan as needed to adapt to the patient's response to the anesthesia; (2) Monitor the patient's physiologic condition for untoward identifiable reactions and initiate appropriate corrective actions as required; (3) Enter prompt, complete, and accurate documentation of pertinent information on the patient's record; (4) Transfer responsibility for care of the patient to other qualified providers in a manner which assures continuity of care and patient safety; (5) Ensure that appropriate safety precautions are taken to minimize the risks of fire, explosion, electrical shock, and equipment malfunction; (6) Maintain appropriate infection control standards; (7) Evaluate anesthesia care to assure its quality; (8) Maintain continual competence in anesthesia practice; (9) Respect and maintain the basic rights of patients; and (10) Maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .07 Unlawful Practices. *COMAR 10.27.06.07* A. Under Health Occupations Article, Title 8, Subtitle 7, Annotated Code of Maryland, a person may not: (1) Practice nurse anesthesia unless certified under this chapter, or otherwise permitted by law to engage in these activities; or (2) Use the title nurse anesthetist, or any other words, letters, or symbols with the intent to represent that the individual is a nurse anesthetist unless certified by the Board. B. A person certified under this chapter is subject to the disciplinary sanctions set forth in Health Occupations Article, Title 8, Annotated Code of Maryland. C. This chapter does not limit or prohibit a registered nurse from performing those functions which constitute the practice of registered nursing as defined by law. #### Regulation .08 CRNA Peer Review/Advisory Committee. *COMAR 10.27.06.08* A. The Board shall appoint at least four CRNAs to act as the Board's advisory committee. B. The Committee shall: (1) Meet at least four times a year; (2) Report at least annually on its overall activities; and (3) Function at the Board's direction and provide the Board with expert advice related to the practice of nurse anesthesia. C. Members of the Committee shall be appointed for a 4-year term and may be reappointed for one additional 4-year term. ### Chapter 07 — Practice of the Nurse Practitioner **Authority:** Family Law Article, §2-301; Health-General Article, §§4-208(a), 4-212, §4-403, 5-601(c)—(e), 5-608(c), 10-616, 10-628, 13-701, and 13-704; Health Occupations Article, §§8-205(a)(1), (2), (4), and (5), and 8-302; Transportation Article, §§13-616(a) and (b), Annotated Code of Maryland; Ch. 342, Acts of 2015; Ch. 468, Acts of 2015 **Administrative History:** Effective date: March 6, 1981 (8:5 Md. R. 473) **Administrative History:** Regulation .01B amended effective August 29, 1994 (21:17 Md. R. 1439) **Administrative History:** Regulation .02 amended effective June 7, 1993 (20:11 Md. R. 913) **Administrative History:** Regulation .03A amended effective June 7, 1993 (20:11 Md. R. 913) **Administrative History:** Regulation .04 amended effective June 7, 1993 (20:11 Md. R. 913) **Administrative History:** Regulation .05 repealed and new Regulation .05 adopted effective June 7, 1993 (20:11 Md. R. 913) **Administrative History:** Regulation .08 adopted effective August 29, 1994 (21:17 Md. R. 1439) **Administrative History:** Chapter revised effective July 11, 2011 (38:14 Md. R. 790) **Administrative History:** Chapter revised effective December 10, 2015 (42:24 Md. R. 1505) **Administrative History:** Regulation .02A amended effective August 28, 2017 (44:17 Md. R. 835) **Administrative History:** Chapter revised effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03G adopted effective October 13, 2025 (52:20 Md. R. 1002) **Administrative History:** Regulation .07C amended effective October 13, 2025 (52:20 Md. R. 1002) #### Regulation .01 Definitions. *COMAR 10.27.07.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “AANPNCB” means the American Academy of Nurse Practitioners National Certification Board. (2) “Advanced practice registered nurse (APRN)” means a registered nurse who is certified by the Board as: (a) A certified nurse midwife (CNM); (b) A certified registered nurse anesthetist (CRNA); (c) A certified nurse practitioner (CRNP); or (d) A clinical nurse specialist (CNS). (3) “Board” means the Board of Nursing. (4) “Certification” means permission to practice as a nurse practitioner granted by the Board to a registered nurse who has: (a) Met all the specified requirement of a national certifying body recognized by the Board; and (b) Complied with the requirements of this chapter. (5) “Collaborating” means a cooperative relationship with other health care providers. (6) “Facility” means a health care facility as defined under Health-General Article, §19-114(d), Annotated Code of Maryland. (7) “Mentor” means a certified nurse practitioner or physician, licensed in Maryland, who: (a) Has 3 or more years of clinical practice experience; and (b) Will be available for advice, consultation, and collaboration, as needed, for 18 months beginning on the date an application is received by the Board from an applicant who has never been certified in this or any other State. (8) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (9) “Nurse practitioner” means an advanced practice registered nurse who is certified by the Board to practice as a nurse practitioner in this State. (10) “Personally prepare and dispense” means that a nurse practitioner: (a) Is physically present on the premises where the prescription is filled; and (b) Performs a final check of the prescription before the prescription is provided to the patient. (11) “Physician” means an individual who has an unencumbered license to practice medicine, issued under Health Occupations Article, Title 14, Annotated Code of Maryland. (12) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (13) “Starter dosage” means an amount of a drug sufficient to begin therapy: (a) Of a short duration of 72 hours or less; or (b) Before obtaining a larger quantity of the drug to complete therapy. (14) “Unencumbered license” means a license that is not: (a) Revoked; (b) Suspended; or (c) On probationary status. #### Regulation .02 Certification. *COMAR 10.27.07.02* A. An applicant for certification as a nurse practitioner shall obtain certification from the Board before commencing practice. B. An applicant for certification as a nurse practitioner shall: (1) Hold a current Maryland license in good standing to practice registered nursing or a multistate licensure privilege to practice registered nursing; (2) Have graduated from a Board-approved accredited graduate level program for nurse practitioners at the Masters’ level or higher that meets the requirements of Regulation .06 of this chapter; (3) Hold a current national certification: (a) For each area of specialization in which certification is sought; and (b) From the AANPNCB or other national certifying body recognized by the Board; (4) Submit to the Board a completed application for certification as a nurse practitioner for each area of specialization in which certification is sought; (5) Comply with all the requirements set forth in COMAR 10.27.01.04; (6) Demonstrate written and oral competency in the English language; (7) If the applicant has not been certified by the Board or any other Board of Nursing, identify a designated mentor for 18 months as defined in Regulation .01 of this chapter; and (8) Pay all fees. C. The Board shall: (1) Maintain an up-to-date list of all nurse practitioners certified in the State; and (2) Include on the nurse practitioner’s registered nursing license an indication that the licensee is certified as a nurse practitioner and designate the nurse practitioner’s area of specialization. D. The Board shall certify a nurse practitioner consistent with the nurse practitioner’s specialty, education, and national certification. #### Regulation .03 Nurse Practitioner — Scope and Standards of Practice. *COMAR 10.27.07.03* A. A nurse practitioner may independently perform the following functions: (1) A comprehensive physical assessment of patients; (2) In accordance with Family Law Article, §2-301, Annotated Code of Maryland, certify to the clerk of the court that a: (a) 16 or 17 year old individual, who wants to get married without parental consent, has been examined and found to be pregnant or has given birth to a child; or (b) 15 year old individual, who has parental consent to be married, has been examined and found to be pregnant or has given birth to a child; (3) In accordance with Transportation Article, §13-704, Annotated Code of Maryland, certify to the Department of Transportation that an individual needs special consideration for certain health reasons; (4) In accordance with Health-General Article, §4-208, Annotated Code of Maryland, complete the date of birth and medical information required on a birth certificate; (5) In accordance with Health-General Article, §4-212, Annotated Code of Maryland, complete a death certificate if: (a) The medical examiner does not take charge of the body; and (b) The deceased was under the care of the nurse practitioner; (6) Establish medical diagnosis for common short-term and chronic stable health problems; (7) In accordance with Health-General Article, §4-212, Annotated Code of Maryland, file a replacement death certificate; (8) In accordance with Health-General Article, §5-601, Annotated Code of Maryland, issue a “do not resuscitate order” on a Maryland Emergency Medical Services form. (9) Order, perform, and interpret laboratory and diagnostic tests; (10) Order and perform diagnostic, therapeutic, and corrective measures; (11) Prescribe drugs; (12) Provide emergency care; (13) Refer patients to appropriate licensed physicians or other health care providers as needed; (14) In accordance with COMAR 20.31.03.01, certify that the utility client has a serious illness or the need for life-support equipment; and (15) In accordance with Health-General Article, §5-602, Annotated Code of Maryland, witness an advance directive. B. A psychiatric nurse practitioner together with a physician is authorized to sign applications: (1) In accordance with Health-General Article, §10-615, Annotated Code of Maryland, to admit a minor to a facility for treatment of a mental disorder; and (2) In accordance with Health-General Article, §10-616, Annotated Code of Maryland, to admit an individual on an involuntary basis to a facility for treatment of a mental disorder. C. A nurse practitioner may practice only in the area of specialization in which certified. D. Nothing in this chapter limits or prohibits a registered nurse from performing those functions which constitute the practice of registered nursing as defined by law. E. A nurse practitioner has a right and obligation to refuse to perform any delegated act, oral or written, if in the nurse practitioner's judgment it is unsafe or an invalidly prescribed medical act. F. An individual certified under this chapter shall be subject to disciplinary sanctions set forth in Health Occupations Article, §8-316, Annotated Code of Maryland. G. A nurse practitioner shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .04 Renewal of Certification. *COMAR 10.27.07.04* A. A certification as a nurse practitioner expires at the same time as the nurse practitioner's registered nursing license. B. Before a nurse practitioner’s certification expires, the nurse practitioner may renew the certification biennially if the nurse practitioner: (1) Is otherwise entitled to be certified; (2) Submits to the Board: (a) Documentation of every current national certification as a nurse practitioner from a national certifying body recognized by the Board that was the basis of the Board’s initial certification under Regulation .02B of this chapter; and (b) A completed renewal application on the form that the Board requires; and (3) Pays all fees. C. Certified nurse practitioner renewal applicants who are authorized to practice registered nursing in this State under a multistate licensure privilege shall be periodically required to submit to a criminal history records check in accordance with the schedule and requirements set forth in COMAR 10.27.01.13J—N. D. The certified nurse practitioner shall ensure that the Board has a record of each renewed national certification if any national certification expires before the registered nurse license renewal date. E. Certification as a nurse practitioner in an area of specialization shall be deemed to have lapsed if the Board does not have a record of the current active national certification in that area of specialization. F. Practicing on an expired national certification is prohibited and subject to discipline under Health Occupations Article, §8-316(a), Annotated Code of Maryland. #### Regulation .05 Practice Before Maryland Certification. *COMAR 10.27.07.05* A. A registered nurse who has completed a Board-approved educational program for nurse practitioners and who has applied to take a Board-approved national certifying examination may practice as a nurse practitioner graduate before certification in this State upon approval of the Board if the nurse has: (1) Submitted a completed application for certification as a nurse practitioner in this State in accordance with Regulation .02 of this chapter; (2) Completed a nurse practitioner education program approved by the Board; (3) Presented evidence of submission of an application to take a Board-approved national certification examination; (4) Provided the name of a certified nurse practitioner, who has an active unencumbered Maryland license to practice as a registered nurse or a multistate privilege to practice registered nursing, who will directly supervise the nurse practitioner graduate; and (5) Paid all fees. B. If a certified nurse practitioner is not available in the graduate’s practice setting, as required in §A(4) of this regulation, a physician may provide this direct supervision if the nurse practitioner graduate provides the Board with the name of a certified nurse practitioner, who has an active unencumbered Maryland license to practice registered nursing or a multistate licensure privilege to practice registered nursing, with whom the nurse practitioner graduate has regular consultation. C. A nurse practitioner graduate who fails the Board-required examination shall immediately cease practice as a nurse practitioner graduate. D. An application for Maryland certification shall remain on file for a period of 18 months. During this time, applicants who have failed a national certifying examination may retake the examination and, upon proof of passing, may become eligible for Maryland certification. #### Regulation .06 Education. *COMAR 10.27.07.06* A. An applicant certified by a national certifying body before October 1, 2010, who is certified by the Board and in good standing shall be deemed to meet the education requirements under this regulation. B. An applicant for certification shall be a graduate from a Board-approved nationally accredited education program for nurse practitioners in a school of nursing that: (1) Provides advanced practice instruction at the Masters’ level or higher in a clinical nursing program; (2) Is accredited by a nursing accrediting body recognized by the United States Department of Education, the Council for Higher Education Accreditation or any other national accrediting body recognized by the Board; (3) Follows established educational standards that build upon educational preparation and experience as a registered nurse; (4) Ensures completion of the advanced practice core, nurse practitioner core, and population specific core competencies; (5) Has a didactic and clinical curriculum that, at a minimum, includes advanced courses in: (a) Physiology and pathophysiology; (b) Physical and health assessment; (c) Pharmacology; and (d) Diagnosis and management of health problems and diseases commonly encountered within the respective nurse practitioner’s population focus; (6) Provides didactic courses and supervised clinical experiences of sufficient depth and breadth in the nurse practitioner role and the specific population focus of the program; and (7) Ensures that graduates of the program are eligible for national certification and Maryland certification. C. To be a Board-approved education program the program shall: (1) Be a nationally accredited education program; and (2) Ensure ongoing competence and maintenance of certification by: (a) Providing a mechanism for renewing certification; (b) Having a renewal of certification process that is acceptable to the Board; and (c) Developing a mutually agreeable procedure that ensures communication with the Board. #### Regulation .07 Preparing and Dispensing. *COMAR 10.27.07.07* A. A nurse practitioner may personally prepare and dispense any drug that a nurse practitioner is authorized to prescribe in the course of treating a patient at: (1) A medical facility or clinic that specializes in the treatment of medical cases reimbursable through workers' compensation insurance; (2) A medical facility or clinic that is operated on a nonprofit basis; (3) A health center that operates on a campus of an institution of higher education; (4) A public health facility, a medical facility under contract with a State or local health department, or a facility funded with public funds; or (5) A nonprofit hospital or a nonprofit hospital out-patient facility as authorized under the policies established by the hospital. B. A nurse practitioner who personally prepares and dispenses a drug in the course of treating a patient shall: (1) Comply with the labeling requirements of Health Occupations Article, §12-505, Annotated Code of Maryland; (2) Record the dispensing of the prescription drug on the patient's chart; (3) Allow the Division of Drug Control to enter and inspect the nurse practitioner's office at all reasonable hours; (4) Except for starter dosages or samples dispensed without charge, provide the patient with a written prescription; and (5) Stamp all Schedule III, IV, and V prescriptions with the letter “C” in red ink, not less than 1 inch high in the lower right hand corner. C. A nurse practitioner shall: (1) Maintain two separate files, one for Schedule II prescriptions and another file for all other prescriptions; and (2) Maintain all prescription files for 7 years. D. A nurse practitioner may personally prepare and dispense a starter dosage of any drug the nurse practitioner is authorized to prescribe. The nurse practitioner shall: (1) Label the starter dosage in compliance with the labeling requirements of Health Occupations Article, §12-505, Annotated Code of Maryland; (2) Provide the starter dose free of charge; and (3) Enter the starter dose dispensed in the patient's medical record. #### Regulation .08 Unlawful Practices. *COMAR 10.27.07.08* Unless authorized to practice as a nurse practitioner under Health Occupations Article, Title 8, Annotated Code of Maryland, an individual may not: A. Represent to the public by title or by description of services, methods, procedures, or otherwise, that the individual is authorized to practice as a nurse practitioner in this State; B. Use as a title or describe the services the individual provides by use of the words “nurse practitioner” or “certified nurse practitioner”; or C. Use the abbreviation “NP”, “CRNP”, “CNP”, or any other words, letters, or symbols with the intent to represent that the individual practices as a nurse practitioner. ### Chapter 08 — Petition for Declaratory Ruling **Authority:** State Government Article, §§10-301 — 10-305, Annotated Code of Maryland **Administrative History:** Effective date: February 22, 1988 (15:4 Md. R. 474) **Administrative History:** Regulation .02 amended effective April 16, 2001 (28:7 Md. R. 690) **Administrative History:** Regulation .03 amended effective April 16, 2001 (28:7 Md. R. 690) **Administrative History:** Regulation .04 amended effective April 16, 2001 (28:7 Md. R. 690) #### Regulation .01 Definitions. *COMAR 10.27.08.01* A. The following terms have the meanings indicated. B. Terms Defined. (1) “Board” means the Board of Nursing. (2) “Person” means an individual, an agency, an association, a corporation, or any other entity. #### Regulation .02 Petition. *COMAR 10.27.08.02* A. An interested person may file with the Board a petition for a declaratory ruling with respect to the manner in which the Board would apply: (1) A statute; (2) A regulation; or (3) An order which the Board enforces to a particular case based on the facts presented in the petition. B. The Board may delegate responsibility for consideration of the petition. C. Petition for Declaratory Ruling. (1) The petition for a declaratory ruling shall be filed in writing. (2) The petition shall contain a statement describing in detail: interest of the petitioner in making: (a) The interest of the petitioner in making the request; (b) The issue involved; (c) A statement of the facts; and (d) A list of relevant documents or statements, or both, to be considered. (3) The Board may require an affidavit from the petitioner that the facts contained in the petition are true to the best of the person's knowledge and belief. D. Granting of Petition. (1) Not later than 60 days from receipt of the petition the Board shall inform the petitioner whether the petition will be considered. (2) If the Board decides not to consider the petition, the Board shall inform the petitioner in writing of the reasons for denial. #### Regulation .03 Consideration and Disposition. *COMAR 10.27.08.03* A. In rendering its ruling the Board or its designee: (1) Shall consider all materials submitted with the petition; (2) May consider any document, data, or other relevant material; (3) May consult individuals; (4) May consider comments from the staff; or (5) May require argument of the question or permit the introduction of evidence. B. Disposition. (1) A declaratory ruling issued shall be in writing, stating the: (a) Question; (b) Decision; (c) Description of factors considered; and (d) Sources relied upon. (2) A declaratory ruling issued by the Board shall plainly state that it is a declaratory ruling pursuant to these regulations. (3) A written answer from the Board or any employee of the Board to an inquiry may not be construed as a declaratory ruling unless made in conformity with these regulations. C. Publication and Inspection. (1) The Board shall keep a record of each declaratory ruling issued. (2) The Board may publish declaratory rulings of general interest subject to the mandates of the Public Information Act, State Government Article, §10-601 et seq., Annotated Code of Maryland, and allow inspection of the declaratory rulings subject to the Public Information Act. D. The Board may refuse to consider a petition if the: (1) Request contains incomplete information upon which to base an informed declaratory ruling; (2) Board or its designee concludes that a declaratory ruling cannot reasonably be given on the matter; (3) Matter is adequately covered by a prior: (a) Regulation; (b) Declaratory ruling; (c) Decision; (d) Legal opinion; or (4) The Board or its designee concludes that a ruling would not be in the public interest. #### Regulation .04 Effect, Revision, and Appeal. *COMAR 10.27.08.04* A. Effect. A declaratory ruling shall be binding upon the Board and the petitioner on the statement of facts covered in the declaratory ruling and set forth in the petition. B. Revision. (1) The petitioner's application for revision of the declaratory ruling shall: (a) Be filed within 10 days after the issuance of the declaratory ruling; and (b) State the grounds for the revision; (2) Upon receipt of the application, the Board may: (a) Open the declaratory ruling to receive additional information; (b) Amend its ruling or its statement or reasons for the ruling; (c) Set forth additional findings or reasons; (d) Enter new findings, new reasons, or a new ruling. (3) The Board shall grant or deny the application within 90 days of its submission. (4) The Board may exercise revisory power and control over the declaratory ruling in the case of fraud, mistake, or irregularity. C. Appeal. A declaratory ruling is subject to review as provided in State Government Article, §10-305, Annotated Code of Maryland. ### Chapter 09 — Standards of Practice for Registered Nurses **Authority:** Health-General Article, §4-403; Health Occupations Article, §§8-205 and 8-316, Annotated Code of Maryland **Administrative History:** Effective date: February 20, 1989 (16:3 Md. R. 343) **Administrative History:** Regulation .03 amended effective October 25, 1993 (20:21 Md. R. 1654) **Administrative History:** Regulations .01—.03 repealed and new Regulations .01—.03 adopted effective April 3, 2000 (27:6 Md. R. 642) **Administrative History:** Regulation .01B amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .02G adopted effective October 13, 2025 (52:20 Md. R. 1002) **Administrative History:** Regulation .04 adopted effective March 17, 2014 (41:5 Md. R. 346) #### Regulation .01 Definitions. *COMAR 10.27.09.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Accountability” means being answerable for the actions of self and others. (2) “Aggregate” means the sum total of nursing care the client received. (3) “Assessment” means a systematic, dynamic process by which the nurse, through interaction with the client, family, significant others, and other health care providers, collects and analyzes data. (4) “Assign” means the transfer of responsibility from one nurse to another with each nurse having the legal authority to perform the function as permitted by the licensee's scope of practice. (5) “Client” means an individual, family, group, or community under the licensee's direct or indirect care. (6) “Continuity of care” means an interdisciplinary process that: (a) Includes the client, family, and significant other in the development and communication of a coordinated plan of care; and (b) Based on changing needs and available resources, facilitates the client's: (i) Care within a setting, and (ii) Transition between settings. (7) “Criteria” means relevant, measurable indicators of the standards of registered nurse practice. (8) “Delegate” means the registered nurse: (a) Invests authority to act on behalf of the registered nurse to an unlicensed person; (b) Authorizes the unlicensed person to augment and supplement the care the registered nurse provides; and (c) Retains the accountability and responsibility for the delegated act. (9) “Evaluation” means the review and analysis of the extent to which the assessment, nursing diagnosis, planning, and implementation is effective in resolving the client's health problems or progress toward the attainment of expected outcomes. (10) Health Care Providers. (a) “Health care provider” means an individual with special expertise who provides health care services or assistance to clients. (b) “Health care provider” includes: (i) Nurses; (ii) Physicians; (iii) Psychologists; (iv) Social workers; (v) Nutritionists/dietitians; and (vi) Various therapists. (11) “Health care team” means a group of individuals, which includes health care providers and unlicensed personnel, working in collaboration with the client, family, and significant others to achieve identified outcomes. (12) Health Status Data. (a) “Health status data” means information obtained through nursing assessment of the client. (b) “Health status data” includes but is not limited to: (i) Growth and development; (ii) Biophysical status; (iii) Emotional status; (iv) Cultural, religious, and socioeconomic background; (v) Activities of daily living and instrumental activities of daily living; (vi) Patterns of coping; (vii) Interaction patterns; (viii) Client perception of and degree of satisfaction with health status; (ix) Client health goals; (x) Physical, social, emotional, and ecological environments; and (xi) Access to and availability of human and material resources. (13) “Implementation” means the process of performing, delegating, assigning, supervising, and coordinating interventions. (14) “Instrumental activities of daily living” means home management skills such as shopping for food and personal items, preparing meals, or handling money. (15) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (16) “Nursing diagnosis” means a description of the actual or potential, overt or covert health problems which registered nurses are licensed to treat. (17) “Outcomes” means measurable, expected, client-focused goals which translate into observable behaviors. (18) “Plan of care” means designing methods to solve identified problems and to attain outcomes by means of establishing priorities, setting goals, and defining interventions. (19) “Process” means the delivery of care and the fulfillment of the practice standards. (20) “Quality of care” means the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (21) “Recipients of nursing care” means individuals, families, groups, communities, or populations. (22) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (23) “Responsibility” means the obligation and duty to perform. (24) “Scientific principles” means a fundamental belief or reason for action derived from an organized system of study. (25) “Standards of care” means a minimum level of competent nursing practice demonstrated through assessment, analysis, formulation of nursing diagnosis, outcome identification, planning, implementation, and evaluation. (26) Standards of Registered Nurse Practice. (a) “Standards of registered nurse practice” means the minimum criteria the registered nurse shall adhere to in the practice of registered nursing. (b) “Standards of registered nurse practice” includes both standards of care and standards of professional performance. (27) Standards of Professional Performance. (a) “Standards of professional performance” means a competent level of behavior in the professional role. (b) “Standards of professional performance” includes activities related to: (i) Quality of care; (ii) Performance appraisal; (iii) Education; (iv) Collegiality; (v) Ethics; (vi) Collaboration; (vii) Research; (viii) Resource utilization; (ix) Assignment; (x) Delegation and supervision; and (xi) Refusal. (28) “Structure” means: (a) The environment in which care is provided; and (b) Resources available to provide care including but not limited to finances, staffing, supplies, equipment, and medical records. (29) “Technology assessment” means a review of drugs, devices, procedures, and systems in relationship to their safety, effectiveness, and economic and social impact. #### Regulation .02 Standards of Care. *COMAR 10.27.09.02* A. Assessment. (1) The RN shall collect client health data. (2) Measurement Criteria. (a) Data collection shall involve the client, family, significant others, other members of the health care team, and the health record, when appropriate. (b) Data may include the following dimensions: (i) Physical; (ii) Psychological; (iii) Sociocultural; (iv) Spiritual; (v) Cognitive; (vi) Functional abilities; (vii) Developmental; (viii) Economic; (ix) Technology; and (x) Life-style. (3) Priority of data collection is determined by the client's immediate condition or needs, health status, and setting. (4) Pertinent data shall be collected using appropriate assessment techniques. (5) Data collection shall include a technology assessment. (6) The data collection process shall be comprehensive, systematic, and ongoing. (7) Relevant health status data, including changes, shall be documented in an authorized record which is accessible and in a retrievable form. B. Analysis and Nursing Diagnosis. (1) The RN shall analyze the assessment data in determining nursing diagnoses. (2) Measurement Criteria. (a) The RN shall analyze the data, consider the options, including technology, and make a determination as to whether the selected options are appropriate for the needs of the client. (b) Nursing diagnoses shall be: (i) Derived in a complete, systematic, and ongoing manner from the assessment data; (ii) Validated with the client, family, significant others, and other members of the health care team, when possible; and (iii) Documented in a manner that facilitates the determination of expected outcomes and plan of care. (c) Nursing diagnoses shall identify the nature and extent of the client's health status, capabilities, and limitations. C. Outcome Identification. (1) The RN shall identify expected outcomes individualized to the client. (2) Measurement Criteria. (a) Outcomes shall be: (i) Derived in a comprehensive, systematic, and ongoing manner from the diagnoses; (ii) Directed toward management of the client's health problems; (iii) Formulated with the client, family, significant other, or other members of the health care team, when possible and appropriate; (iv) Culturally appropriate and realistic in relation to the client's present and potential capabilities; (v) Attainable in relation to the resources available to the client; (vi) Documented as measurable goals with time estimates for attainment as appropriate; and (vii) Documented in an authorized record which is accessible and in a retrievable form. (b) Outcomes provide direction for continuity of care. D. Planning. (1) The RN shall develop a plan of care that prescribes interventions to attain expected outcomes. (2) Measurement Criteria. (a) The plan shall be: (i) Individualized in a comprehensive, systematic and ongoing manner; (ii) Developed utilizing available data; (iii) Prioritized to meet the client's condition or needs; (iv) Developed, coordinated, and communicated with the client, family, significant other, and other members of the health care team as appropriate; (v) Congruent with the client's therapeutic regime; and (vi) Documented. (b) The plan shall: (i) Reflect current nursing practice; (ii) Provide for continuity of care; and (iii) Include identification, coordination, and utilization of available resources. E. Implementation. (1) The RN shall implement the interventions identified in the plan of care. (2) Measurement Criteria. (a) Interventions shall be: (i) Implemented recognizing the rights of the client, the family, and significant others; (ii) Consistent with the established plan of care; (iii) Implemented in a competent, safe, and appropriate manner consistent with knowledge of scientific principles; and (iv) Documented. (b) Interventions may include, but are not limited to: (i) Patient teaching; (ii) Counseling; (iii) Implementing clinical practice guidelines, protocols, and pathways; and (iv) Independent nursing functions. (c) Selected interventions may be assigned and delegated to other personnel participating in delivering care. (d) When assignment or delegation occurs, supervision is provided. (e) A safe and therapeutic environment is provided for the delivery of nursing care. (f) Relevant information which may be needed to carry out the nursing plan is provided to the client, family, significant others, and other members of the health care team without violating the client's confidentiality. F. Evaluation. (1) The RN shall evaluate the client's progress toward attainment of outcomes. (2) Measurement Criteria. (a) Evaluation shall be systematic, ongoing, and criterion-based. (b) The client, family, significant other, and other members of the health care team shall be involved in the evaluation process, when appropriate. (c) Ongoing assessment data shall be used to evaluate the process of care and to revise the nursing diagnosis, outcomes, and the plan of care. (d) Revisions of diagnoses, outcomes, and the plan of care shall be documented. (e) The effectiveness of interventions shall be evaluated in relation to outcomes. (f) The responses to interventions shall be documented and communicated to the client and other members of the health care team. (g) The RN charged with the documentation of the client's discharge shall make the final nursing evaluation. G. Documentation. The RN shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .03 Standards of Professional Performance. *COMAR 10.27.09.03* A. Quality of Care. (1) The RN systematically shall evaluate the quality and effectiveness of nursing practice in the aggregate. (2) Measurement Criteria. The RN shall: (a) Participate in activities to evaluate quality of care including, but not limited to, monitoring the structure, process, and outcome of nursing practice, with consideration for access and cost; (b) Use quality monitoring data to identify opportunities for improving care; and (c) Participate in activities related to implementing changes designed to improve care. B. Performance Appraisal. (1) The RN shall be accountable for evaluating the RN's own nursing practice on a regular basis in relation to professional practice standards and relevant statutes and regulations. (2) Measurement Criteria. (a) The RN shall: (i) Participate in peer review as appropriate; and (ii) Seek guidance, support, education, and supervision as necessary. (b) The RN shall demonstrate knowledge of and shall comply with: (i) Relevant professional practice standards; (ii) Statutes and regulations governing nursing; and (iii) The policies and procedures of the practice setting. C. Education. (1) The RN shall acquire and maintain current knowledge and competency in nursing practice. (2) Measurement Criteria. The RN shall: (a) Participate in educational opportunities and experiences to maintain professional competence; and (b) Obtain knowledge and skills appropriate to the practice setting. D. Collegiality. (1) The RN shall contribute to the professional development of peers, colleagues, and others. (2) Measurement Criteria. (a) The RN shall share knowledge and skills with peers, colleagues, and others. (b) The RN shall contribute to a supportive and healthy work environment. E. Ethics. (1) The RN's decisions and actions shall reflect ethical principles. (2) Measurement Criteria. The RN shall: (a) Comply with the Code of Ethics in COMAR 10.27.19; (b) Maintain client confidentiality within legal and regulatory standards; (c) Act as a client advocate and assist clients to advocate for themselves; (d) Deliver care in a nonjudgmental and nondiscriminatory manner that is sensitive to client diversity; (e) Deliver care in a manner that preserves client autonomy, dignity, and rights; and (f) Seek available resources to help formulate ethical decisions. F. Collaboration. (1) The RN shall collaborate with the client, family, significant others, and other health care providers in providing care. (2) Measurement Criteria. The RN shall: (a) Collaborate with the client, family, significant others, and other health care providers in the formulation of overall goals, the plan of care, and decisions related to care and the delivery of services; and (b) Consult with health care providers for client care. G. Research. (1) The RN shall participate in research activities appropriate to the licensee's position, education, and practice environment. (2) Measurement Criteria. The RN shall: (a) Support the client's rights related to research; (b) Participate in data collection; (c) Participate in identification of clinical problems suitable for nursing research; and (d) Utilize established facility-approved research protocols. H. Resource Utilization. (1) The RN shall consider factors related to safety, effectiveness, and cost in planning and delivering client care. (2) Measurement Criteria. The RN: (a) Shall assist the client, family, and significant others in identifying services and options available to address health-related needs; (b) Shall evaluate factors related to safety, effectiveness, and cost when performing, assigning, delegating, and supervising nursing care, and teaching the client, family, and significant others; and (c) As a case manager, may identify and facilitate options and services for meeting individual health needs by enhancing quality, cost-effective clinical outcomes while decreasing fragmentation and duplication of care. I. Assignment, Delegation, and Supervision. (1) The RN may assign nursing acts or delegate nursing tasks to individuals who are competent to perform those acts or tasks, when the assignment or delegation does not jeopardize the client's welfare. (2) Measurement Criteria. (a) When delegating a nursing task to an unlicensed person, the RN shall assess the client and determine that the delegation is consistent with COMAR 10.27.11. (b) When delegating a nursing task to an unlicensed person, the registered nurse shall: (i) Instruct; (ii) Direct; (iii) Regularly evaluate the performance of nursing tasks by the unlicensed person; (iv) Rectify a situation in which the unlicensed person under the licensee's supervision is performing nursing tasks incorrectly; and (v) Prohibit the continued performance of an unlicensed person who is performing the delegated nursing task or tasks incompetently. (c) When the RN is assigning a nursing act to another licensed nurse, the RN shall: (i) Verify that the nursing act is within the licensed nurse's legal scope of practice; (ii) Verify that the licensed nurse has the knowledge, skills and clinical competency to perform the assigned act; (iii) Verify that the assigned act is consistent with the facility's policies and procedures; (iv) Regularly evaluate the licensed nurse who is performing the assigned nursing act; (v) Rectify a situation in which the licensed nurse assigned to perform the nursing act has performed the nursing act incorrectly; and (vi) Prohibit the continued performance of the assigned nursing act by a licensed nurse who is performing the assigned nursing act or acts incompetently. J. Refusal. (1) The RN has the right and the responsibility to refuse to perform, assign, or delegate nursing acts. (2) Measurement Criteria. (a) The RN has the right and responsibility to refuse to perform a nursing act which is beyond the parameters of the nurse's education, capabilities, and clinical competency. (b) The RN shall obtain appropriate education, training, and supervision as required to perform nursing functions which are beyond the parameters of the nurse's education and clinical competence. (c) The RN has the right to refuse to accept responsibility and accountability for supervising, monitoring, instructing, or evaluating an unlicensed person performing a nursing task that has not been delegated by that nurse. #### Regulation .04 Specialty Practice. *COMAR 10.27.09.04* A. A registered nurse functioning in a specialty practice shall have additional education, training, and experience. Specialty practice does not include advanced practice nursing. B. Definitions. (1) In this regulation, the following terms have the meanings indicated. (2) Terms Defined. (a) “Critically ill client” means a client who: (i) Has developed or is at high risk for developing life threatening problems; (ii) Requires constant intensive multidisciplinary assessment and intervention to restore stability and prevent complications; and (iii) Needs restoration or maintenance of physiologic stability. (b) “Interfacility specialty care transport” means the movement of a critically ill client by transport vehicle when the client’s level of care requires the care of a registered nurse during transport. (c) On-Line Medical Direction. (i) “On-line medical direction” means oversight and orders by licensed physicians at base stations to EMS providers or members of the transport team providing patient care at an Advanced Life Support (ALS) or Basic Life Support (BLS) level. (ii) “On-line medical direction” includes medical orders and oversight by a licensed practitioner at a specialty care unit at a hospital to a registered nurse during a specialty care transport, provided the licensed practitioner is permitted by the facility to provide these services and the services are within the scope of the individual’s license. (d) Licensed Practitioner. (i) “Licensed practitioner” means a dentist, physician, nurse practitioner, nurse anesthetist, or nurse midwife or any other individual permitted by law and the facility to provide care and services within the scope of the individual’s license. (ii) “Licensed practitioner” does not include a student in a graduate education program whose practice requires supervision and whose orders must be countersigned. (e) “Specialty care transport” means transport for all ages of critically ill clients in accordance with the definitions under COMAR 30.09.01.02. C. Practice Specialty Care Transport. (1) Education, Training, and Experience Requirements. Except for the provisions under §C(2) and (4) of this regulation, a registered nurse who provides interfacility specialty care transport shall meet the education, training, and experience requirements for staffing an interfacility specialty care transport mission in accordance with COMAR 30.09.14.02G(1)—(3). (2) When a specialty care transport ambulance is not available within a clinically reasonable time, a registered nurse who has not completed a program of study in accordance with COMAR 30.09.14.02G(1)—(3) for the transport of patients by ambulance can provide interfacility specialty care, if: (a) The registered nurse has education, training, and experience in the critical care area required by the mission as determined by the referring physician; (b) The registered nurse is accompanied by an individual who is currently licensed as a Maryland ALS provider, in accordance with COMAR 30.02.02, to support the registered nurse with the transport; and (c) On-line medical direction is available to the registered nurse. (3) A registered nurse providing specialty care transport who does not have national certification for working with the client population to be transported shall have at least: (a) 2 years of clinical nursing experience in critical or specialty care within the last 5 years; (b) Age appropriate advanced life support training; and (c) Nursing expertise in the specialty care area required by the client’s age and diagnosis. (4) This regulation does not apply to, restrict, or limit: (a) Other health care practitioners who are authorized to perform these duties under their respective laws; or (b) A registered nurse providing care to a critically ill patient during a declared natural disaster or emergency. (5) A registered nurse is prohibited from accepting a transport assignment that exceeds the nurse’s knowledge and expertise. ### Chapter 10 — Standards of Practice for Licensed Practical Nurses **Authority:** Health-General Article, §4-403; Health Occupations Article, §§8-205(a)(2) and 8-316, Annotated Code of Maryland **Administrative History:** Effective date: February 20, 1989 (16:3 Md. R. 343) **Administrative History:** Regulation .03 amended effective October 25, 1993 (20:21 Md. R. 1655) **Administrative History:** Regulations .01—.03 repealed and new Regulations .01—.04 adopted effective May 2, 2011 (38:9 Md. R. 553) **Administrative History:** Regulation .01B amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .02C amended effective October 13, 2025 (52:20 Md. R. 1002) #### Regulation .01 Definitions. *COMAR 10.27.10.01* A. The following terms have the meanings indicated. B. Terms Defined. (1) “Assessment” means the act of gathering and identifying data about the client. (2) “Assign” means the transfer of responsibility from one nurse to another, each having legal authority to perform the function as permitted by the licensee’s scope of practice. (3) “Board” means the Board of Nursing. (4) “Case management” means a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet the client’s health needs through enhanced communication and use of available resources to promote quality client outcomes and cost effective care. (5) “Client” means an individual who is under the licensee’s direct or indirect care. (6) Comprehensive Nursing Assessment. (a) “Comprehensive nursing assessment” means an assessment performed by a registered nurse which is the foundation for the analysis of the assessment data to determine: (i) The nursing diagnosis; (ii) Expected client outcomes; and (iii) The client’s plan of care. (b) “Comprehensive nursing assessment” includes, but is not limited to: (i) Extensive initial and ongoing data collection for individuals, families, groups, and communities; (ii) A focused nursing assessment; (iii) Past history, current health status, and potential changes in the client’s condition; (iv) Identification of alterations to the client’s previous condition; and (v) Synthesis of the biological, psychological, spiritual, and social aspects of the client’s condition. (7) “Contributes” means to participate as a team member in the nursing team relationship. (8) “Delegating” means the act of authorizing an unlicensed individual, a certified nursing assistant, or a certified medication technician to perform selected acts of registered nursing or licensed practical nursing. (9) “Evaluation” means the review and analysis of the extent to which the assessment, planning, and implementation were effective in resolving the client’s health problem. (10) Focused nursing assessment. (a) “Focused nursing assessment” means an appraisal of a client’s current health status and situation at hand; (b) “Focused nursing assessment” includes the reporting of information to other members of the health care team. (11) “Goal” means a measurable result to be achieved by a client which is either long- or short-term. (12) “Implementation” means the carrying out of the nursing plan of care. (13) “Licensed nurse” means a licensed practical nurse or registered nurse. (14) “Licensed practical nurse (LPN)” means an individual who is licensed by the Board to practice licensed practical nursing or holds a multistate licensure privilege to practice licensed practical nursing. (15) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (16) “Nursing plan of care” means an established set of goals, priorities, and methods designed to solve, prevent, and manage a client’s identified problems. (17) “Nursing team relationship” means that each licensed or certified individual who participates in providing care for a client is a part of the nursing team. (18) “ Nursing triage” means the systematic collection of client data at the client’s point of entry or re-entry into the health care system for the purpose of sorting clients by acuity levels to determine the allocation of available health care resources to direct each client to the right health care provider at the right time. (19) “Record” means a written retrievable document containing the client’s health information. (20) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Who holds a multistate licensure privilege to practice registered nursing. (21) Standards of Licensed Practical Nurse Practice. (a) “Standards of licensed practical nurse practice” means the minimum criteria to which the licensed nurse shall adhere in the practice of licensed practical nursing. (b) “Standards of licensed practical nurse practice” includes standards of professional performance as described in Regulation .03 of this chapter. (22) “Supervision” means the process of critically watching an individual’s performance with the intention of evaluating and directing the individual’s performance in the delivery of nursing care. (23) “Support” means to promote, assist, or help. #### Regulation .02 Nursing Process. *COMAR 10.27.10.02* A. In a team relationship the licensed practical nurse contributes to the nursing process. The nursing process shall include, but is not limited to, the following elements listed in §B—C of this regulation. B. Nursing Assessment. The LPN contributes to the nursing assessment by: (1) Collecting data for the assessment of the client: (a) Through direct observation; (b) From interviews with the client, client’s family, and significant others; (c) From the review of the client’s medical records including, but not limited to: (i) Past history; (ii) Laboratory studies; (iii) Medications; and (iv) Consultations; and (d) By assessing the environment; (2) Performing a focused nursing assessment of the client’s current conditions and problems or needs which includes: (a) The nursing interview; (b) A physical assessment; (c) The client’s common predictable, chronic, routine, recurrent health problems; and (d) Identification of any changes in the client’s symptoms and behavior; (3) Communicating the assessment on records that reflect: (a) Changes in the client’s health status; and (b) A continuous collection of data by updating and revising of the nursing assessment; and (c) Data recorded in a manner which is: (i) Complete, timely, and accurate; (ii) Consistent with general standards of nursing practice; and (iii) Consistent with the facility’s policies and procedures. C. Nursing Plan of Care. (1) Development. The LPN contributes to the development of the nursing plan of care by: (a) Reporting ongoing data collection; (b) Reporting changes that include, but are not limited to, the client’s; (i) Condition; (ii) Changed goals; and (iii) Changed priorities; (c) Making recommendations to individualize interventions specific to the client; (d) Reporting communication with; (i) The client; (ii) The client’s family; (iii) Significant others; and (iv) Other members of the health care team; and (e) Documenting in appropriate records. (2) Implementation. The LPN participates in the implementation of the nursing plan of care by: (a) Continuing to collect and report data; (b) Assisting in the coordination of client care with other health care team members as directed by the RN; (c) Implementing standardized or RN developed teaching plans under the direction of the RN; (d) Contributing to the nursing case management by: (i) Implementing assigned components of the nursing care plan; and (ii) Continuing to collect and report data regarding the implemented plan including the client’s response to intervention and problem identification; (e) Contributing to nursing management and supervision of the certified nursing assistant and unlicensed personnel by: (i) Assuring nursing functions are performed competently and timely; and (ii) Reporting to the leader of the nursing team; and (f) In accordance with the nursing team’s plan of care for the client and with COMAR10.27.11, delegating acts of the LPN’s practice to: (i) The certified nursing assistant; (ii) The certified medication technician; and (iii) Unlicensed personnel; (g) Performing nursing interventions in a competent safe manner appropriate to the LPN’s scope of practice including: (i) Administration of medications and treatments; (ii) Administration of infusion therapy consistent with COMAR 10.27.20; and (iii) Nursing intervention consistent with any declaratory rulings and regulations issued by the Board; (h) Documenting implementation of nursing care timely, completely, and accurately; and (i) Utilizing identified nursing approaches which include, but are not limited to: (ii) Reflecting knowledge of scientific principles; (iii) Recognizing the rights of the client, the client’s family, and significant others; and (iv) Providing a safe and therapeutic environment. (3) Evaluation. The LPN contributes to the evaluation of the nursing plan of care by: (a) Collecting and communicating data on the client’s goal achievement; (b) Assisting in identifying barriers to the client’s meeting any identified goal; (c) Reporting to other members of the health care team in a timely, accurate, and complete manner on data collected from; (i) The client; (ii) The client’s family; (iii) Significant others; and (iv) Other health care providers; (d) Assisting in evaluating the client’s competency in performing any treatment and self administering medication by utilizing established competency based evaluation tools; (e) Making recommendations regarding modification of the teaching nursing plan based on the client’s response; (f) Making recommendations regarding any revision to the nursing plan of care; and (g) Documenting the evaluation data on appropriate records. (4) Nursing Team Relationship. (a) The LPN as a part of the nursing team: (i) Functions as a team member under the leadership of the RN who is the team leader; (ii) Participates in providing care for the client; and (iii) Provides care for the client to the fullest extent allowed by the LPN’s scope of practice. (b) Each licensed nurse has responsibility for oversight or supervision of nursing practice appropriate to his or her level of licensure which includes critically watching, instructing, directing, and evaluating anothers nursing practice. (5) Documentation. The LPN shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .03 Standards of Professional Performance. *COMAR 10.27.10.03* A. Quality of Care. (1) The LPN shall participate in evaluating the quality and effectiveness of nursing practice. (2) Measurement Criteria. The LPN shall: (a) Assist in collecting quality data; and (b) Participate in activities related to implementing changes designed to improve care. B. Performance Appraisal. (1) The LPN shall be accountable for evaluating the LPN’s own nursing practice on a regular basis in relation to: (a) Relevant professional practice standards; and (b) Relevant statutes and regulations governing licensed practical nursing. (2) Measurement Criteria. (a) The LPN shall: (i) Participate in peer review as appropriate; and (ii) As necessary, seek guidance, support, education, and supervision. (b) The LPN shall demonstrate knowledge of and comply with: (i) Relevant professional practice standards; (ii) Relevant statutes and regulations governing licensed practical nursing; and (iii) The policies and procedures of the practice setting. C. Education. (1) The LPN shall acquire and maintain current knowledge and continued competency in the practice of licensed practical nursing. (2) Measurement Criteria. The LPN shall: (a) Participate in educational opportunities and experiences to maintain professional competence; and (b) Obtain knowledge and skills appropriate to the practice setting. D. Collegiality. (1) The LPN shall support the professional development of the: (a) Licensed practical nurse; (b) Certified nursing assistant; (c) Certified medication technician; and (d) Unlicensed personnel. (2) Measurement Criteria. (a) As directed by the RN, the LPN shall share knowledge and skills with: (i) Other LPNs; (ii) Certified nursing assistants; (iii) Certified medication technicians; and (iv) Unlicensed personnel. (b) The LPN shall contribute to a supportive and healthy work environment. E. Ethics. (1) The licensed practical nurse’s decisions and actions shall reflect ethical principles. (2) Measurement Criteria. The LPN shall: (a) Comply with the Code of Ethics as described in COMAR 10.27.19; (b) Maintain client confidentiality within legal and regulatory standards; (c) Act as a client advocate; (d) Deliver care in a nonjudgmental and nondiscriminatory manner that is sensitive to client diversity; (e) Deliver care in a manner that preserves the client’s; (i) Autonomy; (ii) Dignity; and (iii) Rights; (f) Communicate with the RN regarding potential ethical issues; and (g) Communicate to the RN, observations of actions by other health care providers which may jeopardize the client’s safety and well being. F. Collaboration. (1) The LPN shall participate with the client, the client’s family, significant others, the RN, and other health care providers in providing care. (2) Measurement Criteria. The LPN shall: (a) Participate with the client, the client’s family, significant others, the RN, and other health care providers by contributing to: (i) The development of overall goals; (ii) The nursing plan of care; and (iii) Decisions related to care and the delivery of services; and (b) Consult with the RN and other health care providers regarding client care. G. Research. (1) The LPN shall support research activities appropriate to the LPN’s scope of practice. (2) Measurement Criteria. The LPN shall: (a) Have knowledge of the client’s rights related to research; (b) Participate in data collection; and, (c) Utilize established facility-approved research protocols. H. Resource Utilization. (1) The LPN shall consider factors related to safety and cost when participating in client care planning and implementing client care. (2) Measurement Criteria. The LPN shall: (a) Assist the client, the client’s family, and significant others to identify: (i) Unmet client needs; and (ii) Potential services to meet any unmet needs; and (b) Evaluate factors related to client safety and cost when performing or delegating client care. I. Delegation and Supervision. (1) When the delegation does not jeopardize the client’s welfare, the LPN may delegate nursing tasks to a certified nursing assistant, medication technician, or an unlicensed person who is competent to perform those acts or tasks. (2) Measurement Criteria. (a) When delegating a nursing task, the LPN shall assess the client and determine that the delegation is consistent with COMAR 10.27.11. (b) When delegating nursing tasks, the LPN shall assess the capabilities, experience, and competency of a person working under the LPN’s supervision. (c) When delegating a nursing task to a certified nursing assistant, medication technician, or an unlicensed person, the LPN shall: (i) Instruct; (ii) Direct; (iii) Regularly evaluate the performance of nursing tasks by the certified nursing assistant, medication technician, or unlicensed person; (iv) Rectify a situation in which the certified nursing assistant, medication technician, or unlicensed person under the LPN’s supervision is performing nursing tasks that are inconsistent with generally accepted professional standards and notify the registered nurse leader of the nursing team; and (v) Prohibit the continued performance of the certified nursing assistant, medication technician, or unlicensed person who is performing the delegated nursing task or tasks incompetently and notify the registered nurse leader of the nursing team. J. Refusal. (1) The LPN has the right and the responsibility to refuse to perform, or delegate nursing acts. (2) Measurement Criteria. (a) The LPN has the right and responsibility to refuse to perform a nursing act which is beyond the parameters of the LPN’s: (i) Education; (ii) Capabilities; (iii) Clinical competency; and (iv) Scope of practice. (b) The LPN shall obtain appropriate education, training, and supervision as required to perform nursing functions which are within the LPN’s scope of practice but are beyond the parameters of the licensee’s clinical competency. (c) The LPN has the right to refuse to accept responsibility and accountability for supervising, monitoring, instructing, or evaluating a certified nursing assistant, certified medication technician, or an unlicensed person performing a nursing task that has not been delegated by that licensee. #### Regulation .04 Prohibited Acts. *COMAR 10.27.10.04* The LPN may not: A. Perform nursing triage; B. Perform the responsibilities of, or serve in the role of, the circulating nurse in the intraoperative phase of surgery including, but not limited to: (1) Assessing the client in the intraoperative phase of surgery to identify emerging client situations which would require anticipating and responding to the needs of the: (a) Client; (b) Anesthesiologist; and (c) Surgical team; (2) Administering or transporting to the surgical field medications, infusates, or solutions that may be required by the anesthesia or surgical team during the course of the intraoperative procedure; (3) Gathering needed equipment and anticipating resuscitation efforts during the intraoperative phase; (4) Collaborating with other members of the surgical team for ongoing assessment and planning for the client’s postoperative care; and (5) Documenting completely, timely, and accurately on appropriate records; C. Perform the comprehensive nursing assessment; D. Serve as the case manager for client care; E. Supervise the nursing practice of RNs and other LPNs; and F. Analyze client data in order to determine client outcome identification and formulation of a nursing diagnosis. ### Chapter 11 — Delegation of Nursing Functions **Authority:** : Health Occupations Article, §§8-102, 8-205, 8-6A-01, 8-6A-02, 8-6A-03, 8-6A-05(a)(4), and 8-6A-08(f)(5), Annotated Code of Maryland **Administrative History:** Effective date: October 2, 1989 (16:19 Md. R. 2105) **Administrative History:** Regulations .01—.06 amended as an emergency provision effective February 5, 1992 (19:4 Md. R. 468); emergency status expired August 7, 1992 **Administrative History:** Regulations .01—.06 amended permanently effective August 8, 1992 (19:11 Md. R. 1015) **Administrative History:** Regulations .02—.06 amended effective July 4, 1994 (21:13 Md. R. 1158) **Administrative History:** Regulations .01—.06 repealed and new Regulations .01—.06 adopted effective May 10, 2004 (31:9 Md. R. 712) **Administrative History:** Regulation .01H adopted as an emergency provision effective July 8, 2015 (42:16 Md. R. 1053); adopted permanently effective July 20, 2015 (42:14 Md. R. 880) **Administrative History:** Regulation .01I adopted effective August 4, 2025 (52:15 Md. R. 812) **Administrative History:** Regulation .02B amended effective February 28, 2005 (32:4 Md. R. 411); January 26, 2009 (36:2 Md. R. 101); September 19, 2011 (38:19 Md. R. 1147); July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03 amended effective June 29, 2009 (36:13 Md. R. 900) **Administrative History:** Regulation .04 amended effective January 26, 2009 (36:2 Md. R. 101) **Administrative History:** Regulation .04C, D amended effective September 19, 2011 (38:19 Md. R. 1147) **Administrative History:** Regulation .05 amended effective February 28, 2005 (32:4 Md. R. 411); January 26, 2009 (36:2 Md. R. 101) **Administrative History:** Regulation .05H amended effective September 19, 2011 (38:19 Md. R. 1147) **Administrative History:** Regulation .06C, D amended effective January 26, 2009 (36:2 Md. R. 101) #### Regulation .01 Exclusion from Regulations. *COMAR 10.27.11.01* This chapter is not applicable to and does not restrict or limit: A. Other health care practitioners who are authorized delegatory powers under their respective acts; B. The gratuitous provision of care by self, family, or friends; C. Provision of care by a child care provider employed in the child's home by the child's parent or by a child care provider licensed by the Child Care Administration under COMAR 07.04.01 (Family Day Care) or COMAR 07.04.02 (Child Care Center Licensing) except for those providers enrolling a majority of children with health or medical conditions or both; D. The cognitively capable adult from employing an unlicensed caregiver in the adult's home to assist the adult in treatments of a routine nature and in self-administration of medication; E. An individual who performs nursing assistant tasks while a nursing student enrolled in an accredited nursing education program and practicing under the direct supervision of: (1) Qualified faculty or preceptors; or (2) A nurse while working as a nursing assistant; F. An individual who performs nursing assistant tasks as a student while: (1) Enrolled in a Board-approved nursing assistant training program; (2) Practicing under the direct supervision of qualified faculty or preceptors; or (3) Practicing under the direct supervision of a nurse while working as a nursing assistant; G. A nurse from delegating a nursing task to an unlicensed individual if acceptance of delegated nursing tasks does not become a routine part of the unlicensed individual's job duties; or H. A youth camp regulated in accordance with COMAR 10.16.06. I. A certified dialysis technician regulated in accordance with COMAR 10.39.06. #### Regulation .02 Definitions. *COMAR 10.27.11.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Accountability” means being answerable for actions of self or others. (2) “Board” means the Board of Nursing. (3) “Certified medicine aide (CMA)” means an individual who meets the requirements as stated in COMAR 10.39.01 and 10.39.03. (4) “Certified nursing assistant (CNA)” means an individual certified by the Board as a nursing assistant. (5) “Client” means the recipient of nursing care. (6) “Delegation” means the act of authorizing an unlicensed individual, a certified nursing assistant, or a medication technician to perform acts of registered nursing or licensed practical nursing. (7) “Evaluation” means the review and analysis of the extent to which the assessment, nursing diagnosis, planning, and implementation phases of the nursing process were effective in resolving the client's identified problems. (8) “Family” means related family members, foster parents, domestic partners, and legal guardians. (9) “Geriatric nursing assistant (GNA)” means a CNA who has successfully completed the requirements for a GNA set forth in 42 CFR §§483.151 — 483.156 and COMAR 10.39.01. (10) “Home health aide (HHA)” means a CNA who has successfully completed the requirements for certification as a HHA set forth in 42 CFR §484.36 and COMAR 10.39.01. (11) “Licensed practical nurse” means an individual who is licensed by the Board to practice licensed practical nursing or has a multistate licensure privilege to practice licensed practical nursing. (12) “Medication technician” means an individual who completes a 20-hour course in medication administration approved by the Board and is certified by the Board. (13) Model of Nursing Practice. (a) “Model of nursing practice” means the policies, procedures, and practice guidelines: (i) Established by the facility, which are consistent with this chapter regarding delegation of nursing functions and regulations governing the facility; and (ii) That provide direction to nursing staff on the delivery of care to the client population which the facility serves. (b) "Model of nursing practice” may not supersede a delegating nurse's prudent judgment regarding: (i) Delegation of a nursing function to a certified nursing assistant, an unlicensed individual, or a medication technician; or (ii) A particular delegated nursing function to that individual or individuals. (14) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (15) “Nurse” means a registered nurse or licensed practical nurse. (16) “Pressure ulcer” means a decubitus ulcer stage I through IV, the care for which includes cleaning, applying topical medication, and dressing without packing. (17) “Readily available” means, in: (a) A structured setting: (i) The delegating nurse is physically present on the unit; and (ii) The nurse may transfer responsibility for the nursing supervision and delegation to another nurse who then becomes the nurse delegating the nursing functions; and (b) Other settings, the delegating nurse is on the premises or else is available by telephone. (18) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (19) “Responsibility” means the charge to do something. (20) “Routine care” means those activities necessary on a daily basis for the client to gain or maintain a level of functioning. (21) “Structured setting” means a hospital, nursing home, long-term care facility, ambulatory care setting, surgicenter, or any other acute or chronic care facility. (22) “Supervised group living settings” means assisted living facilities, group homes for juveniles, group homes for emotionally disturbed children, alternative living units for the developmentally disabled, or any other facility or setting providing supervised living arrangements for groups of unrelated individuals. (23) “Supervision” means the process of critical watching, directing, and evaluating another's performance. (24) “Unlicensed individual” means an individual who is not licensed or certified to provide nursing care under Health Occupations Article, Title 8, Annotated Code of Maryland. (25) Wound. (a) “Wound” means venous stasis ulcer or ulcers, a dehissed wound, or any other break in the integrity of the full thickness of skin that involves the subcutaneous tissue or fascia. (b) “Wound” may include tunneling or a sinus tract. (c) “Wound” does not include an uncomplicated healing surgical wound. #### Regulation .03 Criteria for Delegation. *COMAR 10.27.11.03* A. The nurse may delegate the responsibility to perform a nursing task to an unlicensed individual, a certified nursing assistant, or a medication technician. The delegating nurse retains the accountability for the nursing task. B. A nursing task delegated by the nurse shall be: (1) Within the area of responsibility of the nurse delegating the act; (2) Such that, in the judgment of the nurse, it can be properly and safely performed by the unlicensed individual, certified nursing assistant, or medication technician without jeopardizing the client welfare; and (3) A task that a reasonable and prudent nurse would find is within the scope of sound nursing judgment. C. A nursing task delegated by the nurse may not require the unlicensed individual, certified nursing assistant, or medication technician to exercise nursing judgment or intervention except in an emergency situation. D. When delegating a nursing task to an unlicensed individual, certified nursing assistant, or medication technician the nurse shall: (1) Make an assessment of the patient's nursing care needs before delegating the task; (2) Either instruct the unlicensed individual, certified nursing assistant, or medication technician in the delegated task or verify the unlicensed individual's, certified nursing assistant's, or medication technician's competency to perform the nursing task; (3) Supervise the performance of the delegated nursing task in accordance with Regulation .04 of this chapter; (4) Be accountable and responsible for the delegated task; (5) Evaluate the performance of the delegated nursing task; and (6) Be responsible for assuring accurate documentation of outcomes on the nursing record. E. The nurse shall be the primary decision maker when delegating a nursing task to an unlicensed individual, certified nursing assistant, or medication technician. Nursing judgment shall be exercised within the context of the employing facility's model of nursing practice which includes a mechanism for: (1) Identifying those individuals to whom nursing tasks may be delegated; (2) Reevaluation of the competency of those to whom nursing tasks may be delegated; (3) Recognizing that the final decision regarding delegation is within the scope of the nurse's professional judgment; (4) Determining the competency of the nurse to delegate; and (5) Determining to whom nursing tasks may be delegated, which includes input by nurses employed in the facility. F. The registered nurse shall assume the role of case manager in delegating nursing tasks, including the administration of medications, only in accordance with Regulation .05G of this chapter in situations where the nurse has thoroughly assessed and documented that: (1) The client's health care needs are chronic, stable, uncomplicated, routine, and predictable; (2) The environment is conducive to the delegation of nursing tasks; and (3) The client is unable to perform his or her own care. #### Regulation .04 Supervision. *COMAR 10.27.11.04* A. The nurse shall determine the required degree of supervision after an evaluation of appropriate factors including, but not limited to the: (1) Stability of the condition of the client; (2) Training of the individual to whom the nursing task is being delegated; (3) Nature of the nursing task being delegated; (4) Orientation of the unlicensed individual, certified nursing assistant, or medication technician to the specific patient environment; (5) Ability of the unlicensed individual, certified nursing assistant, or medication technician to perform the delegated nursing task in a safe and competent manner; and (6) Reevaluation of the client's health status. B. The delegating nurse shall be readily available when delegating a nursing task to an unlicensed individual, certified nursing assistant, or medication technician. C. For the client whose health status meets the criteria as stated in Regulation .03F of this chapter, the registered nurse managing the case shall make a supervisory on-site visit to the client at a minimum of every 45 days to: (1) Evaluate the client's health status; (2) Evaluate the nursing acts to be delegated; (3) Determine whether health goals are being met; (4) Evaluate the continued competence of the certified nursing assistant, unlicensed individual, or medication technician to perform the delegated nursing task; and (5) Evaluate the environment in which the delegated task is performed. D. For the client whom the registered nurse has determined does not meet the criteria as stated in Regulation .03F of this chapter, the registered nurse shall: (1) Make a supervisory on-site visit to the client at least every 2 weeks to evaluate the criteria described in §C of this regulation; and (2) Determine whether the: (a) Nursing tasks may be safely delegated in that setting and given the client's clinical status; and (b) Nursing assistant, unlicensed individual, or medication technician is competent to perform the nursing tasks to be delegated. #### Regulation .05 Nursing Functions. *COMAR 10.27.11.05* A. The following nursing functions require nursing knowledge, judgment, and skill and may not be delegated: (1) The nursing assessment including, but not limited to, the admission, shift, transfer, or discharge assessment; (2) Development of the nursing diagnosis; (3) The establishment of the nursing care goal; (4) Development of the nursing care plan; (5) Evaluation of the client's progress, or lack of progress, toward goal achievement; and (6) Any nursing task which requires nursing knowledge, judgment, and skill. B. The nurse may delegate treatments of a routine nature if: (1) The licensed nursing staff of the specific unit of care has identified the function as being routinely performed; (2) The specific treatments are performed at a high frequency necessary to retain competency; (3) The treatment has an inherently low risk to the client; as determined by weighing the following factors: (a) Type of equipment utilized to perform the function; (b) Nurse staffing ratio that allows for close supervision; (c) Basic educational preparation of the unlicensed individual or certified nursing assistant performing the delegated function; and (d) Knowledge and skill set of the nurse delegating and supervising the delegated function; and (4) There is a quality assurance mechanism in place to assure the function is performed safely and client outcomes meet accepted professional nursing standards including, but not limited to: (a) An ongoing formalized documented performance appraisal mechanism designed to assure that unlicensed individual or certified nursing assistant's revalidation of continued competency is a component of the quality assurance mechanism; and (b) Client outcomes meeting accepted professional standards, as reflected by: (i) Infection rates; (ii) Rates of adverse events; (iii) Error rates; and (iv) Patient satisfaction surveys. C. The nurse may delegate the obtaining of specific information to an unlicensed individual or certified nursing assistant. D. When implementing the plan of care, the nurse may delegate a nursing task to an unlicensed individual or certified nursing assistant after the nurse has completed a client assessment and when the delegation of that task does not jeopardize the client's welfare. E. The nurse may delegate the responsibility to perform a nursing task to an unlicensed individual if: (1) Acceptance of the delegated nursing task does not become a routine part of the unlicensed individual's job duties; or (2) An unlicensed individual merely provides assistance with activities of daily living unless the client's needs are such that adverse health consequences are predictable. F. Administration of medication is a nursing function. As such, the nurse retains full responsibility for medication administration. G. The following activities related to medication administration may not be delegated except as provided in §H of this regulation: (1) Calculation of any medication dose; (2) Administration of medications by injection route; (3) Administration of medications by way of a tube inserted in a cavity of the body; and (4) Administration of medication by intravenous route. H. Delegation of Medication Administration. (1) The administration of medication as listed in §H(3) of this regulation may be delegated to certified medicine aides and medication technicians only in compliance with §H(2) of this regulation and when clients meet the requirements of Regulation .03F or .04D of this chapter in the following situations: (a) Supervised group living settings; (b) Supervised or sheltered work settings; (c) Independent living settings; (d) Schools; (e) Correctional institutions; (f) Hospice care; (g) Adult medical day care centers; and (h) Child care centers established for children with health or medical conditions or both. (2) A nurse may delegate to a medication technician or certified medicine aide under this section when: (a) The nurse has provided instruction and direction; and (b) The medication technician or certified medicine aide is on site in the unit of care on a continuing basis to: (i) Monitor the therapeutic effects of the medication; (ii) Observe, record, and report untoward effects of the medication; (iii) Perform monitoring procedures required for each medication; (iv) Observe for changes in the individual client's behavior and clinical status; (v) Record and report the changes observed to the delegating nurse; and (vi) Withhold administration of the medication. (3) A nurse may delegate administration of the following medications to a medication technician or a certified medicine aide according to Regulations .03F, .04C, and .05H(1) of this chapter: (a) Medication by metered dose inhalant, nebulizer, and oxygen by nasal cannula or mask; (b) Medication by gastrostomy tube or rectal tube if the nurse has calculated the dosage; (c) Oral medication, including: (i) Measuring as prescribed an amount of liquid medication where the nurse has calculated the dose; and (ii) Administering a fraction of a tablet if the nurse has cut the tablet; (d) Medication by subcutaneous injection if the nurse has calculated the dose; (e) Medication administered by topical route excluding stage III and IV pressure ulcers and wound care; (f) Medication administered by suppository route; (g) Medication drops administered by routes involving eye, ear, and nose; and (h) Where the registered nurse makes an on-site visit at least every 7 days to assess the client status and the performance of the medication technician's or certified medicine aide's administration of topical medication to stage three or four pressure ulcers or wounds. #### Regulation .06 Client Health Teaching and Health Counseling. *COMAR 10.27.11.06* A. The registered nurse shall be accountable and responsible for the development and initiation of the health teaching plan and for health counseling of the client. B. The nurse shall be accountable and responsible for facilitating and promoting: (1) Client education; and (2) Participation of the client and significant others in implementation of health goals. C. Unlicensed individuals, certified medicine aides, medication technicians, and certified nursing assistants given instruction and direction by the nurse may supplement the health teaching by providing standardized information to the client. D. The unlicensed individual, certified medicine aide, medication technician, and certified nursing assistant are responsible and accountable for reporting information to the nurse regarding the client's: (1) Request for information; and (2) Response to teaching provided by the nurse. ### Chapter 12 — Nurse Psychotherapists in Independent Practice — Clinical Nurse Specialists **Authority:** Health Occupations Article, §8-205, Annotated Code of Maryland **Administrative History:** Effective date: June 25, 1990 (17:12 Md. R. 1494) **Administrative History:** Regulation .07C adopted effective August 1, 1994 (21:15 Md. R. 1306) **Administrative History:** Chapter revised effective June 26, 2000 (27:12 Md. R. 1140) **Administrative History:** Regulation .02B amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03B, C amended effective October 17, 2011 (38:21 Md. R. 1279) **Administrative History:** Regulation .04 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .05 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .07 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .08A, C amended effective July 2, 2018 (45:13 Md. R. 667) #### Regulation .01 Exclusion from Regulations. *COMAR 10.27.12.01* Nothing in this chapter shall be applicable to or restrict or limit a registered nurse from performing those functions which constitute the practice of registered nursing as defined by law. #### Regulation .02 Definitions. *COMAR 10.27.12.02* A. The following terms have the meanings indicated. B. Terms Defined. (1) “Advanced practice registered nurse (APRN)” means a registered nurse who is certified by the Board as: (a) A certified nurse midwife (CNM); (b) A certified registered nurse anesthetist (CRNA); (c) A certified nurse practitioner (CRNP); or (d) A clinical nurse specialist (CNS). (2) “Board” means the Maryland Board of Nursing. (3) “Certification” means the permission to practice as a PMH/APRN granted by the Board to a registered nurse who has: (a) Met all the specified requirements of a national certifying body recognized by the Board; and (b) Complied with the requirements of this chapter. (4) “Mental health diagnosis” means the identification of a potential or an actual alteration in an individual's mental health status. (5) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (6) “Nurse psychotherapist” means a registered nurse, certified under this chapter, who utilizes psychotherapy in a formally structured, contractual relationship between the nurse therapist and a client. (7) “Psychiatric mental health/ advanced practice registered nurse (PMH/APRN)” means an advanced practice registered nurse who: (a) Is certified by the Board as a clinical nurse specialist in the practice of psychiatric mental health; and (b) Autonomously and independently engages in activities authorized by this chapter. (8) “Psychobiological interventions” means interventions which integrate physiological and psychological dimensions of care and include a range of therapies from diet/nutrition regulation, hypnosis, and relaxation techniques to the use of pharmacologic agents. (9) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. #### Regulation .03 Certification. *COMAR 10.27.12.03* An applicant for certification to practice as a PMH/APRN in independent practice shall: A. Hold a current Maryland license in good standing to practice registered nursing or a multistate licensure privilege to practice registered nursing; B. Have graduated from a Board-approved graduate level education program for clinical nurse specialists in psychiatric mental health nursing at the Masters’ level or higher that is accredited by a national accrediting body recognized by the Board; C. Hold current national certification as a clinical nurse specialist in psychiatric or mental health nursing issued by the American Nurses Credentialing Center (ANCC) or any other national certifying body recognized by the Board; D. Submit to the Board a completed application for certification as a clinical nurse specialist, PMH/APRN; E. Comply with all the requirements set forth in COMAR 10.27.01.04; F. Demonstrate written and oral competency in the English language; and G. Pay all fees. #### Regulation .04 Practice Before Maryland Certification. *COMAR 10.27.12.04* A. A registered nurse who meets the qualifications to sit for a national certifying examination acceptable to the Board or who has taken that examination and is waiting for the results, may practice in this State as a PMH/APRN graduate if the: (1) Practice is under the supervision of a Maryland certified PMH/APRN who shall be readily available to the PMH/APRN graduate; (2) Supervising PMH/APRN agrees in a written supervision agreement on a form to be prescribed by the Board to provide the supervision; and (3) PMH/APRN graduate: (a) Completes the application for Maryland certification as a as a clinical nurse specialist in psychiatric mental health; and (b) Pays the certification application fee established by the Board in COMAR 10.27.01. B. A PMH/APRN graduate who has entered into a supervision agreement shall immediately notify the Board and the supervising PMH/APRN of the results of the national certifying examination. C. A PMH/APRN graduate may not continue to practice under supervision for more than 24 months from the filing of all documents required under §A of this regulation or after the denial of certification, whichever occurs first. #### Regulation .05 Scope of Practice. *COMAR 10.27.12.05* The PMH/APRN may perform independently, autonomously, and in a variety of settings, the following functions: A. Establish a mental health diagnosis; B. Evaluate and manage psychobiological intervention; C. Provide individual therapy; D. Provide group therapy; E. Provide family therapy; F. Provide any therapy which purpose is to: (1) Effect change in the client in an attempt to alleviate emotional disturbances, (2) Reverse or change maladaptive behavior, and (3) Facilitate personality growth and development; G. Provide consultation to health care providers and others to: (1) Influence the plans of care for clients, (2) Enhance the abilities of others to provide behavioral, psychiatric, and mental health care, and (3) Effect change in systems; H. Provide behavioral rehabilitation care; and I. Utilize advanced practice skills to independently provide: (1) Case management including psychiatric rehabilitation and home care, and (2) Health teaching, health promotion, health prevention, and aid to the client in developing healthy patterns of living. #### Regulation .06 Standards of Practice. *COMAR 10.27.12.06* A. Advanced practice skills shall be utilized in the collection of relevant data to comprehensively assess the client's mental health. B. Assessment data shall be analyzed in determining diagnosis. C. A plan of care shall be developed and implemented that outlines treatment to attain expected outcomes. D. Individual, group, and family psychotherapy, child psychotherapy, behavioral care, case management, and other therapeutic treatments shall be utilized to assist clients in fostering mental health, preventing mental illness and disability, and improving or regaining previous health status and functional abilities. E. Advanced knowledge of psychobiological interventions shall be utilized and clinical skills applied to maximize the client's health and prevent further disability. F. The use of psycholobiological interventions in this chapter does not authorize the prescription of medications. G. The client's progress in attaining the expected outcome shall be evaluated. H. Strategies and interventions shall be utilized to promote and maintain health and prevent mental illness. I. Decisions and actions on behalf of clients shall be determined in an ethical manner. #### Regulation .07 Renewal of Maryland Certification. *COMAR 10.27.12.07* A. Certification as a PMH/APRN expires at the same time as the license to practice registered nursing. B. Before a PMH/APRN’s certification expires, the PMH/APRN may renew the certification biennially if the PMH/APRN: (1) Is otherwise entitled to be certified; (2) Submits to the Board: (a) Documentation of a current national certification as a PMH/APRN from a national certifying body recognized by the Board; and (b) A completed renewal application on a form that the Board requires; and (3) Pays all fees. C. PMH/APRN renewal applicants who are authorized to practice registered nursing in this State under a multistate licensure privilege shall be periodically required to submit to a criminal history check in accordance with the schedule and requirements set forth in COMAR 10.27.01.13J.—N. D. The PMH/APRN shall ensure that the Board has a record of the renewed national certification if the national certification expires before the registered nurse license renewal date. E. Certification as a PMH/APRN shall be deemed to have lapsed if the Board does not have a record of a current active national certification. F. Practicing on an expired national certification is prohibited and subject to discipline under Health Occupations Article, §8-316(a), Annotated Code of Maryland. G. The Board shall maintain an up-to-date list of all PMH/APRNs certified in this State and include on the license an indication that the licensee is a PMH/APRN. #### Regulation .08 Unlawful Practices. *COMAR 10.27.12.08* A. Unless authorized to practice under this chapter, an individual may not use the words “advanced practice registered nurse/psychiatric mental health”, “nurse psychotherapist”, “psychiatric mental health/advanced practice registered nurse”, or any other words, letters, or symbols with the intent to represent that the individual is a psychiatric-mental health/advanced practice registered nurse. B. An individual certified under this chapter is subject to the disciplinary sanctions set forth in Health Occupations Article, Title 8, Annotated Code of Maryland. C. An individual may not practice as a PMH/APRN or nurse psychotherapist in this State unless the individual is certified under this chapter. ### Chapter 13 — Safe Practice Committee **Authority:** Health Occupations Article, §§8-205 and 8-208, Annotated Code of Maryland **Administrative History:** Effective date: July 20, 1992 (19:14 Md. R. 1283) **Administrative History:** Chapter revised effective March 5, 2001 (28:4 Md. R. 418) **Administrative History:** Chapter revised effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .01B amended effective August 4, 2025 (52:15 Md. R. 812) **Administrative History:** Regulation .02E amended effective August 4, 2025 (52:15 Md. R. 812) **Administrative History:** Regulation .03B amended effective August 4, 2025 (52:15 Md. R. 812) #### Regulation .01 Definitions. *COMAR 10.27.13.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Applicant” means an individual who has submitted an application to the Board to be licensed as a registered nurse, licensed practical nurse, electrologist, licensed certified midwife or direct-entry midwife or to be certified as an advanced practice registered nurse, a certified nursing assistant, a certified dialysis technician, or medication technician in this State. (2) “Board” means the Maryland Board of Nursing. (3) “Committee” means the Safe Practice Committee. (4) “Certificate holder” means a certified nursing assistant, a certified dialysis technician, or medication technician. (5) “Certified dialysis technician” means an individual certified as a dialysis technician by the Board in accordance with COMAR 10.39.06. (6) “Certified nursing assistant” means an individual certified as a nursing assistant by the Board. (7) “Licensee” means a licensed certified midwife, direct-entry midwife, electrologist, licensed practical nurse, registered nurse, or advanced practice registered nurse. (8) “Licensed practical nurse” means an individual who is licensed by the Board to practice licensed practical nursing or has a multistate licensure privilege to practice licensed practical nursing. (9) “Medication technician” means an individual certified as a medication technician by the Board. (10) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (11) “Nurse” means registered nurse, advanced practice registered nurse, or licensed practical nurse. (12) “Participant” means a registered nurse, an advanced practice registered nurse, a licensed practical nurse, a certified nursing assistant, a certified dialysis technician, a medication technician, an electrologist, a licensed direct-entry midwife, a licensed certified midwife or an applicant enrolled in the Safe Practice Program. (13) “Program” means the Safe Practice Program. (14) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (15) “Substance use disorder” means a disorder that occurs when an individual exhibits a pattern of behaviors ranging from the misuse of, dependence on, or addiction to drugs, alcohol, or other chemicals. #### Regulation .02 Safe Practice Committee. *COMAR 10.27.13.02* A. Committee Appointments. (1) Annually, before the September meeting, the Board shall determine the number of rehabilitation committees required in the State. (2) The Board shall make appointments to the committee in October in accordance with Health Occupations Article, §8-208(c)(1), Annotated Code of Maryland. (3) Appointments are for a 4-year term, except in the first year of any committee when the terms are staggered. (4) Committee members may be reappointed for one additional 4-year term. B. Committee Meetings. (1) The committee shall determine where meetings are held and the frequency of meetings. (2) Confidential minutes shall be kept of the committee meetings and maintained in a confidential file at the Board's office. C. The Board shall review and approve all procedures established by the committee. D. The committee shall function in accordance with Health Occupations Article, §8-208(j) — (q), Annotated Code of Maryland. E. Powers and Duties of the Committee. (1) The committee may: (a) Evaluate each individual who requests to participate in the program or is referred to the program; (b) Receive and review information about program participants; and (c) Consider in each case if the participant can practice safely or an applicant qualifies for licensure or certification to practice. (2) The committee shall: (a) Prepare a written plan or agreement for each participant that establishes the requirements for supervision and monitoring; and (b) Inform each licensee, certificate holder, or applicant who requests participation in the program about: (i) The procedures to be followed; (ii) The rights and responsibilities of a participant in the program; and (iii) The possible consequences for a participant’s noncompliance with the program. (3) At the request of the Board, the committee may evaluate a nurse, certified nursing assistant, certified dialysis technician, medication technician, electrologist, direct-entry midwife, or licensed certified midwife with a substance use disorder or mental illness for readiness to return to practice. F. Annual Committee Report. The committee shall submit to the Board each year, and as requested, a report that provides: (1) The number of cases accepted, denied, or terminated with compliance or noncompliance; (2) The number of cases referred to the program that were not eligible; (3) The number of individuals referred to the program who declined admission to the program; and (4) A cost analysis of the program. #### Regulation .03 Criteria for Participation in the Program. *COMAR 10.27.13.03* A. Admission to the program is voluntary. B. Registered nurses, licensed practical nurses, direct-entry midwives, electrologists, medication technicians, advanced practice registered nurses, certified nursing assistants, certified dialysis technicians, licensed certified midwives or applicants for licensure or certification with a substance use disorder or mental illness, may be referred to the program through self-report, formal complaint, or the Board of Nursing. C. A licensee, certificate holder, or applicant requesting to participate in the program may not have: (1) Caused injury to an individual while the licensee or certificate holder was practicing as a licensee or certificate holder; or (2) Been arrested, convicted, or both, for diversion of controlled substances for sale or distribution. D. The committee and each program participant shall enter into a written agreement which lists the individual requirements for the participant’s participation in the program and the conditions which shall be met by the participant. E. If a licensee, certificate holder, or applicant fails to enter into a written agreement provided by the committee, the committee shall deny admission to the program and refer the licensee, certificate holder, or applicant to the Board for consideration of disciplinary action or denial of licensure or certification. #### Regulation .04 Noncompliance with a Written Plan or Agreement. *COMAR 10.27.13.04* A. The committee may expel a participant from the program for failure to comply with any of the conditions of the plan or agreement. B. The committee shall: (1) Report to the Board the name and license number of any participant who is expelled from the program; and (2) Transfer to the Board the records of any participant expelled from the program. C. A participant who is expelled from the program may be subject to discipline. #### Regulation .05 Board and Committee Records. *COMAR 10.27.13.05* A. All Board and committee records concerning a participant are confidential and are not subject to discovery or subpoena in any civil or criminal action or disclosure under General Provisions Article, Title 4, Annotated Code of Maryland. B. Records shall be maintained in a confidential file in the Board’s office. C. After the committee has determined that a participant no longer requires monitoring and may practice safely, all records relating to the participant’s participation in the program shall be purged and destroyed 2 years after the participant is discharged from the program. #### Regulation .06 Participants Leaving the State. *COMAR 10.27.13.06* A. A participant who moves from this State to another state where a safe practice or other rehabilitation program is in place shall be transferred to that program. B. A nurse participant who moves to a state where there is no rehabilitation program shall have the nurse’s program records transferred to the Board of Nursing in that state. C. All non-nurse participants leaving the State shall be referred to the agency responsible for regulating their license or certificate in that state and shall have the participant’s records transferred to the responsible agency in that state. #### Regulation .07 Informational Booklet. *COMAR 10.27.13.07* The committee shall publish an informational booklet for the public that describes the program. ### Chapter 14 — Nursing Staff Agencies *Repealed* **Administrative History:** Effective date: January 2, 1994 (20:26 Md. R. 2028) **Administrative History:** Chapter repealed effective December 17, 2007 (34:25 Md. R. 2211) ### Chapter 15 — Open Meetings — Attendance and Recording, Photographing, and Broadcasting of Sessions **Authority:** Health Occupations Article, §8-205; State Government Article, §§10-502h(2), 10-505, and 10-507; Annotated Code of Maryland **Administrative History:** Effective date: September 13, 1993 (20:18 Md. R. 1431) #### Regulation .01 Exclusion. *COMAR 10.27.15.01* The Board of Nursing is not subject to the provisions of COMAR 10.01.14, but shall be governed by this chapter. #### Regulation .02 Public Attendance. *COMAR 10.27.15.02* A. At any open session of the Board of Nursing, the general public may attend and observe. B. Except in instances when the Board expressly invites public testimony, questions, comments, or other forms of public participation, or when public participation is otherwise authorized by law, a member of the public attending an open session may not participate in the session. #### Regulation .03 Disruptive Conduct. *COMAR 10.27.15.03* A. Prohibition. A person attending an open session of the Board may not engage in any conduct, including visual demonstrations such as the waving of placards, signs, or banners, that disrupts the session or that interferes with the right of members of the public to attend and observe the session. B. Action to Restore Order. (1) The presiding officer may order a person who persists in conduct prohibited by §A of this regulation or who violates any other regulation concerning the conduct of the open session to be removed from the session and may request police assistance to restore order. (2) The presiding officer may recess the session while order is restored. #### Regulation .04 Recording, Photographing, and Broadcasting of Open Sessions. *COMAR 10.27.15.04* A. A member of the public, including any representative of the news media, may record discussions of the Board at an open session by means of a tape recorder or any other recording device if the device does not create an excessive noise that disturbs members of the Board or other persons attending the session. B. A member of the public, including any representative of the news media, may photograph or videotape the proceedings of the Board at an open session by means of any type of camera if the camera: (1) Is operated without excessively bright artificial light that disturbs members of the Board or other persons attending the session; and (2) Does not create an excessive noise that disturbs members of the Board or other persons attending the session. C. A representative of the news media may broadcast or televise the proceedings of the Board at an open session if the equipment used: (1) Is operated without excessively bright artificial light that disturbs members of the Board or other persons attending the session; (2) Does not create an excessive noise that disturbs members of the Board or other persons attending the session; (3) Does not interfere with a person's observation of or participation in the session; and (4) Is used openly so that it is obvious to those in attendance that the session is being recorded. #### Regulation .05 Recordings Not Part of Record. *COMAR 10.27.15.05* A recording of an open session made by a member of the public, or any transcript derived from such a recording, may not be considered a part of the record of any proceeding of the Board of Nursing. ### Chapter 16 — Registered Nurse — Workers' Compensation Medical Case Manager **Authority:** Health-General Article, §4-403; Health Occupations Article, §§8-102 and 8-205; Annotated Code of Maryland **Administrative History:** Effective date: **Administrative History:** Regulations .01—.10 adopted as an emergency provision effective August 2, 1999; adopted permanently effective November 15, 1999 (26:23 Md. R. 1777) **Administrative History:** Regulation .02B amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .04 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .05A amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .06C adopted effective October 13, 2025 (52:20 Md. R. 1002) **Administrative History:** Regulation .09A amended effective July 2, 2018 (45:13 Md. R. 667) #### Regulation .01 Exclusion from Regulations. *COMAR 10.27.16.01* This chapter is not applicable to, and does not restrict or limit, a: A. Registered nurse from performing those functions which constitute the practice of registered nursing as defined by law; and B. Medical claims consultant from performing medical claims consultation as defined in this chapter. #### Regulation .02 Definitions. *COMAR 10.27.16.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Board” means the Board of Nursing. (2) “Board-approved course” means an educational offering specific to the case management of the injured worker under the Workers' Compensation Commission which meets the criteria established by the Board. (3) “Commission” means the Workers' Compensation Commission. (4) Medical Case Management. (a) “Medical case management” means any type of contact, including electronic, written, and personal, with the injured worker, for the purpose of the planning and coordination of health services appropriate to achievement of medical rehabilitation of the injured worker. (b) “Medical case management” includes but is not limited to: (i) Case assessment; (ii) Implementation and coordination of services with the injured worker, family, and health care providers; (iii) Evaluation of treatment results; (iv) Coordinating community re-entry; (v) Return to work with the employer of injury; and (vi) Referral for further vocational rehabilitation services. (5) “Medical claims consultant” means a registered nurse who consults on medical aspects of an injured worker's rehabilitation without any contact with the injured worker. (6) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (7) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (8) “RN-WCCM” means a registered nurse-workers' compensation medical case manager. #### Regulation .03 Certification Requirements. *COMAR 10.27.16.03* A. For certification as an RN-WCCM, an applicant shall: (1) Hold a current license to practice registered nursing in this State or a multistate licensure privilege to practice registered nursing; (2) Submit documentation of successful completion of a Board-approved course; (3) Submit to the Board a completed application for certification as an RN-WCCM; and (4) Pay all fees. B. The Board shall include on the RN's license the designation WCCM. C. Certification by Endorsement. An applicant from out-of-State shall meet the requirements as stated in this regulation. #### Regulation .04 Renewal of Certification. *COMAR 10.27.16.04* A. Unless renewed biennially, a certification to practice as an RN-WCCM expires at the same time as the registered nurse license. B. Before certification as an RN-WCCM expires, the RN-WCCM may renew the certification for an additional term, if the RN—WCCM: (1) Is otherwise entitled to be certified; (2) Has practiced a minimum of 2,000 hours in the past 2 years as an RN—WCCM; (3) Submits a completed application for renewal on the form the Board requires; and (4) Pays all fees. C. If the registered nurse does not meet the practice requirement stated in §B(2) of this regulation, the registered nurse shall complete a Board-approved course to be eligible for renewal of the RN-WCCM certification. #### Regulation .05 Notice to Workers' Compensation Commission. *COMAR 10.27.16.05* The Board shall: A. Notify the Commission of: (1) The status of any RN-WCCM regulated under this chapter; and (2) Any RN-WCCM who fails to renew their certification; and B. Provide the Commission quarterly reports of disciplinary actions taken against any licensee governed by this chapter. #### Regulation .06 Scope of Practice. *COMAR 10.27.16.06* A. The RN-WCCM may perform medical case management of the injured worker as defined in this chapter. B. The RN-WCCM shall comply with all: (1) Other statutes or regulations governing registered nurse practice; and (2) Laws, statutory policies, and procedures of the Commission. C. The RN-WCCM shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .07 Course Approval. *COMAR 10.27.16.07* A. Each provider shall: (1) Submit a course proposal for approval before implementation and at least every 3 years thereafter; and (2) Obtain from the Board a curriculum checklist detailing the content to be included in the course. B. All changes, additions, or deletions to the course shall be approved by the Board before implementation. #### Regulation .08 Course Requirements. *COMAR 10.27.16.08* A. Each course shall have a minimum of 16 hours of theory content. B. The curriculum shall include the following content areas: (1) An historical perspective of case management; (2) Insurance terms and types of coverage—general; (3) Federal and State insurance statutes and regulations governing workers' compensation; (4) Stakeholders—roles, responsibilities, ethical considerations, and goals; (5) Maryland Nurse Practice Act; and (6) Case management, including: (a) Assessment; (b) Planning; (c) Implementation; (d) Evaluation; (e) Written reporting; and (f) Communication. C. The course offering shall use texts from a Board-approved list. #### Regulation .09 Faculty. *COMAR 10.27.16.09* A. Qualifications. Faculty shall hold a: (1) Current license in Maryland to practice registered nursing or a multistate licensure privilege to practice registered nursing; and (2) Certification as a case manager by a certifying body recognized by the Board. B. Responsibilities. Faculty shall: (1) Plan, implement, and evaluate the course at periodic planned intervals; and (2) Develop and utilize written examinations to measure achievement of course objectives. #### Regulation .10 Unlawful Practice. *COMAR 10.27.16.10* A. Unless authorized to practice under this chapter, an individual may not use the words “registered nurse—workers' compensation medical case manager”, RN—WCCM, or any other words, letters, or symbols with the intent to represent that the individual is a registered nurse-workers' compensation medical case manager. B. An individual certified under this chapter is subject to disciplinary sanctions set forth in Health Occupations Article, Title 8, Annotated Code of Maryland. C. An individual may not practice medical case management for the Commission unless authorized under this chapter. ### Chapter 17 — Teletherapy **Authority:** Health Occupations Article, §§1-901, 1-902, and 8-205(a)(2)—(5), Annotated Code of Maryland **Administrative History:** Effective date: July 29, 2019 (46:15 Md. R. 655) #### Regulation .01 Scope. *COMAR 10.27.17.01* This chapter applies to all certified registered nurse practitioners/psychiatric mental health (CRNP/PMH) and psychiatric mental health/advanced practice registered nurses (PMH/APRN) in Maryland, with a specialty certification in psychiatric mental health, who will be providing behavioral health services using teletherapy. #### Regulation .02 Definitions. *COMAR 10.27.17.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Certified registered nurse practitioner/psychiatric mental health (CRNP/PMH)” means a certified registered nurse practitioner who: (a) Is certified by the Board as a certified registered nurse practitioner in the practice of psychiatric mental health; and (b) Autonomously and independently engages in activities authorized by this chapter and in accordance with COMAR 10.27.07. (2) “Psychiatric mental health/advanced practice registered nurse (PMH/APRN)” means an advanced practice registered nurse who: (a) Is certified by the Board as a clinical nurse specialist in the practice of psychiatric mental health; and (b) Autonomously and independently engages in activities authorized by this chapter and in accordance with COMAR 10.27.12. (3) “Synchronous” means simultaneous or quick enough to allow two or more individuals to interact. (4) Teletherapy. (a) “Teletherapy” means the delivery of behavioral health services by a CRNP/PMH or a PMH/APRN at a location other than the location of the client through the use of synchronous interactive audio, video, audio-visual, or other telecommunications or electronic technology. (b) “Teletherapy” does not include: (i) An audio-only telephone conversation between the CRNP/PMH or PMH/APRN and a client; (ii) An electronic mail message between a CRNP/PMH or PMH/ APRN and a client; or (iii) A facsimile transmission between a CRNP/PMH or PMH/APRN and a client. #### Regulation .03 Licensure. *COMAR 10.27.17.03* An individual shall be licensed as a registered nurse in Maryland, or have an active multistate licensure privilege to practice as a registered nurse in Maryland, and be certified by the Board as a CRNP/PMH or PMH/APRN in order to provide teletherapy services in Maryland if either the client or the CRNP/PMH or PMH/APRN is physically located in Maryland. #### Regulation .04 Teletherapy. *COMAR 10.27.17.04* A. In order to provide teletherapy services to a client, a CRNP/PMH or PMH/APRN shall have: (1) Established a client-therapist relationship; (2) Performed a mental status assessment; (3) Established a diagnosis; (4) Developed a treatment plan; and (5) Obtained an informed consent from the client to provide teletherapy. B. Before providing teletherapy services, the CRNP/PMH or PMH/APRN shall develop a procedure to: (1) Verify the identity of the client receiving teletherapy services; (2) Ensure that all medical records are protected from unauthorized access through encryption or other means; (3) Ensure that the CRNP/PMH or PMH/APRN provides a secure and private teletherapy connection and complies with federal and state privacy laws; (4) Notify a client in the event of a data breach in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and the Maryland Confidentiality of Medical Records Act; and (5) Establish safety protocols to be used in the case of an emergency. C. At the outset of each teletherapy session, the CRNP/PMH or PMH/APRN shall: (1) Identify all individuals present at each location and confirm that they are permitted to hear or access personal health information; (2) Obtain or confirm an alternative method of contacting the client in case of a technological failure; and (3) Determine whether the client is in Maryland. #### Regulation .05 Standards of Practice. *COMAR 10.27.17.05* A. A CRNP/PMH or PMH/APRN providing teletherapy services shall be held to the same standards of practice and documentation as those applicable in in-person health care settings. B. A CRNP/PMH or PMH/APRN may not treat a patient or prescribe medication based solely on an online questionnaire. #### Regulation .06 Discipline. *COMAR 10.27.17.06* A. The Board shall use the same standards in evaluating and investigating a complaint and disciplining a CRNP/PMH or PMH/APRN who provides teletherapy as it would use for a CRNP/PMH or PMH/APRN who is not. B. A CRNP/PMH or PMH/APRN who provides teletherapy services and fails to comply with this chapter may be subject to discipline under Health Occupations Article, §8-316, Annotated Code of Maryland. ### Chapter 18 — Monetary Penalties **Authority:** Health Occupations Article, §§8-316, 8-6C-20, and 8–6D–10, Annotated Code of Maryland **Administrative History:** Effective date: April 10, 1995 (22:7 Md. R. 536) **Administrative History:** Regulation .01 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .02B amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03A amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .04A, H amended effective July 2, 2018 (45:13 Md. R. 667) #### Regulation .01 Scope. *COMAR 10.27.18.01* This chapter establishes standards for the imposition of monetary penalties not exceeding $5,000 against a registered nurse, licensed practical nurse, direct-entry midwife, licensed certified midwife, or advanced practice registered nurse if the Board finds that there are grounds to take action under Health Occupations Article, §8-316, Annotated Code of Maryland. #### Regulation .02 Definitions. *COMAR 10.27.18.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Board” means the Board of Nursing. (2) “Licensee” means, unless the context requires otherwise, a: (a) Registered nurse, a licensed practical nurse, or an advanced practice registered nurse as defined in Health Occupations Article, §8-101, Annotated Code of Maryland; (b) A licensed direct-entry midwife as defined in Health Occupations Article, §8-6C-01, Annotated Code of Maryland; and (c) A licensed certified midwife as defined in Health Occupations Article, §8-6D-01, Annotated Code of Maryland. (3) “Penalty” means monetary fine. #### Regulation .03 Imposition of Penalty Generally. *COMAR 10.27.18.03* A. The Board may impose a penalty against a licensee if the Board finds that there are grounds to take action against the licensee pursuant to Health Occupations Article, §8-316, Annotated Code of Maryland. B. The penalty in §A of this regulation may be imposed instead of or in addition to suspending or revoking the license, reprimanding the licensee, or placing the licensee on probation. #### Regulation .04 Imposition of Penalties on Licensees. *COMAR 10.27.18.04* A. A penalty of not less than $100 or more than $1,000 may be imposed by the Board on a licensee if found guilty of any of the following: (1) Filing a false report or record of an individual under the licensee's care; (2) Giving any false or misleading information about a material matter in an employment application; (3) Failing to file or record any health record that is required by law; (4) Obstructing the filing or recording of any health record as required by law; (5) Inducing another individual to fail to file or record any health record as required by law; (6) Violating any provision of Health Occupations Article, §8-316, Annotated Code of Maryland; (7) Submitting a false statement to collect a fee; (8) Being professionally, physically, or mentally incompetent; (9) Providing professional services while: (a) Under the influence of alcohol, or (b) Using any narcotic or controlled dangerous substance, as defined in Criminal Law Article, Annotated Code of Maryland, or other drug that is in excess of therapeutic amounts or without valid medical indication; (10) Knowingly failing to report suspected child abuse in violation of Family Law Article, §5-704, Annotated Code of Maryland; (11) Refusing, withholding, denying, or discriminating against an individual with regard to the provision of professional services for which the licensee is licensed and qualified to render care because the individual is HIV positive; (12) Except in an emergency life-threatening situation where it is not feasible or practicable, failing to comply with the guidelines on universal precautions which are incorporated by reference in COMAR 10.06.01.02B(13); (13) Being in independent practice and failing to display the notice required under Health Occupations Article, §8-506, Annotated Code of Maryland; (14) Failing to begin to fulfill a public service requirement within 1 year of when the assignment is to begin that was a condition of the applicant or licensee receiving State or federal loans or scholarships for the applicant's or licensee's nursing education; or (15) Being expelled from the Safe Practice Program established pursuant to Health Occupations Article, §8-208, Annotated Code of Maryland, for failure to comply with the conditions of the program. B. Violation of Probation. A penalty of $100 per violation may be imposed by the Board on a licensee who fails to comply with the conditions of probation. C. A penalty of not less than $1,000 or more than $5,000 may be imposed by the Board on a licensee found guilty of any of the following: (1) Fraudulently or deceptively obtaining or attempting to obtain a license for the applicant or for another; (2) Fraudulently or deceptively using a license; (3) Being disciplined by a licensing or disciplinary authority of any other state or country or convicted or disciplined by a court of any state or country for an act that would be grounds for disciplinary action under the Board's disciplinary statutes; (4) Being convicted of or pleading guilty or nolo contendere to a felony or to a crime involving moral turpitude whether or not any appeal or other proceeding is pending to have the conviction or plea set aside. D. The Board may impose a penalty of not less than $500 or more than $5,000 upon a licensee found guilty of knowingly doing any act that has been determined by the Board, in the Board's regulations, to exceed the scope of practice authorized to the individual under this title when the violation is: (1) Determined to be willful or actual harm results, or both, the penalty may range from $500 to $5,000; (2) Determined to be willful and there is potential harm to the public, the penalty may range from $500 to $2,000; (3) Determined to be negligent or actual harm results, or both, the penalty may range from $500 to $5,000; (4) Determined to be negligent and there is potential harm to the public, the penalty may range from $500 to $2,000; and (5) A repeat offense, the penalty may be double the amount for the category of offense described in this section, not to exceed $5,000. E. A penalty of up to $1,000 per violation may be imposed by the Board on a licensee who knowingly abuses a patient without causing patient harm. F. A penalty of up to $5,000 per violation may be imposed by the Board on a licensee who knowingly abuses a patient and causes patient harm. G. Fines other than those stated above may be imposed at the discretion of the Board. H. Failure to Renew. (1) The Board may impose the following penalties on a licensee for failure to renew licensure: (a) Not less than $150 per month for practicing on a non-renewed license for a period of up to 1 year; or (b) Amount to be determined by the Board for practicing nursing with a license that was non-renewed for a period of more than 1 year. (2) A penalty of up to $5,000 may be imposed by the Board on a director of nursing found guilty of employing nurses with lapsed licenses on two or more occasions within 1 year. #### Regulation .05 Payment of Monetary Penalties. *COMAR 10.27.18.05* A. The licensee shall pay all fines by cashier's check or money order made payable to the Board and delivered personally or by certified mail to the Board within 60 days of the date of the order. B. The Board shall pay all monies collected by the Board pursuant to these regulations into the general fund of the State. ### Chapter 19 — Code of Ethics **Authority:** Health Occupations Article, §§8-205 and 8-316(a)(25), Annotated Code of Maryland **Administrative History:** Effective date: July 1, 1996 (23:13 Md. R. 944) **Administrative History:** Regulations .01—.04 repealed and new Regulations .01—.03 adopted effective September 16, 2002 (29:18 Md. R. 1443) **Administrative History:** Regulation .01B amended effective December 11, 2014 (41:24 Md. R. 1428); July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .02 amended effective December 11, 2014 (41:24 Md. R. 1428) **Administrative History:** Regulation .03 amended effective July 2, 2018 (45:13 Md. R. 667) #### Regulation .01 Definitions. *COMAR 10.27.19.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) Abandonment. (a) “Abandonment” means: (i) Termination by a nurse of a client assignment which had been accepted by the nurse, without reasonable notification to the immediate supervisor to allow for the continuation of the client’s care; (ii) In the case of a natural disaster or a federal, State, county, or city declaration of an emergency, refusal by a nurse of an assignment, mandatory overtime, or both; or (iii) In the case of a private duty assignment or hospice, if the nurse is the sole provider of care, failure to report for assigned duty or leaving the client unattended at the end of the assigned shift without prior notification to the nursing supervisor, the cognitive capable adult client, or the client’s designated representative. (b) “Abandonment” does not include the declining by a nurse of employer-stipulated mandatory overtime. (2) “Accepting a client assignment” means a nurse has arrived on duty and assumed responsibility for client care based on the nurse’s reasonable and prudent professional judgment and the standards of nursing practice. (3) “Board” means the Board of Nursing. (4) “Client” means a patient, resident, or recipient of care. (5) “Electronic devices” means, but is not limited to, any of the following: (a) Telephones with recording and picture-taking ability; (b) Digital cameras or any other device that can record pictures and data; (c) Facsimile machines, photocopiers, and scanners for copying; and (d) Recording devices. (6) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (7) “Nurse” means a registered nurse, licensed practical nurse, or advanced practice registered nurse as defined in Health Occupations Article, §8-101, Annotated Code of Maryland. (8) “Social media” means any form of electronic communication, including, but not limited to, communication by use of websites for social networking and blogging through which users create online communities to share information, ideas, personal messages, and other content such as videos. #### Regulation .02 Ethical Responsibilities. *COMAR 10.27.19.02* A. A nurse shall: (1) Provide services with respect for human dignity and the uniqueness of a client unrestricted by consideration of social or economic status, religious affiliation, personal attributes, or the nature of health problems; (2) Safeguard a client's right to privacy by maintaining confidentiality of information; (3) Act to safeguard a client and the public if health care and safety are affected by the incompetent, unethical, or illegal practice of any person; (4) Promptly report a breach of confidentiality or privacy; (5) Assume responsibility and accountability for individual nursing judgments and actions; (6) Maintain competence in nursing; (7) Exercise informed judgment and use individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others; and (8) Inform the Board regarding unethical conduct by another licensed nurse. B. A nurse may not, when acting in the capacity or identity of a licensed nurse: (1) Knowingly participate in or condone dishonesty, fraud, deceit, or misrepresentation; (2) Engage or participate in an action that violates or diminishes the civil or legal rights of a client; (3) Perform new techniques and procedures without adequate education and practice; (4) Assume duties and responsibilities in the practice of nursing without adequate preparation or without maintaining competency; (5) Practice nursing if unfit to perform procedures or make decisions because of physical or mental impairment, including, but not limited to, the effects of prescription drugs; (6) If engaged in research, coerce or pressure a subject to participate or continue to participate in the research; or (7) Abandon a client. C. A nurse may not engage in behavior that dishonors the profession whether or not acting in the capacity or identity of a licensed nurse, including, but not limited to: (1) Verbal abuse, including use of racial or ethnic slurs, directed toward a coworker, employer, Board staff member, client, or client’s family member; (2) Physically abusing, threatening, or intimidating a coworker, employer, Board staff member, client, or client’s family member; (3) Deceiving, defrauding, or stealing from a coworker, employer, client, or client’s family member; (4) Diverting any medication or providing false or misleading information to an authorized prescriber or a pharmacist to obtain or attempt to obtain any medication; (5) Knowingly employing another person to practice or engage in or attempt to practice or engage in an occupation or profession licensed under this title if the employee is not licensed to do so under Health Occupations Article, Title 8, Annotated Code of Maryland; (6) Performing acts beyond the authorized scope of the level of nursing practice for which the individual is licensed; (7) Obtaining or copying any part of a client’s health record for purposes other than: (a) Providing health care to the client; (b) Conducting quality improvement activities; (c) Complying with legal requirements such as a subpoena; or (d) Allowing a nursing student to use records for educational purposes if client identification has been redacted or disguised; (8) Using, possessing, supplying, administering, or attempting to use, possess, supply, or administer prescription drugs or controlled dangerous substances without valid medical indication; (9) Reporting for employment under the influence of alcohol or a controlled dangerous substance or submitting a pre-employment sample that is positive for alcohol or a controlled dangerous substance without having provided evidence of valid prescriptions for all controlled dangerous substances in the sample; (10) Reporting for employment under the influence of an illicit drug or submitting a pre-employment sample that is positive for an illicit drug; (11) Using the power, influence, or knowledge, inherent in or obtained during the nurse-patient relationship, for the nurse’s personal gratification or benefit; (12) Engaging in unprofessional or immoral conduct; (13) Misrepresenting or concealing a material fact in obtaining a license, renewing a license, or reinstating a license; or (14) Committing an act of moral turpitude, dishonesty, or corruption when the act directly or indirectly affects the health, welfare, or safety of the citizens of this State, and, if the act constitutes a crime, conviction thereof in a criminal proceeding is not a condition precedent to disciplinary action. D. A nurse may not engage in sexual misconduct. Sexual misconduct includes, but is not limited to: (1) Sexual behavior with a client in the context of a professional evaluation, treatment, procedure, or service to the client, regardless of the setting in which the professional service is rendered; (2) Sexual behavior with a client under the pretext of diagnostic or therapeutic intent or benefit; (3) Solicitation of a sexual relationship, whether consensual or nonconsensual, with a client; (4) Sexual advances toward, or the request of sexual favors from, a coworker, student, employer, client, or client’s family member; (5) Discussion of nontherapeutic sexual matters while treating a client; (6) Taking photographs of a client for a sexual purpose; (7) Sexual harassment of a coworker, student, employer, client, or client’s family member; (8) Sexual contact with an incompetent or unconscious client; (9) Intentionally exposing any of the nurse's sexual body parts; and (10) Intentionally exposing any of the client’s sexual body parts for a nontherapeutic purpose. E. Electronic devices, including but not limited to telephones, may not be used to record medical records and take pictures or videos of clients without written client authorization. F. A nurse: (1) May not make use of electronic devices and social media to transmit or place any client information online; and (2) Shall adhere to the following principles for the use of electronic devices and social media: (a) Every nurse has an obligation to understand the nature, benefits, and consequences of the use of electronic devices and participating in social media networking; (b) Nurses are bound to observe ethically prescribed client-nurse boundaries online as in any other setting; (c) Client information shall be maintained in separate encrypted and secured files on personal computers and online; (d) A nurse has an obligation to report any electronically generated material that could harm a client’s privacy rights; and (e) The standards of professionalism are the same when using electronic devices and social media as in any other circumstance. #### Regulation .03 Penalties. *COMAR 10.27.19.03* Violation of this chapter may result in the Board taking disciplinary action against a nurse pursuant to Health Occupations Article, §8-316, Annotated Code of Maryland. ### Chapter 20 — Management of Infusion Therapy by the Registered Nurse and the Licensed Practical Nurse **Authority:** Health-General Article, §4-403; Health Occupations Article, §8-205; Annotated Code of Maryland **Administrative History:** Effective date: October 7, 1996 (23:20 Md. R. 1423) **Administrative History:** Regulations .01—.04 repealed and new Regulations .01—.06 adopted effective November 15, 1999 (26:23 Md. R. 1777) **Administrative History:** Regulation .02B amended effective October 27, 2003 (30:21 Md. R. 1529); July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .03 amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .04 amended effective July 2, 2018 (45:13 Md. R. 667); October 13, 2025 (52:10 Md. R. 1002) **Administrative History:** Regulation .05 amended effective October 27, 2003 (30:21 Md. R. 1529) **Administrative History:** Regulation .06B amended effective October 27, 2003 (30:21 Md. R. 1529) #### Regulation .01 Exclusion from Regulations. *COMAR 10.27.20.01* This chapter is not applicable to, and does not restrict or limit, other health care practitioners who are authorized to perform these duties under their respective laws. #### Regulation .02 Definitions. *COMAR 10.27.20.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Administer” means to hang or give subsequent fluids and medications. (2) “Antineoplastic” means: (a) Chemical or biologic agents that have a toxic effect on the disease-causing agent or modify the host environment; or (b) Drugs that are capable of destroying invading organisms or malignant tumor cells. (3) “Arterial catheter” means a catheter or needle inserted into an artery. (4) “Assign” means to designate another licensee to be responsible and accountable to perform nursing acts that are within the licensee's scope of practice, knowledge, judgment, and skill. (5) “Central venous catheter (CVC)” means a catheter whose tip is located in a central vessel. (6) “Chronic dialysis client” means a client with end stage renal disease who is receiving routine dialysis treatments in an outpatient facility. (7) “Clinical competence” means the demonstrated ability to perform the identified IV tasks consistent with the standards established by the INS, ONS, or other bodies approved by the Board. (8) “Comprehensive assessment” means a nursing assessment that includes: (a) The specific individual patient's clinical status; (b) Medical treatment regime; and (c) Complexity of the infusion therapy treatment regime including: (i) The purpose and effects of the specific infusate or medication; (ii) Skills to access and de-access the infusion catheter access device; and (iii) The potential harm to the patient should an error occur. (9) Direct Supervision. (a) “Direct supervision” means oversight exercised by a registered nurse who is present on the unit of care during the infusion therapy process. (b) “Direct supervision” includes the actions of: (i) Observation; (ii) Assessment; (iii) Evaluation; and (iv) Direction. (10) “First dose” has the meaning defined by the facility's policies and procedures. (11) “Hypodermoclysis” means the infusion of fluids into subcutaneous tissue for hydration. (12) Implanted Port. (a) “Implanted port” means a reservoir surgically placed under the skin and attached to a catheter which is placed in a vessel, body cavity, or organ. (b) “Implanted port” is often referred to as a medi-port, port-a-cath, infuse-a-port, infusion port, or a subcutaneous port. (13) “Implanted pump” means a catheter surgically placed into a vessel, body cavity, or body space, and attached to a reservoir placed under the skin, that contains a pumping mechanism for continuous medication administration. (14) “Infusion therapy” means the initiation and administration of medication, fluids, and nutrients via an intravenous access device. (15) “Initiate” means to hang and administer the first dose of medications or fluids. (16) “INS” means Infusion Nurses Society. (17) “Intraventricular reservoir” means a catheter threaded through the dura into a ventricle of the brain. (18) “Licensee” means a registered nurse or licensed practical nurse. (19) “LPN” means an individual who: (a) Is licensed by the Board to practice licensed practical nursing; or (b) Has a multistate licensure privilege to practice licensed practical nursing. (20) “Midclavicular catheter” means a peripherally inserted catheter with the distal tip located between the axilla and the vena cava. (21) “Midline catheter” means a peripherally inserted catheter with the tip terminating below the axilla. (22) “Multi-lumen catheter” means a venous access device that has more than one lumen. (23) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (24) “Non-tunneled catheter” means a percutaneously placed catheter inserted into the vein. (25) “ONS” means Oncology Nursing Society. (26) “On-site supervision” means oversight exercised by a supervising registered nurse who is: (a) Present in the facility; and (b) Quickly and easily available to the patient and the assigned nurse during the course of infusion therapy. (27) “Peripheral catheter” means a catheter or needle inserted into a superficial vein with the tip residing outside of the central venous system. (28) “Peripheral veins” means those veins in the superficial aspects of the body excluding the external jugular vein. (29) “Peripherally inserted central catheter (PICC)” means a catheter, inserted with or without a guide wire, whose tip is located in the vena cava. (30) “PPN” means partial parenteral nutrition. (31) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (32) “Specialized catheter” means an epidural, intrathecal, intrapleural, or peripheral nerve catheter. (33) “Subcutaneous infusion of medication” means a continuous or intermittent infusion of medication by an indwelling needle or catheter inserted into subcutaneous tissue. (34) “TPN” means total parenteral nutrition administered into the central venous system. (35) “Tunneled catheter” means a CVC designed to have a portion of the catheter lie in a subcutaneous passage before exiting the body. (36) “Nonsurgically placed” means a catheter placed percutaneously. #### Regulation .03 Education. *COMAR 10.27.20.03* To perform infusion therapy, the licensee shall: A. Complete an infusion therapy program of study which contains didactic content and a clinical practicum consistent with the standards of practice established by the INS or other bodies approved by the Board that includes but is not limited to: (1) Infusion access devices; (2) Selected infusates, blood, and blood components; (3) Nursing assessment and monitoring skills required for the infusion therapy acts to be performed; (4) Management of complications related to the infusion therapy and access devices; and (5) Delivery devices; B. Have documented evidence of clinical competency before independently: (1) Inserting infusion devices; or (2) Managing the care of patients receiving infusion therapy; C. Perform the infusion therapy acts on a frequent routine predictable basis in order to retain practice proficiency; D. Be evaluated for continued clinical competency at planned periodic time intervals; and E. Obtain additional education on nursing assessment and monitoring when the patient population changes. #### Regulation .04 Infusion Therapy Acts — General. *COMAR 10.27.20.04* A. The licensee shall comply with the employer's written policies and procedures which are in compliance with this chapter regarding infusion therapy. B. The licensee shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .05 Infusion Therapy Acts — LPN. *COMAR 10.27.20.05* A. The LPN may perform the following infusion therapy acts for peripheral and subcutaneous infusions when there is an RN on site or available by telephone: (1) Calculate and adjust flow rate including pumps; (2) Observe and report on: (a) Insertion site; and (b) Objective and subjective signs of adverse reactions to infusion therapy; (3) Change the dressing on the insertion site; (4) Change the administration set; (5) Insert subcutaneous needle or catheter to: (a) Rotate sites for an existing infusion; and (b) Administer a medication which is routine for the patient; (6) Insert a peripheral IV needle or catheter (excluding midline) to: (a) Withdraw a blood specimen; or (b) Initiate IV fluids; (7) Remove a peripheral and subcutaneous IV needle or catheter; (8) Flush a peripheral and midline IV device; (9) Convert an existing continuous infusion to an intermittent infusion; (10) Convert an intermittent infusion to a continuous infusion; (11) Change injection cap; (12) Insert device and initiate hypodermoclysis and add replacement solutions; and (13) Administer medication via a peripheral IV line (including midline) using: (a) Pharmacy-prepared medication; and (b) PPN solutions; and (14) Add medications to an intravenous solution. B. The LPN may perform the following acts for midclavicular, CVC, PICC, and implanted ports: (1) Calculate and adjust flow rate including a pump; (2) Observe and report on: (a) The insertion site; and (b) Objective and subjective signs of adverse reactions to infusion therapy; (3) Change the dressing on the insertion site; (4) Flush a midclavicular, PICC, CVC, and an accessed implanted port; (5) Change injection cap; (6) Change administration sets; (7) Convert an existing continuous infusion to an intermittent infusion; and (8) Convert an intermittent infusion to a continuous infusion. C. The LPN may perform the following additional acts under the direct supervision of the RN following a comprehensive patient assessment: (1) Administer TPN via PICC, implanted ports, or CVC; (2) Administer medications by midclavicular, PICC, CVC, and implanted ports by hanging pharmacy prepared solutions; (3) Add medication to a solution administered via PICC, midclavicular CVC, and implanted ports; (4) Observe, monitor, and report on the patient: (a) With specialized catheters; and (b) During a blood transfusion; (5) Initiate and administer blood and blood components; (6) Draw blood specimens via midline, PICC, CVC, and implanted ports; (7) Access and de-access implanted ports; and (8) Initiate the first dose of a medication after it has been reviewed and evaluated for potential risk by the RN. D. On completion of a second specialized educational program in infusion therapy, containing didactic content and a clinical practicum, consistent with the standards of ONS or other bodies approved by the Board and with documented evidence of clinical competency, the LPN may administer standardized doses of non-vesicant chemotherapeutic agents and antiviral agents to an existing infusion in accord with the facility's written protocol or practice guidelines. The LPN shall perform these additional procedures under the direct supervision of the RN following a comprehensive patient assessment. E. The LPN may perform additional infusion therapy acts in a licensed outpatient dialysis facility serving the chronic dialysis client when: (1) The requirements of Regulations .03 and .04 of this chapter and §§A—C of this regulation have been met; (2) The outpatient dialysis unit RN skilled in chronic dialysis has taught a didactic and clinical practicum for the LPN which includes but is not limited to: (a) Pharmacological interventions specific to: (i) Physiological alterations and effects of chronic renal failure; (ii) Indication, dosage, side effects, and contraindications of each drug intervention; and (iii) Special considerations of each drug intervention specific to the chronic renal failure client; and (b) Route of medication administration and access delivery systems; (3) The outpatient dialysis RN documents evidence of the LPN's clinical competency of the additional activities under §F of this regulation. F. The LPN may perform the following additional infusion acts, that may include the flushing of catheters, in a licensed outpatient dialysis facility serving the chronic dialysis client under the direct supervision of the RN skilled in chronic dialysis: (1) Venipuncture for the purpose of hemodialysis; (2) Initiation of and discontinuation from dialysis utilizing the various accesses, including: (a) Subclavian catheters; (b) Internal jugular catheters; (c) Femoral vein catheters; (d) Arterial catheters; (e) Fistulas; and (f) Grafts; (3) Withdrawal of blood and heparinized saline from the various accesses for the purpose of removing the heparin and establishing patency; (4) Withdrawal of blood from access for the purpose of obtaining blood for a laboratory specimen; (5) Administration of IV medications and solutions during hemodialysis; (6) Performance of dressing changes to various access device sites; and (7) Administration of the following medications by IV “push” per physician order and nationally recognized standards of care: (a) Anticoagulant agents; (b) Saline; (c) Erythropoeitic agents; (d) Vitamin D products; (e) Iron preparation agents; and (f) Anti-emetic agents. G. The LPN may not perform the following acts: (1) Administer medication via IV “push”, except as set forth in §F(7) of this regulation; (2) Insert a midline catheter; (3) De-clot the catheter; (4) Repair a catheter; (5) Insert and remove PICC, midline catheters, and midclavicular catheters; (6) Manage specialized catheters for analgesia; and (7) Remove nonsurgically placed central and arterial catheters. #### Regulation .06 Infusion Therapy Acts — RN. *COMAR 10.27.20.06* A. In addition to all previously identified procedures in Regulations .04 and .05A—C of this chapter, the RN may perform the following procedures: (1) Administer medication via IV “push”; (2) Initiate subcutaneous infusion of medication; and (3) Provide care and manage arterial catheters and arterial ports by: (a) Changing IV administration set; (b) Flushing or aspirating; (c) Changing dressing; (d) Obtaining blood specimens; (e) Accessing and de-accessing; and (f) Changing injection cap. B. The RN, upon completion of a second specialized educational program in infusion therapy which includes didactic content and a clinical practicum consistent with the standards established by the ONS or other bodies approved by the Board and with documented evidence of clinical competency, may perform the following additional infusion therapy activities: (1) Administer antineoplastic agents; (2) Aspirate fluid from an intraventricular reservoir; (3) Administer fluids and medications via an intraventricular reservoir; (4) Manage implantable pumps by programming and filling with fluids and medications; (5) Insert, repair, and remove PICC and midclavicular catheters; (6) Insert and remove midline catheters; (7) Manage specialized catheters for analgesia; (8) Remove nonsurgically placed central and arterial catheters; (9) Administer pharmacological agents to de-clot or restore blood return; and (10) Repair a catheter. C. The RN may not perform the following acts: (1) Administer the initial dose of any medication by intrathecal, epidural, intrapleural, or peripheral nerve catheter; or (2) Remove any tunneled catheter. ### Chapter 21 — Registered Nurse — Forensic Nurse Examiner **Authority:** Health-General Article, §4-403; Health Occupations Article, §§8-205 and 8-312; Annotated Code of Maryland **Administrative History:** Effective date: December 13, 1999 (26:25 Md. R. 1898) **Administrative History:** Regulations .01—.08 repealed and new Regulations .01—.08 adopted effective April 28, 2003 (30:8 Md. R. 542) **Administrative History:** Regulation .05 amended effective September 25, 2006 (33:19 Md. R. 1561) **Administrative History:** Regulation .07D adopted effective September 25, 2006 (33:19 Md. R. 1561) **Administrative History:** Chapter revised effective March 19, 2012 (39:5 Md. R. 383) **Administrative History:** Regulation .02B amended effective February 27, 2017 (44:4 Md. R. 254); September 10, 2018 (45:18 Md. R. 834) **Administrative History:** Regulation .03 amended effective February 27, 2017 (44:4 Md. R. 254) **Administrative History:** Regulation .03B amended effective September 10, 2018 (45:18 Md. R. 834) **Administrative History:** Regulation .04A, C amended effective February 27, 2017 (44:4 Md. R. 254) **Administrative History:** Regulation .04E adopted effective October 13, 2025 (52:20 Md. R. 1002) **Administrative History:** Regulation .05 amended effective February 27, 2017 (44:4 Md. R. 254) **Administrative History:** Regulation .07 amended effective January 18, 2016 (43:1 Md. R. 13); February 27, 2017 (44:4 Md. R. 254) **Administrative History:** Regulation .08A amended effective September 10, 2018 (45:18 Md. R. 834) #### Regulation .01 Exclusion from Regulations. *COMAR 10.27.21.01* This chapter is not applicable to and does not restrict or limit: A. Other health care practitioners who are authorized to perform these duties under the Maryland Health Occupations Article; or B. A licensed practical or registered nurse from acting as a chaperone during a forensic examination. #### Regulation .02 Definitions. *COMAR 10.27.21.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Alternate light source (ALS)” means equipment that produces visible and invisible light at various wave lengths to enhance the visualization of evidence. (2) “Board” means the Board of Nursing. (3) “Chain of custody” means a written list identifying, without interruption or lapse, every individual having control or possession of specified items or evidence. (4) “Chaperone” means an individual who does not perform any part of the forensic examination but is present during the course of that examination. (5) “Clinical preceptor” means an RN-FNE educator or physician who has credentials and experience in forensic examinations. (6) “Education” means: (a) Giving presentations, including mentored clinical presentations; (b) Attending conferences or seminars; (c) Completing accredited professional computerized or periodical learning modules; and (d) Participating in the facility evaluation or audit process. (7) “FNE program” means a facility authorized by the Maryland Department of Health to provide forensic nursing services. (8) “Forensic evidentiary examination” means an examination for the purpose of gathering, labeling, preserving, and handling evidence that includes, but is not limited to: (a) Photographic and written descriptive documentation of the findings; (b) A general health and assault history interview; and (c) A physical assessment which may include, but is not limited to: (i) Skin surface examination; (ii) Oral examination; (iii) Genital examination; (iv) Anal examination; and (v) Speculum vaginal examination. (9) “Gynecological Urological teaching associate (GUTA)” means an adult who is trained to teach techniques for performing gender-specific physical examination to health care trainees, using self as a demonstration and practice model with emphasis on teaching from the patient perspective. (10) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (11) “Peer review” means a process by which an RN-FNE’s clinical examination and documentation is reviewed by one or more peers who are authorized to perform the duties of an RN-FNE. (12) “Physician” means an individual licensed to practice medicine in this State. (13) “Practice guideline” means a written documentation that details the standards of care and practice protocols the facility has established to guide the practice of the RN-FNE. (14) “Program coordinator” means an RN-FNE designated by the facility to manage and oversee the FNE program. (15) “Proper authority” means a representative of law enforcement, adult or child protective services, or the jurisdictional authority for a minor or mentally incapacitated individual. (16) “Refresher course” means a curriculum that: (a) Includes didactic and clinical education; and (b) Meets the practice requirements for reinstatement of certification as an RN-FNE. (17) “Registered nurse” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (18) “RN-FNE” means a registered nurse forensic nurse examiner certified by the Board. (19) “RN-FNE Educator” means an individual who: (a) Has a current: (i) License to practice as a registered nurse in Maryland; (ii) Multistate licensure privilege to practice registered nursing under the Nurse Licensure Compact; or (iii) Certification to practice as an advanced practice registered nurse in Maryland; and (b) Is certified under this chapter as a: (i) Registered Nurse Forensic Examiner — Adult (RN-FNE-A); (ii) Registered Nurse Forensic Examiner — Pediatric (RN-FNE-P); or (iii) Registered Nurse Forensic Examiner — Adult and Pediatric (RN-FNE-AP); and (c) Is qualified to teach the theoretical and clinical portions of the RN-FNE training program. (20) “RN-FNE-A” means a registered nurse certified by the Board to practice as a forensic nurse examiner with respect to forensic examinations performed on adults and individuals 13 years old or older. (21) “RN-FNE-P” means a forensic nurse examiner-pediatric who is certified by the Board to practice as a forensic nurse examiner with respect to examinations of children who are younger than 13 years old. (22) “RN-FNE-AP” means a registered nurse certified by the Board to practice as a forensic nurse examiner with respect to examinations of individuals of all ages. (23) “SAFE” means a registered nurse who was certified by the Board before December 13, 1999, as a sexual assault forensic examiner under this chapter. (24) “SANE” means a registered nurse who has successfully completed a program which meets the Sexual Assault Nurse Examiner Standards of Practice established by the International Association of Forensic Nurses. (25) “SANE-A” means a forensic nurse examiner certified by the International Association of Forensic Nurses (IAFN) to perform a forensic evidentiary examination on adults and individuals 13 years old or older. (26) “SANE-P” means a forensic nurse examiner certified by the IAFN to perform a forensic evidentiary examination on children who are younger than 13 years of age. (27) "Simulation” means the utilization of an adult anatomically correct manikin or a GUTA in the performance of a forensic evidentiary examination. (28) “Training program” means the instructional process utilizing the standardized curriculum approved by the Board. #### Regulation .03 Authorization to Practice. *COMAR 10.27.21.03* A. An individual may be certified as: (1) A registered nurse forensic nurse examiner-adult (RN-FNE-A); (2) A registered nurse forensic nurse examiner-pediatric (RN-FNE-P); or (3) A registered nurse forensic nurse examiner-adult/pediatric (RN-FNE-AP). B. An applicant applying for certification to practice as an RN-FNE-A, RN-FNE-P or RN-FNE-AP shall: (1) Either: (a) Hold a current license to practice as a registered nurse in Maryland; or (b) Have a multistate licensure privilege to practice registered nursing; (2) Have at least 18 months of continuous clinical experience as a registered nurse; (3) Complete a training program that includes a standardized curriculum approved by the Board and designed for the RN-FNE-A; (4) Complete in full the application for certification in the category selected; and (5) Pay all fees established by the Board in COMAR 10.27.01.02. C. In addition to the requirements listed in §B of this regulation, an applicant applying for certification as an RN-FNE-P or RN-FNE-AP shall complete a training program that includes the following standardized curricula approved by the Board: (1) The standardized curriculum designed for the RN-FNE-A; and (2) The standardized curriculum designed for the RN-FNE-P. D. A registered nurse who has been certified by the Board as a SAFE on or after December 13, 1999 may be certified to practice as an RN-FNE-A, RN-FNE-P, or RN-FNE-AP if the individual: (1) Submits a form required by the Board attesting that the individual has: (a) Served in the role of SAFE for 200 hours in the previous 12 months; (b) Obtained a total of 8 education clock hours in forensic science or forensic nursing in the previous 12 months; (c) Completed three sexual assault evidentiary examinations in the previous 12 months with respect to: (i) Adults and individuals 13 years old or older if applying for RN-FNE-A; (ii) Children who are younger than 13 years old if applying for RN-FNE-P; or (iii) Each category, if applying for RN-FNE-AP, for a total of six examinations; and (2) Complies with all other requirements of this chapter. E. The Board shall: (1) Maintain an up-to-date list of all RNs certified to practice as RN-FNEs in the State; and (2) Include on the RN's license an indication that the licensee is certified to practice as an RN-FNE, and a designation of the RN-FNE's area of specialization. #### Regulation .04 Scope and Standards of Practice. *COMAR 10.27.21.04* A. An RN-FNE may perform the following tasks and functions with respect to the age group for which the RN-FNE is certified under Regulation .03 of this chapter: (1) Perform forensic evidentiary examinations on victims and alleged perpetrators in connection with physical, sexual, or domestic assaults, whether chronic or acute; (2) Before the forensic evidentiary examination, obtain consent from the individual being examined, from the parent or guardian of a minor individual, or from the proper authority for photographing and evidence collection; (3) Prepare and document the assault history interview; (4) Perform the forensic evidentiary physical assessment, which may include use of an ALS; (5) Complete the physical evidence kit provided by law enforcement; (6) Gather, preserve, handle, document, and label forensic evidence, including but not limited to: (a) Labeling evidence collection containers with the patient's identifying data per local jurisdiction requirements; (b) Placing evidence in the evidence collection container and sealing the container; (c) Signing the evidence collection container as the collector of the evidence; (d) Taking photographs; and (e) Obtaining swabs, smears, and hair and body fluid samples; (7) Maintain the chain of custody; (8) Provide immediate health interventions using clinical practice guidelines; (9) Obtain consultations and make referrals to health care personnel and community agencies; (10) Provide immediate crisis intervention at the time of the examination; (11) Provide discharge instructions; (12) Participate in forensic proceedings including courtroom testimony; (13) Interface with law enforcement officials, crime labs, and State attorney's offices; and (14) Assist the licensed physician in performing a forensic evidentiary examination. B. Clinical Practice Guidelines. An RN-FNE may practice only in a clinical setting in which clinical policy and practice guidelines: (1) Have been approved by the facility's medical and nursing departments; (2) Designate the availability of qualified physician resources; (3) Identify the department in which an RN-FNE shall function; and (4) Designate a program coordinator who has experience in forensic evidentiary examinations to administer the RN-FNE training program. C. The program coordinator: (1) Is responsible for obtaining Board approval of the curriculum before conducting a training program; (2) Has responsibility for oversight and administration of the facility’s RN-FNE training program and the practice of the facility’s RN-FNEs; (3) Verifies the qualifications and certifications of any RN-FNE practicing in the facility; (4) Administers and manages the RN-FNE practice; (5) Approves practice protocols and standards of care for RN-FNE practice; (6) Shall develop a peer review process that includes, but is not limited to: (a) Coordinating the peer review of cases; (b) Ensuring that the peer review is consistent with the standardized data collection process; (c) Ensuring that a peer reviewer meets the qualifications in Regulation .05 of this chapter; and (d) Using the standardized form for peer review that is required by the Board; (7) Interfaces with law enforcement, the State's attorney, and community resource groups; (8) Implements the facility's Board-approved RN-FNE curricula; and (9) Facilitates reimbursement for RN-FNE services by cooperating with the facility's billing department and interacting with the State reimbursement system. D. An RN-FNE shall comply with all State and federal statutes and regulations related to the RN-FNE practice. E. An RN-FNE shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .05 Standards for Training Programs. *COMAR 10.27.21.05* A. The Board shall approve two RN-FNE standardized curricula as follows: (1) An RN-FNE-Adult curriculum for the examination of adults and individuals 13 years old or older; and (2) An RN-FNE-Pediatric curriculum for the examination of children who are younger than 13 years old. B. New RN-FNE training programs shall: (1) Be approved by the Board before implementation of the FNE training program; (2) Ensure that the didactic and clinical experiences are the same as existing FNE programs; (3) Teach the Board-approved curriculum in forensic nurse practice and forensic evidentiary examinations; and (4) Submit the qualifications and curriculum vitae of each faculty member to the Board for review before implementation of the training program. C. An application for a new FNE program shall be submitted to the Board at least 6 months before the date of the first class. D. The successful completion of the RN-FNE-Adult training program shall be a prerequisite to admission to the RN-FNE-Pediatric training program. E. The RN-FNE-Adult training program shall include a minimum of 80 clock hours that includes: (1) A minimum of 40 clock hours of theory; and (2) A minimum of 40 clock hours of clinical experience with adults and individuals 13 years old or older. F. The RN-FNE-Pediatric training program shall include a minimum of 62 clock hours that includes: (1) A minimum of 30 clock hours of theory; and (2) A minimum of 32 clock hours of pediatric clinical experience. G. All clinical requirements for an FNE training program shall be completed within a 12-month period. H. Faculty Qualifications. (1) An RN-FNE educator who meets the requirements of this section or a physician whose credentials demonstrate experience in the skills required in forensic evidentiary examinations is qualified to teach both theory and clinical portions of the curriculum and may serve as clinical preceptor for the clinical practicum of the FNE training program. (2) An RN-FNE educator who teaches in an RN-FNE training program or is the clinical preceptor of the training program shall: (a) Be approved by the coordinator of the FNE program: and (i) Have 2 years of experience as an RN-FNE or as a SANE, if from another state; (ii) Have 1 year of FNE experience with ten forensic examinations performed; or (iii) Be deemed by the FNE program coordinator to have the necessary FNE experience and competencies; (b) Have experience teaching the adult learner; (c) Possess broad knowledge and experience in the multidisciplinary treatment approach to family or sexual interpersonal violence, including intervention techniques; and (d) Have either: (i) Qualified as a forensic nurse examiner expert witness in a criminal proceeding; or (ii) Obtained trial preparation experience with the State's attorney's office. (3) The clinical preceptor for the clinical practicum of the FNE training program shall document the clinical competency of the RN-FNE candidate at the completion of the clinical practicum. I. All changes, additions, or deletions to the FNE training program shall be submitted to the Board for approval not later than 3 months before the date of the first class. #### Regulation .06 Certification by Endorsement. *COMAR 10.27.21.06* A. Endorsement Applicant. (1) In addition to the requirement listed in Regulation .03 of this chapter and COMAR 10.27.01.09, an applicant from another state applying for certification to practice as a RN-FNE, RN-FNE-P, or RN-FNE-AP shall: (a) Meet all applicable requirements in §§B—C of this regulation; (b) Provide evidence of an active practice as a sexual assault nurse examiner which meets the requirements for renewal of certification as stated in Regulation .07 of this chapter; (c) Demonstrate competency of a three orifice evidentiary examination by simulation as verified by a Board approved RN-FNE educator; (d) Complete the endorsement process within 6 months from the date of initial application; (e) Complete in full the application for certification in the area of specialization; and (f) Pay all fees established by the Board in COMAR 10.27.01.02. (2) An applicant who does not meet the requirements for renewal under Regulation .07 of this chapter shall complete a Board approved refresher course which is 6.5 hours of didactic education including, but is not limited to: (a) Evidence based best practice for forensic evidentiary examination; (b) Evidence collection; (c) Local jurisdiction requirements; and (d) Maryland criminal law. (3) An applicant who fails to meet the criteria for endorsement shall meet the requirements in Regulation .03 of this chapter. B. An applicant from another state applying for certification to practice as a RN-FNE shall submit evidence of prior training and certification by providing the Board with: (1) A current national SANE-A or SANE-P certification, or both, from IAFN; or (2) Proof of successful completion of a SANE-A or RN-FNE-A, adult curriculum which is: (a) Substantially equivalent to the Board’s approved RN-FNE-A curriculum; and (b) A minimum of 80 clock hours that includes: (i) A minimum of 40 clock hours of theory; and (ii) A minimum of 40 clock hours of clinical experience with adults and individuals 13 years of age or older. C. An applicant from another state applying for certification to practice as a RN-FNE-P or RN-FNE-AP, shall submit proof of successful completion of the following two curricula: (1) A SANE-A curriculum as referenced in §A(1) of this regulation; and (2) A SANE-P or RN-FNE-P, pediatric curriculum that is: (a) Substantially equivalent to the Board-approved RN-FNE-P curriculum; and (b) A minimum of 62 clock hours of instruction that includes: (i) A minimum of 32 clock hours of theory; and (ii) A minimum of 30 clock hours of pediatric clinical experience with individuals who are younger than 13 years of age. #### Regulation .07 Renewal of Certification. *COMAR 10.27.21.07* A. Certification to practice as a FNE expires at the same time as the RN license. B. Beginning January 1, 2016, renewal requirements will change to reflect the 2-year biennial license renewal that was implemented during 2015. C. An FNE who has an even-numbered birth year shall be required: (1) Beginning January 1, 2016, to complete the renewal requirements under §E of this regulation; and (2) Beginning January 1, 2018, to complete the renewal requirements under §F of this regulation. D. Beginning January 1, 2017, an FNE who has an odd-numbered birth year shall be required to complete the renewal requirements under §F of this regulation. E. Before the certification to practice as an RN-FNE expires, the individual may renew for an additional term, if the RN-FNE: (1) Is otherwise entitled to be certified; (2) Has practiced in the role of RN-FNE for a minimum of 400 hours in the previous 24 months in a facility recognized to perform sexual assault forensic evidentiary examinations; (3) Has completed the following evidentiary examinations: (a) If applying for renewal as an RN-FNE-A, three evidentiary examinations on adult patients 13 years of age or older by simulation; (b) If applying for renewal as an RN-FNE-P, three evidentiary examinations on children who are younger than 13 years old; or (c) If applying for renewal as an FNE-AP, three evidentiary examinations on children who are younger than 13 years old, and an additional three evidentiary examinations on adult patients 13 years of age or older by simulation, for a total of six evidentiary examinations performed; or (d) Completed the following requirements: (i) If applying for renewal as an RN-FNE-A, performed ten speculum examinations and observed three evidentiary examinations on adult patients 13 years of age or older; (ii) If applying for renewal as a RN-FNE-P, has observed three evidentiary examinations on children who are younger than 13 years old; (iii) If applying for renewal as an FNE-AP, has observed three evidentiary examinations on children who are younger than 13 years old, has observed an additional three evidentiary examinations on adult patients 13 years of age or older, and performed ten speculum examinations on adult patients 13 years of age or older, for a total of six evidentiary examinations observed and ten speculum examinations performed; and (iv) Have a minimum number of cases submitted to peer review annually in accordance with §G of this regulation; (4) Provides evidence of having obtained a minimum of 8 education clock hours per year in forensic science or forensic nursing; (5) Pays all appropriate renewal fees set forth by the Board in COMAR 10.27.01.02; and (6) Submits an application for renewal of the certification on the form the Board requires. F. Before the certification to practice as an RN-FNE expires, the individual may renew for an additional term, if the RN-FNE: (1) Is otherwise entitled to be certified; (2) Has practiced in the role of RN-FNE for a minimum of 400 hours in the previous 24 months in a facility recognized to perform sexual assault forensic evidentiary examinations; (3) Has completed the following evidentiary examinations: (a) If applying for renewal as an RN-FNE-A, six evidentiary examinations on adult patients 13 years old or older by simulation; (b) If applying for renewal as an RN-FNE-P, six evidentiary examinations on children who are younger than 13 years old; (c) If applying for renewal as an FNE-AP, six evidentiary examinations on children who are younger than 13 years old, and an additional six evidentiary examinations on adult patients 13 years old or older by simulation, for a total of twelve evidentiary examinations performed; or (d) Completed the following requirements: (i) If applying for renewal as an RN-FNE-A, performed twenty speculum examinations and observed six evidentiary examinations on adult patients 13 years old or older; (ii) If applying for renewal as an RN-FNE-P, has observed six evidentiary examinations on children who are younger than 13 years old; or (iii) If applying for renewal as an FNE-AP, has observed six evidentiary examinations on children who are younger than 13 years old, has observed an additional six evidentiary examinations on adult patients 13 years old or older, and has performed ten speculum examinations on adult patients 13 years old or older, for a total of twelve evidentiary examinations observed and ten speculum examinations performed; and (iv) Have a minimum number of cases submitted to peer review annually in accordance with §G of this regulation; (4) Provides evidence of having obtained a minimum of 16 education clock hours per 24 months in forensic science or forensic nursing; (5) Pays all appropriate renewal fees set forth by the Board in COMAR 10.27.01.02; and (6) Submits an application for renewal of the certification on the form the Board requires. G. Peer Review. (1) As a condition of renewal, the following number of cases shall be submitted annually to peer review: (a) Three cases for an RN-FNE-A; (b) Three cases for an RN-FNE-P; and (c) Three adult cases and three pediatric cases for a total of six cases for an RN-FNE-AP. (2) An examination done by simulation may be included in the cases for peer review. H. If the individual does not meet the requirement of §§E(2) and F(2) of this regulation, the individual shall complete a Board-approved course before becoming eligible for renewal of the certification. I. With respect to the requirement set forth in §§E(3) and F(3) of this regulation, an examination performed on a live model or by simulation may substitute for evidentiary examinations for the purpose of certificate renewal. #### Regulation .08 Reinstatement of Certification. *COMAR 10.27.21.08* A. If the applicant does not meet the requirements in Regulation .07 of this chapter, the applicant may apply for re-instatement if the applicant: (1) Either: (a) Has a current, active RN license; or (b) Has a multistate licensure privilege to practice registered nursing; (2) Has not practiced as a RN-FNE for more than 36 months; (3) Has successfully completed a Board-approved refresher course that is 6.5 hours of didactic instruction for the RN-FNE which includes, but is not limited to: (a) Evidence based best practice for forensic evidentiary examination; (b) Evidence collection; (c) Local jurisdiction requirements; and (d) Maryland criminal law; and (4) Has demonstrated clinical competency of a three orifice evidentiary examination for: (a) An adult patient 13 years of age or older or by simulation for certification as an RN-FNE-A; (b) Children younger than 13 years of age for certification as an RN-FNE-P; or (c) An adult patient 13 years of age or older by simulation and by patient examination on children younger than 13 years of age or older for certification as an RN-FNE-AP. B. An applicant for reinstatement of certification has 6 months from the date of initial application to complete the reinstatement process. C. An applicant who fails to meet the criteria for reinstatement of the certification shall meet the requirements in Regulation .03 of this chapter. #### Regulation .09 Unlawful Practice. *COMAR 10.27.21.09* A. Unless authorized to practice under this chapter, an individual may not use the words “forensic nurse examiner” or the acronyms “RN-FNE”, “RN-FNE-A”, “RN-FNE-P”, or “RN-FNE-AP”, or any other words, letters, or symbols with the intent to represent the individual as any category of RN-FNE. B. An individual may not use any form of the designation RN-FNE unless authorized by the Board. C. An individual may not offer to perform or perform the activities of a RN-FNE enumerated in Regulation .04A of this chapter unless certified under this chapter or otherwise permitted by law to engage in these activities. D. A registered or licensed practical nurse may not perform any task or function listed under Regulation .04A of this chapter unless certified under this chapter. E. An individual authorized under this chapter to practice as an RN-FNE is subject to the disciplinary prohibitions and sanctions set forth in Health Occupations Article, Title 8, Annotated Code of Maryland. ### Chapter 22 — Multistate Licensure Compact Regulations **Authority:** Health Occupations Article, §§8-205(a)(1) and 8-7A-01—8-7A-05, Annotated Code of Maryland **Administrative History:** Effective date: **Administrative History:** Regulations .01—.04 adopted as an emergency provision effective January 1, 2000 (27:2 Md. R. 140); adopted permanently effective April 17, 2000 (27:7 Md. R. 705) **Administrative History:** Regulation .01B amended effective August 28, 2017 (44:17 Md. R. 835) **Administrative History:** Regulation .02 amended effective August 28, 2017 (44:17 Md. R. 835) **Administrative History:** Regulation .02B, C amended effective January 18, 2016 (43:1 Md. R. 13) **Administrative History:** Regulation .03 amended effective August 28, 2017 (44:17 Md. R. 835) **Administrative History:** Regulation .04 amended effective August 28, 2017 (44:17 Md. R. 835) #### Regulation .01 Definitions. *COMAR 10.27.22.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Board” means the regulatory body responsible for issuing nurse licenses. (2) “Information System” means the coordinated licensure information system. (3) “Primary state of residence” means the state of an individual's declared, fixed, permanent, and principal home for legal purposes: domicile. (4) “Public” means any individual or entity other than designated staff or representatives of party state boards or the National Council of State Boards of Nursing, Inc. #### Regulation .02 Issuance of a License by a Compact Party State. *COMAR 10.27.22.02* A. As of July 1, 2005, no applicant for initial licensure will be issued a compact license granting a multistate privilege to practice unless the applicant first obtains a passing score on the applicable NCLEX examination or any predecessor examination used for licensure. B. Home Party State License. (1) A nurse applying for a license in a home party state shall produce evidence of the nurse’s primary state of residence. (2) The evidence required in §B(1) of this regulation shall include a declaration signed by the licensee. (3) Further evidence that may be requested may include but is not limited to a: (a) Driver's license with a home address; (b) Voter registration card displaying a home address; (c) Federal income tax return declaring the primary state of residence; (d) Military Form No. 2058, State of Legal Residence Certificate; or (e) W2 form from the United States government or any bureau, division, or agency thereof indicating the declared state of residence. C. A nurse on a visa from another country applying for licensure in a party state may declare either the country of origin or the party state as the primary state of residence. If the foreign country is declared the primary state of residence, a single state license shall be issued by the party state. D. A license issued by a party state is valid for practice in all other party states unless clearly designated as valid only in the state which issued the license. E. Single State License. (1) When a party state issues a license authorizing practice only in that state and not authorizing practice in other party states, the license shall be clearly marked with words indicating that it is valid only in the state of issuance. (2) A license that is only valid for the party state is called a single state license. F. A nurse changing primary state of residence, from one party state to another party state, may continue to practice under the former home state license and multistate licensure privilege during the processing of the nurse’s licensure application in the new home state for a period not to exceed 90 days. G. The licensure application in the new home state of a nurse under pending investigation by the former home state shall be held in abeyance, and the 90-day period in §F of this regulation shall be stayed until resolution of the pending investigation. H. The former home state license is not valid upon the issuance of a new home state license. I. If a decision is made by the new home state denying licensure, the new home state shall notify the former home state within 10 business days, and the former home state may take action in accordance with that state's laws and regulations. #### Regulation .03 Limitations on Multistate Licensure Privilege — Discipline. *COMAR 10.27.22.03* A. Home state boards shall include, in all disciplinary orders or agreements that limit practice or require monitoring, the requirement that the licensee subject to the order or agreement shall limit the licensee's practice to the home state during the pendency of the disciplinary order or agreement. B. The requirement referred to in §A of this regulation may, in the alternative, allow the nurse to practice in other party states with prior written authorization from both the home state and other party state boards. C. An individual who had a license which was surrendered, revoked, or suspended, or an application denied for cause in a prior state of primary residence, may be issued a single state license in a new primary state of residence until such time as the individual would be eligible for an unrestricted license by the prior state or states where there was an adverse action. D. Once eligible for licensure in the prior state or states, a multistate license may be issued. #### Regulation .04 Information System. *COMAR 10.27.22.04* A. Levels of Access. (1) Public access to nurse licensure information shall be limited to: (a) The licensee's name; (b) Jurisdictions of licensure; (c) Licensure expiration date; (d) Licensure classification and status; (e) Public emergency, summary, and final disciplinary actions, as defined by contributing state authority; and (f) The status of multistate licensure privileges. (2) Non-party state boards shall have access to all Information System data except current significant investigative information and other information as limited by contributing party state authority. (3) Party state boards shall have access to all Information System data contributed by the party states and other information as allowed by contributing non-party state authority. B. Right to Review. (1) The licensee may request, in writing, to the home state board to review data relating to the licensee in the Information System. (2) If a licensee asserts that any data relating to the licensee is inaccurate, the burden of proof is on the licensee to provide evidence substantiating that claim. (3) Within 10 business days, the Board shall correct information that it finds to be inaccurate in the Information System. C. Changes in Disciplinary Data. (1) Within 10 business days, the Board shall report to the Information System: (a) Disciplinary action, agreement, or order requiring participation in alternative programs or which limit practice or require monitoring unless the agreement or order relating to participation in alternative programs is required to remain nonpublic by the contributing state authority; (b) Dismissal of the complaint; and (c) Changes in status of disciplinary action, or licensure encumbrance. (2) The Board shall delete current significant investigative information from the Information System within 10 business days after: (a) A disciplinary action; (b) An agreement or order requiring participation in alternative programs; (c) An agreement or agreements which limit practice or require monitoring; or (d) Dismissal of a complaint. (3) The Information System administrator shall make changes to licensure information in the Information System within 10 business days upon notification by a board. ### Chapter 23 — Code of Conduct for Board Members and Investigators **Authority:** Health Occupations Article, §8-205(a)(1), Annotated Code of Maryland **Administrative History:** Effective date: December 25, 2000 (27:25 Md. R. 2282) #### Regulation .01 Scope. *COMAR 10.27.23.01* This chapter establishes a code of conduct for: A. Members of Board of Nursing; and B. Investigators employed by the Board of Nursing. #### Regulation .02 Definitions. *COMAR 10.27.23.02* A. In this chapter, the following terms have the meanings indicted. B. Terms Defined. (1) “Board” means the Board of Nursing. (2) “Board member” means an individual appointed by the Governor to serve on the Board. (3) “Charging document” means the notice from the Board pursuant to State Government Article, §10-208, Annotated Code of Maryland, which informs a licensee of an alleged violation or violations of a Board's statute by the licensee. (4) “Complaint” means a communication to a Board of a possible violation of the disciplinary provisions outlined in Health Occupations Code, Title 8, Annotated Code of Maryland. (5) “Conflict of interest” means a situation in which a personal interest of a Board member or a Board investigator presents a potential conflict with the public interest in connection with an anticipated public action or decision. (6) “Ex parte communication” means a direct or indirect communication between a Board member and another party regarding the merits of an issue in a pending contested disciplinary case, if the communication is made outside the presence of the opposing party. (7) “Investigator” means an individual who investigates complaints received by the Board. (8) “Recusal” means nonparticipation of a Board member in a specific matter before the Board. #### Regulation .03 Recusal of Board Members. *COMAR 10.27.23.03* A. Standard for Recusal. (1) A Board member shall recuse himself or herself from Board proceedings which involve situations in which the Board member: (a) Has a conflict of interest; or (b) Cannot participate fairly and impartially. (2) Personal familiarity with a respondent does not, of itself, require recusal of a Board member. (3) A Board member may seek advice of the Board's counsel in determining the need for recusal on a specific matter. B. Recusal. (1) The Board member who is recused from a matter before the Board, may not: (a) Participate in the Board's discussion or vote on the matter; or (b) Discuss the matter or the Board's review of the matter with members of the Board or other individuals. (2) If the matter before the Board is a disciplinary matter, the Board member who is recused shall physically leave the room to ensure nonparticipation. (3) The Board shall document the recusal of the Board member in the minutes of the Board meeting. C. Recusal for Complaint Against a Board Member. (1) A Board member against whom a complaint is filed shall follow §B of this regulation for all discussion and voting concerning the complaint filed against the Board member. (2) If the Board determines that there is an additional matter before the Board which is reasonably related to the complaint filed against the Board member, the Board member against whom the complaint is filed shall follow §B of this regulation for the additional matter also. (3) If, after investigation of the complaint, the Board refers the case to the Attorney General's Office, the Board member shall recuse himself or herself from all Board activities until the final disposition of the case. #### Regulation .04 Investigator. *COMAR 10.27.23.04* A. An investigator may not conduct or participate in an investigation of a complaint in which the investigator has a conflict of interest. B. In the investigation of a complaint against a member of a Board, the Board may consider using an investigator other than the investigator who is regularly assigned to conduct investigations for the Board. #### Regulation .05 Confidentiality. *COMAR 10.27.23.05* A. A Board member or investigator may not discuss disciplinary or other confidential matters with a person other than: (1) A Board member; (2) Board staff; (3) The Attorney General's Office; (4) A witness; or (5) Another person authorized by law to be involved in the case. B. In the case of an ex parte communication, the Board member shall follow the provisions of the State Government Article, §10-219, Annotated Code of Maryland. ### Chapter 24 — Compelling Purpose Disclosure **Authority:** State Government Article, §10-617(h)(3), Annotated Code of Maryland **Administrative History:** Effective date: July 23, 2001 (28:14 Md. R. 1322) #### Regulation .01 Disclosure for Compelling Public Purpose. *COMAR 10.27.24.01* A custodian of Board records may find that a compelling public purpose warrants disclosure of information in a certification, licensing, or investigative file, whether or not there has been a request for the information under the following circumstances: A. There is possible criminal activity and the disclosure is to a federal, state, or local law enforcement or prosecutorial official or authority; B. There is possible violation of law and the disclosure is to a federal, state, or local authority that has jurisdiction over the individual whose conduct may be a violation or over a facility in which the individual has practiced and the information disclosed is limited to that information relevant to the possible violation by that individual; or C. There is conduct by an individual that the Board reasonably believes may pose a risk to the public health, safety, or welfare and the disclosure is to a law enforcement authority, administrative official, or agency that regulates the individual or regulates a facility in which the individual has practiced, or to a hospital or other health care facility where the individual has privileges. #### Regulation .02 Other Disclosures. *COMAR 10.27.24.02* This chapter does not prevent or limit the ability of the Board to disclose general licensing information as provided in State Government Article, §10-617(h), Annotated Code of Maryland, or any information which the Board may otherwise disclose by law. ### Chapter 25 — Cosmetic Procedures **Authority:** Health-General Article, §4-403; Health Occupations Article, §8-205(a)(1) and (2); Annotated Code of Maryland **Administrative History:** Effective date: May 30, 2011 (38:11 Md. R. 671) **Administrative History:** Regulation .05E adopted effective October 13, 2025 (52:20 Md. R. 1002) #### Regulation .01 Exclusion from Regulations. *COMAR 10.27.25.01* A. This chapter is not applicable to, and does not restrict or limit, other health care practitioners who are authorized to perform these duties under their respective practice acts. B. This chapter does not restrict or limit a Maryland Certified Registered Nurse Practitioner from possessing, prescribing, evaluating, or performing the procedures under this chapter. #### Regulation .02 Definitions. *COMAR 10.27.25.02* A. The following terms have the meanings indicated. B. Terms Defined. (1) “Body treatment” means cellulite lymphatic drainage and cellulite vacuum massage. (2) “Cellulite lymphatic drainage” means a therapy in which the practitioner uses a range of specialized and gentle rhythmic pumping techniques to move the skin in the direction of the lymph flow. (3) “Cellulite vacuum massage” means: (a) The massage of peripheral blood, lymph, and inter-tissue liquid with the goal of reducing stagnation of these fluids and increasing the skin’s elasticity; and (b) The external use of a vacuum component directly on the area to be massaged followed by a straight line, circular, or zigzag movement to massage the area. (4) “Chemical peels” also called deep skin peels, means the removal of the top layers of skin using chemicals applied directly to the skin. (5) “Clinical preceptor” means a licensed or certified individual who is: (a) Proficient in the procedure for which they are precepting; and (b) Permitted by the appropriate health occupation licensing board to provide care and treatment for cosmetic services. (6) “Cryotherapy” means the application of: (a) Extreme cold to destroy abnormal or diseased tissue, warts, moles, skin tags, and solar keratoses; and (b) Liquid nitrogen to freeze tissues at the cellular level. (7) “Dermal fillers” means various types of natural or man-made materials which are injected intradermally to correct imperfections in the skin and subcutaneous tissue. (8) “Direct supervision” means on site, physically present, accessible in the immediate patient care area and available to intervene if necessary. (9) “Injectable treatments” means the use of FDA approved medication and includes the following: (a) Dermal fillers; (b) Micropigmentation, also known as cosmetic tattoo or permanent make-up; and (c) Neuromuscular agents. (10) “Laser treatment” means a technique in which exposure to low-level laser light or light emitting diodes are used to stimulate or inhibit cellular function possibly leading to beneficial clinical effects. (11) Light Treatment. (a) “Light treatment” also known as phototherapy, means the use of non-ionizing electro-magnetic radiation for therapeutic benefit. (b) “Light treatment” does not mean laser treatment. (12) “Lipodissolve” means a procedure that uses subcutaneous micro-injections of drugs with the sole purpose of dissolving fat for body contouring. (13) Magenta Light. (a) “Magenta light” means a non-invasive technique that combines infrared and magenta light with subdermal tissue massage to produce a penetrating light that affects the epidermis, alters cellulite formation, and controls cellulite formation at the cellular level. (b) “Magenta light” does not mean laser or intensive pulse light. (14) “Mesotherapy” also known as intradermotherapy, means a non-invasive cosmetic treatment which employs multiple intra or subcutaneous injections of pharmaceutical and homeopathic medications, plant extracts, vitamins, and other ingredients for the treatment of fat or cellulite. (15) “Micro current treatment” means passing radio frequency electricity through the skin to: (a) Heat up tissue; (b) Cause the tissue to contract; and (c) Stimulate collagen production. (16) “Neuromuscular agents” means injectable drugs that cause muscle weakness for the purpose of cosmetic softening of wrinkles and includes, but is not limited to, Botox and Dysport. (17) “Nurse” means a registered nurse (RN) or a licensed practical nurse (LPN). (18) “Peels” or “Topicals” means: (a) Chemicals peels; (b) Cryotherapy; or (c) Microdermabrasion. (19) “Photochemotherapy” means the use of a photodynamic light source to destroy dystrophic cells. (20) “Photodynamic (PDT)” means the use of a light source, combined with a light-sensitive drug to destroy dystrophic cells. (21) “Photosensitizing agent” means a drug used with a photodynamic light source to produce a therapeutic photosensitivity. (22) “Precepted clinical practice” means after theoretical learning and until competency is achieved: (a) Working directly with patients; (b) Performing cosmetic or dermatologic procedures on patients; and (c) Working under the direct supervision of a clinical preceptor who has the knowledge and ability to perform the procedure independently. (23) Radio Frequency and Current. (a) “Radio frequency and current” means: (i) Magenta light; (ii) Microcurrent treatment; (iii) Photochemotherapy; (iv) Photodynamic; (v) Thermage; and (vi) Ultrasound (therapeutic only). (b) “Radio frequency and current” does not mean laser. (24) Theory. (a) “Theory” means the body of knowledge regarding the principles underlying the safe execution of a cosmetic procedure and is obtained through didactic instruction provided by a licensed health care provider who has the knowledge and skill to perform the procedure. (b) “Theory” includes didactic instruction by the licensed health care provider which may be augmented by a manufacturer’s representative. (25) “Thermage” means the use of radio frequency technology to: (a) Target collagen in the dermis layer of the skin around the eyes and forehead; and (b) Cause the dermis and underlying tissue to tighten. (26) Ultrasound. (a) “Ultrasound” means the therapeutic use of inaudible sound in the frequency range of approximately 20,000 to 10,000,000,000 cycles per second for therapeutic use at low intensity producing a heating effect to stimulate collagen production. (b) “Ultrasound” does not mean the use of ultrasound for diagnostic purposes. #### Regulation .03 Procedural Categories. *COMAR 10.27.25.03* A. Procedures designated as Category A shall include body treatments with: (1) Cellulite lymphatic drainage; and (2) Cellulite vacuum massage. B. Procedures designated as Category B shall include light treatments with: (1) Infrared light; (2) Magenta light; (3) Photochemotherapy; (4) Photodynamic; (5) Photosensitizing agents; (6) UVA light; and (7) UVB light. C. Procedures designated as Category C shall include laser treatments administered by a selective laser. D. Procedures designated as Category D shall include injectable treatments with: (1) Dermal fillers; (2) Micropigmentation with topical anesthetics only; and (3) Neuromuscular agents. E. Procedures designated as Category E shall include radio frequency and current treatments with: (1) Micro current; (2) Thermage; and (3) Ultrasound. F. Procedures designated as Category F shall include peels or topicals with: (1) Chemical peels; (2) Cryotherapy; (3) Microdermabrasion; and (4) Power peel. #### Regulation .04 Education. *COMAR 10.27.25.04* To administer medication or to perform cosmetic and dermatologic treatments, a nurse shall: A. Complete a program of study that includes theory appropriate to the medication to be administered and the procedure to be performed that includes, but is not limited to: (1) Anatomy, physiology, and pathophysiology related to the integumentary system as well as systems specific to the procedure being performed; (2) Appropriate technique for each cosmetic procedure; (3) Nursing assessment, cosmetic indications, and contraindications for treatment; (4) Pharmacology intervention specific to the cosmetic procedure including, but not limited to: (a) Assessment and monitoring of the receiving the medication; (b) Effects and potential side effects of the medication; (c) Contraindications to the administration of the medication; (d) The ability to anticipate and recognize potential complications of the medication; (e) The ability to recognize emergency situations and institute appropriate interventions; (f) Preparation, storing, and handling of the medication; and (g) Proficiency in administering the medication by the required route; (5) Selection, maintenance, and utilization of equipment; (6) Identification of realistic and expected outcomes of the procedure; (7) Identification of complications or adverse reactions; (8) Nursing care required and appropriate nursing interventions in the event of complications or untoward outcomes; (9) Infection control procedures; (10) Safety precautions appropriate to each procedure; (11) Documentation appropriate to the type of the procedure being performed; and (12) Precepted clinical practice by a clinical preceptor that includes documented initial and annual competency of the nurse in each cosmetic procedure the nurse is to perform; B. Document evidence of clinical and psychomotor proficiency competency before independently performing each cosmetic procedure; C. Perform the procedures on a frequent routine predictable basis in order to retain practice proficiency; D. Be evaluated for continued clinical competency at periodic intervals; and E. Obtain additional education when the population changes or new procedures are introduced into the practice. #### Regulation .05 Cosmetic Procedures in General. *COMAR 10.27.25.05* A. The nurse shall comply with the employment settings written cosmetic policies and procedures that comply with this chapter. B. The nurse shall be guided by and comply with the written policies and procedures in keeping with recognized standards of care that include, but are not limited to: (1) Care and maintenance of appropriate equipment and safe operation; (2) Description of how the procedure is to be performed; (3) Education; (4) Assessment; (5) Emergency procedures; (6) Monitoring guidelines; (7) Operator and safety when utilizing equipment; (8) A continuous quality improvement process which includes, but is not limited to: (a) Unexpected outcomes; (b) Side effects; and (c) Complications; (9) Obtaining or ensuring that the client’s informed consent has been obtained that documents the patient’s awareness that it is the licensed nurse who will perform the cosmetic procedure; and (10) Documenting the performance of the cosmetic procedure including, but not limited to: (a) Patient response; (b) Patient education; and (c) Safety precautions taken on behalf of the patient. C. The nurse may perform the identified cosmetic procedure when there is a completed prescriptive order from an authorized prescriber that includes, but is not limited to: (1) The procedure to be performed; (2) Identification of the specific treatment area; (3) Identification of medication, dosage, route, and time interval for administration of the medication for the specific cosmetic procedure; (4) Identification of the light source and the radio frequency, current dosage, intensity, and time period it is to be applied; and (5) The use of any topical anesthetic. D. Before a nurse performs any of these cosmetic procedures, the authorized prescriber shall: (1) Complete an initial assessment and evaluation of the patient before the procedure is performed; (2) Develop a treatment plan for the specific patient; (3) Be physically present in the setting; and (4) Be immediately available: (a) At the time the procedure is performed; and (b) Post-treatment to evaluate the patient. E. The nurse shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .06 Cosmetic Procedures — Licensed Practical Nurse. *COMAR 10.27.25.06* Except for Category C, the LPN may perform the cosmetic procedures identified in Regulation .03 of this chapter. #### Regulation .07 Cosmetic Procedures — RN. *COMAR 10.27.25.07* The RN may perform all of the procedures identified in Regulation .03 of this chapter. #### Regulation .08 Exceptions. *COMAR 10.27.25.08* Except for cryotherapy, the nurse may perform the cosmetic procedures identified in Regulation .03 Category F independent of the requirements stated in Regulation .05D of this chapter. #### Regulation .09 Prohibited Acts. *COMAR 10.27.25.09* A. The licensed nurse may not: (1) Perform cosmetic procedures on a standing order or protocol; (2) Perform the pre-procedure medical assessment or evaluation; (3) Perform medical diagnosis or prescribe cosmetic procedures; (4) Develop the client treatment plan; (5) Prescribe medications for cosmetic or dermatological procedures; (6) Perform the post-procedure medical evaluation of the client; and (7) Administer injections for the purpose of: (a) Mesotherapy; and (b) Lipodissolve. B. The nurse may not perform: (1) Liposuction; (2) Hair transplants; (3) Invasive radiofrequency procedures; (4) Phenopeels; (5) Sculptra injections; and (6) Lipostabil or phosphatidycholine for the purpose of lipodissolve. ### Chapter 26 — Sanctioning Guidelines **Authority:** Health Occupations Article, §§1-606, 8-205(a)(1), 8-316, 8-6A-10, 8-6B-18, 8-6C-20, and 8-6D-10, Annotated Code of Maryland **Administrative History:** Effective date: April 16, 2012 (39:7 Md. R. 492) **Administrative History:** Regulation .02B amended effective September 10, 2018 (45:18 Md. R. 834) **Administrative History:** Regulation .07M amended effective September 10, 2018 (45:18 Md. R. 834) #### Regulation .01 Scope. *COMAR 10.27.26.01* A. This chapter shall be used by the Board as a guide for sanctioning licensees and certificate holders in formal and informal disciplinary proceedings. B. The Board shall take into consideration a range of activity within certain types of conduct rather than assigning particular sanctions to each specific violation. C. There may be conduct by a licensee or certificate holder that does not fall squarely within a particular category of misconduct contained in Regulation .07 of this chapter. In that event, the Board will use its discretion to determine the appropriate category and sanction. D. The Board shall make determinations that maximize the protection of the public’s health while maintaining the rights of licensees and certificate holders. #### Regulation .02 Definitions. *COMAR 10.27.26.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Board” means the Maryland State Board of Nursing. (2) “Certificate holder” means an individual who has been issued a certificate by the Board to practice as a certified nursing assistant, a certified dialysis technician, or a certified medication technician. (3) “Conditions” means any requirements in a public or nonpublic order that a licensee or certificate holder is required to satisfy, which include, but are not limited to: (a) Treatment and counseling for a psychological or physical illness, including, but not limited to substance abuse; (b) Submission to drug and alcohol testing; (c) Abstinence from specified drugs; (d) Abstinence from alcohol; (e) Remedial training; (f) Inspection of a private practice site; (g) Monitoring; (h) Evaluation; (i) Supervision; (j) Compliance with a rehabilitation agreement; (k) Testing of clinical skills; (l) Submission of written reports; (m) A demonstration of knowledge or competency; (n) Submit to a physical or mental health examination; (o) Limitation of practice; and (p) Limitation on the administration of prescription or specified drugs to clients. (4) “Conduct” means behavior or action or a failure to behave or act, which results in a violation of the Maryland Nurse Practice Act or regulations adopted by the Board. (5) “Licensee” means an individual who: (a) Has been issued a license or certification by the Board to practice as: (i) A registered nurse; (ii) A licensed practical nurse; (iii) An advanced practice registered nurse; (iv) An electrologist; (v) A licensed direct-entry midwife; or (vi) A licensed certified midwife; or (b) Has a multistate licensure privilege to practice licensed practical nursing or registered nursing under the Nurse Licensure Compact. (6) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (7) “Recklessly” means characterized by the creation of a substantial and unjustifiable risk of harm to others and by a conscious, sometimes deliberate, disregard for or indifference to that risk. (8) “Sanction” means a disciplinary action against a licensee or certificate holder, including a reprimand, probation, suspension, revocation, or a monetary penalty. #### Regulation .03 Application. *COMAR 10.27.26.03* A. This chapter is not applicable to cases in which the Board, after investigating a matter, decides to issue a public advisory letter in lieu of discipline in accordance with Health Occupations Article, §8-317(h) or 8-6B-19(h), Annotated Code of Maryland. B. This chapter is not applicable to: (1) An individual seeking an initial license or certificate; or (2) The summary suspension of a licensee or certificate holder under State Government Article, §10-226, Annotated Code of Maryland, or Health Occupations Article, §8-317(g), Annotated Code of Maryland. C. This chapter is not applicable to violations for which a mandatory sanction or penalty is set by statute or regulation. D. The severity of sanctions is ranked as follows, from least severe to most severe: (1) Reprimand; (2) Probation; (3) Suspension; and (4) Revocation. E. The addition of a monetary penalty to a sanction does not change the ranking of the severity of the sanction. F. If a monetary penalty is added to a sanction, a sanction with a higher monetary penalty is more severe than the same sanction with a lesser monetary penalty. G. When a licensee or certificate holder’s conduct results in multiple violations of the Maryland Nurse Practice Act or regulations adopted by the Board, the Board: (1) May consider sanctions that are greater than those imposed for a single violation; and (2) Has discretion to apply the category with the highest maximum sanction. H. In the event that a licensee’s or certificate holder’s violation of the Maryland Nurse Practice Act or regulations adopted by the Board does not fall within a particular category of misconduct included in Regulation .07 of this chapter, the Board shall: (1) Use its discretion to determine the appropriate sanction; and (2) Consider, to the extent possible, the sanctioning guidelines set forth in Regulation .07 of this chapter. I. In the event that the Board determines that a licensee’s or certificate holder’s violation of the Maryland Nurse Practice Act or regulations adopted by the Board falls within more than one category of misconduct established under Regulation .07 of this chapter, the Board shall, in its discretion, determine the category under which the violation shall be adjudicated. J. The period of a suspension may be stayed in whole or in part. K. Any sanction imposed by the Board in accordance with the sanctioning guidelines set forth in Regulation .07 of this chapter may be accompanied by conditions reasonably related to the violation or to the rehabilitation of the licensee or certificate holder. L. The inclusion of conditions with any sanction is within the discretion of the Board and does not factor into a determination of whether a particular sanction falls within or outside of the sanctioning guidelines set forth in Regulation .07 of this chapter, nor does it increase the severity of the sanction. M. The Board is not required to make findings of fact or to articulate its reasoning for imposing a sanction that falls within the range of sanctions set forth in Regulation .07 of this chapter. N. If the Board imposes a sanction that departs from the sanctioning guidelines set forth in Regulation .07 of this chapter, the Board shall state its reasons for doing so in its final decision and order. O. A departure from the sanctioning guidelines set forth in Regulation .07 of this chapter is not a ground for any hearing or appeal of a Board action. P. To resolve a pending disciplinary matter, the Board and licensee or certificate holder may agree to a consent order or the surrender of the license or certificate under terms and conditions agreed to by the Board and the licensee or certificate holder. #### Regulation .04 Aggravating and Mitigating Factors. *COMAR 10.27.26.04* A. Depending on the facts and circumstances of each case, and to the extent that the facts and circumstances apply, the Board may consider aggravating and mitigating factors in determining whether the sanction in a particular case should fall outside the range of sanctions established by the sanctioning guidelines set forth in Regulation .07 of this chapter. B. Aggravating factors include, but are not limited to: (1) A prior criminal or administrative discipline history; (2) Whether the violation was committed: (a) Deliberately (b) With gross negligence; or (c) Recklessly; (3) Whether the violation has the potential for, or caused, serious harm; (4) Whether the violation was a part of a pattern of unacceptable conduct; (5) Whether the licensee or certificate holder pursued their own financial gain over another individual’s welfare; (6) Whether the individual affected by the violation was vulnerable; (7) Whether the licensee or certificate holder attempted to hide the error or misconduct from clients or others; (8) Whether the licensee or certificate holder: (a) Concealed, falsified, or destroyed evidence; or (b) Presented false testimony or evidence; (9) Whether the licensee or certificate holder failed to cooperate with a lawful investigation conducted by the Board; and (10) Whether previous attempts to rehabilitate the licensee or certificate holder were unsuccessful. C. Mitigating Factors include, but are not limited to: (1) Absence of a prior disciplinary record; (2) The length of time since any prior violation; (3) Whether the licensee or certificate holder self-reported to the Board; (4) Voluntary admission of misconduct with full disclosure to the Board and cooperation with the Board’s investigation; (5) Implementation of remedial measures to correct or mitigate harm arising from the misconduct; (6) Timely good-faith efforts to make restitution or to rectify consequences of misconduct; (7) Evidence of rehabilitation or rehabilitative potential; (8) Absence of actual or potential harm; (9) Absence of adverse impact; and (10) Whether the violation was an isolated incident and not likely to recur. D. The existence of one or more aggravating or mitigating factors does not impose any requirement on the Board to make findings of fact or to articulate its reason for not exercising its discretion to impose a sanction outside of the range of sanctions set forth in Regulation .07 of this chapter. E. Nothing in this regulation requires the Board to make findings of fact with respect to the existence or nature of any aggravating or mitigating factor. #### Regulation .05 Imposition of a Monetary Penalty. *COMAR 10.27.26.05* A. Instead of or in addition to a reprimand, probation, suspension, or revocation, the Board may impose a monetary penalty in accordance with Health Occupations Article, §8-316(b), 8-6A-10(b), or 8-6B-20, Annotated Code of Maryland. B. Subject to consideration of the aggravating and mitigating factors set forth in Regulation .04 of this chapter, if the Board elects to impose a monetary penalty, the Board shall use the sanctioning guidelines set forth in Regulation .07 of this chapter to determine an appropriate monetary penalty. #### Regulation .06 Payment of a Monetary Penalty. *COMAR 10.27.26.06* A. The licensee or certificate holder shall pay any monetary penalty imposed by the Board under the provisions of this chapter: (1) By cashier’s check or money order made payable to the Board; (2) Within 60 days of the date of the order; and (3) In person or by certified mail to the Board. B. The Board shall pay all monies collected by the Board under the provisions of this chapter into the General Fund of the State. C. Filing an appeal under State Government Article, §10-222, Annotated Code of Maryland, or Health Occupations Article, §8-318, 8-6A-11, or 8-6B-21, Annotated Code of Maryland, does not automatically stay payment of a monetary penalty imposed by the Board under this chapter. D. If a licensee or certificate holder fails to pay, in whole or in part, a monetary penalty imposed by the Board under this chapter, the Board may not restore, reinstate, or renew a license or certificate until the monetary penalty has been paid in full. E. In its discretion, the Board may refer all cases of delinquent payment to the Central Collection Unit of the Department of Budget and Management to institute and maintain proceedings to ensure prompt payment. #### Regulation .07 Sanctioning Guidelines. *COMAR 10.27.26.07* Subject to the provisions of this chapter, the Board may impose sanctions for violations of the Maryland Nurse Practice Act and its regulations according to the guidelines set forth in the following categories: A. Abuse — Physical and Psychological. B. Criminal History. C. Disciplined by Another Licensing, Military, or Disciplinary Authority. D. Diversion of Controlled Substances or Prescription Drugs or Manufacture, Sale, or Distribution of any Substance for an Illegal or Illegitimate Purpose. E. Noncompliance with Board Orders. F. Practice Inconsistent with Generally Accepted Standards of Care. G. Sexual Misconduct. H. Substance Abuse. I. Unauthorized Practice. J. Unprofessional Conduct. K. Physical or Mental Incompetence. L. Fraud, Deceit, or Misrepresentation. M. Expulsion from Safe Practice Program. ### Chapter 27 — Practice of Clinical Nurse Specialist **Authority:** Health Occupations Article, §§8-205(a)(1), (2), (4), and (5) and 8-302(b)(1)(iii) and (2)(ii), Annotated Code of Maryland **Administrative History:** Effective date: October 1, 2012 (39:19 Md. R. 1236) **Administrative History:** Regulation .02D amended as an emergency provision effective September 1, 2014 (41:19 Md. R. 1074); emergency status expired effective February 27, 2015 **Administrative History:** Regulation .02C, D repealed effective April 13, 2015 (42:7 Md. R. 569) **Administrative History:** Chapter revised effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .01B amended effective November 14, 2022 (49:23 Md. R. 996) **Administrative History:** Regulation .04 amended effective November 14, 2022 (49:23 Md. R. 996) #### Regulation .01 Definitions. *COMAR 10.27.27.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Advanced practice registered nurse (APRN)” means a registered nurse who is certified by the Board as: (a) A certified nurse midwife (CNM); (b) A certified registered nurse anesthetist (CRNA); (c) A certified nurse practitioner (CRNP); or (d) A clinical nurse specialist (CNS). (2) “Board” means the Board of Nursing. (3) “Certification” means the permission to practice as a clinical nurse specialist granted by the Board to a registered nurse who: (a) Met all the specified requirements of a national certifying body recognized by the Board; and (b) Complied with the requirements of this chapter. (4) “Clinical nurse specialist” means an advanced practice registered nurse certified by the Board to practice as a clinical nurse specialist in this State. (5) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (6) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (7) “Standard of care” means the practice of clinical nurse specialist in accordance with the core competencies and behaviors specified by the National Association of Clinical Nurse Specialists (NACNS), American Nurse Credentialing Center (ANCC), American Association of Critical Care Nurses (AACN), or other national certifying body recognized by the Board. (8) “System” means the setting within which the clinical nurse specialist is practicing. #### Regulation .02 Certification. *COMAR 10.27.27.02* A. An applicant for certification as a clinical nurse specialist shall: (1) Hold a current Maryland license in good standing to practice registered nursing or a multistate licensure privilege to practice registered; (2) Have graduated from a Board-approved graduate level education program for a clinical nurse specialist at the master’s level or higher that is accredited by; (a) The National League for Nursing Accreditation Commission (NLNAC); (b) The Commission on Nursing Education (CCNE); or (c) Any other accrediting body recognized by the Board; (3) Successfully complete a national certifying exam recognized by the Board for national certification as a clinical nurse specialist in the applicant’s area of practice; (4) Hold a current national certification as a clinical nurse specialist from a national certifying body recognized by the Board; (5) Submit to the Board a completed application for certification as a clinical nurse specialist on a form required by the Board; (6) Comply with all requirements set forth in COMAR 10.27.01.04; (7) Demonstrate oral and written competency in the English language; and (8) Pay all fees. B. Beginning on October 1, 2012, as long as the applicant remains certified and in good standing, the Board shall deem that an applicant meets the qualifications to be certified as a clinical nurse specialist if the applicant has: (1) Been licensed as a registered nurse in Maryland or has a multistate privilege to practice registered nursing; (2) Obtained a master’s degree or higher in Nursing; (3) Practiced as a clinical nurse specialist; and (4) One of the following: (a) An active certification as a clinical nurse specialist from a national certification body recognized by the Board; (b) An active national certification at the highest level in the applicant’s area of practice; or (c) A national certification at the highest level in the applicant’s area of subspecialty. #### Regulation .03 Renewal of Certification. *COMAR 10.27.27.03* A. Certification as a clinical nurse specialist expires at the same time as the clinical nurse specialist’s registered nursing license. B. Before a clinical nurse specialist’s certification expires, the clinical nurse specialist may renew the certification biennially if the clinical nurse specialist: (1) Is otherwise entitled to be certified; (2) Submits to the Board: (a) A completed renewal application for clinical nurse specialists on a form that the Board requires; and (b) Documentation of current national certification as a clinical nurse specialist from a national certifying body recognized by the Board; and (3) Pays all fees. C. Clinical nurse specialists renewal applicants who are authorized to practice registered nursing in this State under a multistate licensure privilege shall be periodically required to submit to a criminal history records check in accordance with the schedule and requirements set forth in COMAR 10.27.01.13J — N. D. The clinical nurse specialist shall ensure that the Board has a record of the renewed national certification if the national certification expires before the registered nurse license renewal date. E. Certification as a clinical nurse specialist shall be deemed to have lapsed if the Board does not have a record of a current active national certification. F. Practicing on an expired national certification is prohibited and is subject to discipline under Health Occupations Article, §8-316(a), Annotated Code of Maryland. #### Regulation .04 Scope and Standards of Practice. *COMAR 10.27.27.04* A. The unique role of the clinical nurse specialist is to: (1) Integrate care across the continuum and through three spheres of impact: (a) The patient; (b) The nurse; and (c) The system; and (2) Ranges from: (a) Wellness to illness; and (b) Acute to chronic care. B. The clinical nurse specialist provides direct care to patients with complex needs, acts as a consultant, conducts research, and provides education and guidance for staff nurses. C. The practice of the clinical nurse specialist encompasses the continuous improvement of patient outcomes and nursing care. D. The clinical nurse specialist shall adhere to standards of clinical practice, scope of practice, and the standards of professional performance in accordance with this chapter. E. The scope of practice of the clinical nurse specialist includes, but is not limited to: (1) Practicing with individual clients, families, groups, and populations of clients; (2) Performing a comprehensive physical assessment of patients; (3) Establishing medical diagnosis for common short-term and chronic stable health problems; (4) Diagnosing, treating, and managing patients with acute and chronic illness or disease, or both; (5) Ordering, performing, and interpreting laboratory tests; (6) Ordering diagnostic tests and using the findings or results in the care of patients (7) Initiating, monitoring, and altering appropriate therapies or treatments; (8) Providing primary health care, including health promotion and disease prevention by assessing, educating, and providing referrals for the patient, family, and caregiver; (9) Providing emergency care; (10) Referring patients to appropriate licensed physicians or other health care providers as needed; (11) Consulting or collaborating with a licensed physician or other health care provider as needed; and (12) Creating therapeutic environments through mentoring and system changes to: (a) Develop caring, evidence-based practices; (b) Facilitate ethical decision making; (c) Respond to diversity; and (d) Alleviate patient distress. #### Regulation .05 Practice Before Certification. *COMAR 10.27.27.05* A. A registered nurse who has completed the education requirements for the advanced practice of a clinical nurse specialist and has registered for a national certifying exam recognized by the Board may practice in this State as a clinical nurse specialist graduate if the registered nurse has: (1) A current license to practice registered nursing in this State or holds a multistate licensure privilege to practice registered nursing; (2) Submitted a completed application for certification as a clinical nurse specialist graduate; and (3) Submitted satisfactory evidence that the applicant has applied to take a national certifying exam recognized by the Board and has been accepted as a candidate for the exam. B. A clinical nurse specialist graduate shall practice under the direct supervision of a certified clinical nurse specialist. C. A clinical nurse specialist graduate shall cease practice immediately if the clinical nurse specialist graduate fails the required national certification exam as required in Regulation .02A(3) of this chapter. D. A clinical nurse specialist graduate who fails the national certification exam may continue to work as a registered nurse until the clinical nurse specialist graduate passes a national certifying exam for clinical nurse specialist. #### Regulation .06 Unlawful Practices. *COMAR 10.27.27.06* A. Unless authorized to practice under this chapter, an individual may not use the following words or abbreviations: (1) Certified clinical nurse specialist; (2) Clinical nurse specialist (CNS); (3) Clinical Registered Nurse Specialist (CRNS); (4) Clinical nurse specialist graduate; or (5) Nurse specialist graduate. B. An individual certified under this chapter shall be subject to disciplinary prohibitions and sanctions set forth under Health Occupations Article, §§8-316 and 8-701 — 8-703, Annotated Code of Maryland. ### Chapter 28 — Delegation of Acts by an Advanced Practice Registered Nurse **Authority:** Health Occupations Article, §§8-205 and 8-6A-02, Annotated Code of Maryland **Administrative History:** Effective date: **Administrative History:** Regulations .01 — .06 adopted as an emergency provision effective August 26, 2025 (52:20 Md. R. 999); adopted permanently effective October 27, 2025 (52:21 Md. R. 1024) #### Regulation .01 Scope. *COMAR 10.27.28.01* A. This chapter governs the delegation of nursing or other technical tasks by an advanced practice registered nurse to an assistant not otherwise authorized under Health Occupations Article, Annotated Code of Maryland. B. This chapter may not be construed: (1) As establishing the licensure, certification, or registration of assistants by the Board; (2) To apply to an individual who is licensed, certified, or registered by a health occupations regulatory board, or health occupation students, acting pursuant to Health Occupations Article, Annotated Code of Maryland; and (3) To mean that this chapter overrides, or is to be used in lieu of, more stringent regulations, policies, and procedures established by State licensure or certification requirements. #### Regulation .02 Definitions. *COMAR 10.27.28.02* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Advanced practice registered nurse (APRN)” has the meaning stated in Health Occupations Article, §8-101, Annotated Code of Maryland. (2) “Assistant” means an individual: (a) To whom only routine nursing and technical tasks are delegated by an advanced practice registered nurse; (b) Who is trained as defined in §B(12) of this regulation; and (c) Who is not licensed, certified, registered, or otherwise authorized by law by the Board, or any other State health occupations board, to practice any health occupation in the State. (3) “Asynchronous telehealth interaction” has the meaning stated in Health Occupations Article, §1-1001, Annotated Code of Maryland. (4) “Board” means the Maryland Board of Nursing. (5) “Delegating APRN” means an advanced practice registered nurse who directs an assistant to perform nursing and technical tasks. (6) “Direct supervision” means oversight exercised by a delegating APRN who is: (a) Personally treating the patient; and (b) In the physical presence of the patient and the assistant. (7) Mechanical Act. (a) “Mechanical act” means an act which does not require professional judgment, medical or pharmaceutical training, or discretion. (b) “Mechanical act” does not include: (i) Selecting a drug; (ii) Labeling; (iii) Measuring or calculating dosages; (iv) Substituting one drug for another, including substituting a generic or brand drug for the prescribed drug; (v) Substituting one dosage form of a drug for another; (vi) Altering the route of administration; or (vii) Counseling patients. (8) “On-site supervision” means oversight exercised by a delegating APRN who is present at the same site as the assistant and the patient and is: (a) Able to be immediately available in person during the assistant’s performance of a delegated act; (b) In the context of a synchronous telehealth interaction, able to be immediately available via secure telecommunications technology to the telehealth visit during the assistant’s performance of a delegated act; or (c) In the context of an asynchronous telehealth interaction, able to review the assistant’s work and interact with the assistant before communication with the patient. (9) “Site” means any facility or location, including those defined in Health-General Article, §§19-114 and 19-3B-01(b), Annotated Code of Maryland, used for the delivery of health care services. (10) “Synchronous telehealth interaction” has meaning stated in Health Occupations Article, §1-1001, Annotated Code of Maryland. (11) “Technical task” means a routine clinical act or task that does not require clinical or nursing judgment and is performed with supervision as specified within this chapter. (12) “Trained” means possessing the knowledge, skills, and abilities, as determined by the delegating APRN, to perform delegated nursing and technical tasks. #### Regulation .03 Standards for Delegation. *COMAR 10.27.28.03* A. An APRN who delegates shall: (1) Assess the risk to the patient and the outcome of the delegated acts; (2) Delegate only those nursing and technical tasks that are customary to the practice of an APRN; (3) Delegate only those nursing and technical tasks for which the assistant has been trained; (4) Be responsible for the acts of the assistant; (5) Supervise the assistant in accordance with this chapter; and (6) If authorized to dispense prescription medication under Health Occupations Article, Title 8, Annotated Code of Maryland, perform a final check of the prescription medication before it is provided to the patient. B. The responsibility for the delegated act cannot be transferred from the delegating APRN to another APRN, or to another licensed health care provider that is authorized to delegate clinical and technical tasks, without: (1) The expressed consent of the other APRN or licensed health care provider; and (2) Informing the assistant. #### Regulation .04 Scope of Delegation to an Assistant. *COMAR 10.27.28.04* A. An APRN may not delegate nursing and technical tasks to an assistant which shall, by law or regulation, be performed only by an individual that is required to be licensed, certified, registered, or otherwise recognized pursuant to any State laws. B. An APRN may delegate nursing and technical tasks, consistent with national guidelines for nursing delegation established by the National Council of State Boards of Nursing and the approved policies and procedures of the site, in the following categories: (1) Surgical technical tasks that the delegating APRN directly orders while present and personally performing the surgery in the same surgical field; and (2) Nonsurgical technical tasks while the assistant is under the delegating APRN’s direct supervision or on-site supervision. C. Except as provided in §§B(1) and D of this regulation, an APRN shall provide at minimum on-site supervision when delegating nursing or technical tasks to an assistant, including, but not limited to, the following: (1) Patient preparation for physical examination; (2) Patient history interview; (3) Collecting and processing specimens, such as performing phlebotomy, inoculating culture media, pregnancy tests; dipstick and microscopic urinalysis, and microbiology including rapid streptococcal testing and throat cultures; (4) Preparing and performing laboratory tests that the APRN is satisfied the assistant is trained and qualified to perform under State and Clinical Laboratory Improvement Amendments regulations; (5) Clinical tests including, but not limited to: (a) Application of tuberculin skin tests; (b) Electrocardiography; (c) Administering basic pulmonary function tests; and (d) Visual field tests; (6) Transmitting prescriptions to a pharmacy; (7) Preparing and administering oral drugs; (8) Preparing and administering injections limited to intradermal, subcutaneous, and intramuscular within the deltoid, gluteal, or vastus lateralis muscles including small amounts of local anesthetics; (9) Establishing a peripheral intravenous line; and (10) Injecting fluorescein-like dyes for retinal angiography. D. When delegating injecting intravenous drugs or contrast materials to an assistant, an APRN shall provide direct supervision. E. An APRN who is authorized to dispense prescription medication under Health Occupations Article, Title 8, Annotated Code of Maryland may delegate only mechanical acts involved in dispensing a drug. F. An APRN may not delegate to an assistant any act that requires the exercise of clinical judgment by an APRN, including, but not limited to: (1) Conducting physical examinations; (2) Administering any form of anesthetic agent or agent of conscious sedation other than topical anesthetics or small amounts of local anesthetics; (3) Initiating independently any form of treatment, except for cardiopulmonary resuscitation or other forms of emergency treatment authorized to be performed by non-clinicians under State law; (4) Establishing a diagnosis or giving clinical advice; and (5) Providing physical therapy. #### Regulation .05 Prohibited Conduct and Penalties. *COMAR 10.27.28.05* A. An assistant acting beyond the scope of this chapter may be: (1) Considered to be engaged in the unlicensed practice of nursing, advanced practice registered nursing, or any other health occupation recognized by the State; and (2) Subject to all applicable fines and penalties in accordance with Health Occupations Article, §§8-701—8-711, Annotated Code of Maryland and applicable regulations, or any other applicable provision of Health Occupations Article, Annotated Code of Maryland. B. A delegating APRN, through either act or omission, facilitation, or otherwise enabling or forcing an assistant to practice beyond the scope of this chapter, may be subject to discipline as set forth in Health Occupations Article, §8-316, Annotated Code of Maryland. C. A delegating APRN may not: (1) Require an assistant to perform a delegated nursing or technical task; or (2) Permit an assistant to delegate any act to another individual. #### Regulation .06 Enforcement. *COMAR 10.27.28.06* The Board shall conduct any necessary investigation regarding the failure to comply with the requirements of Health Occupations Article, Title 8, Annotated Code of Maryland and this chapter, and it may refer any complaint or investigation to any other appropriate licensing or regulatory authority in accordance with applicable laws and regulations.