This chapter governs the practice of athletic training including “dry needling” within the practice of athletic training. This chapter does not prohibit an athletic training student who is enrolled in an accredited athletic training educational program from performing without pay any of the procedures described in this chapter as part of that program’s athletic training clinical curriculum. This chapter does not prohibit an individual from practicing a health occupation that the individual is authorized to practice under Health Occupations Article, Annotated Code of Maryland. This chapter does not prohibit an individual employed by the federal government as an athletic trainer from practicing within the scope of that employment. This chapter does not apply to an individual employed by or under contract with an entity located in another state who represents that entity: At an athletic event in Maryland; For a period not exceeding 45 days within a calendar year; and By providing athletic training services to individuals representing the entity at the event. In this chapter, the following terms have the meanings indicated. Terms Defined. “Accredited athletic training educational program” means an athletic training educational program that: Awards either a bachelor’s or master’s degree in athletic training; and Is accredited by the Commission on Accreditation of Athletic Training Education or its successor. “Alternate supervising physician” means one or more physicians designated by the supervising physician to provide supervision of an athletic trainer: During the absence of the supervising physician; and In accordance with the evaluation and treatment protocol on file with the Board. “Athlete” means an individual who participates in an athletic activity. “Athletic activity” means an exercise, recreation, sport, competition, or game that: Requires physical strength, range of motion, flexibility, control, speed, stamina, or agility; and Is associated with a setting as defined under this section, an educational institution or a professional, amateur, or recreational sports club or athletic organization. “Athletic injury” means an injury that affects an athlete’s participation or performance in an athletic activity. “Board” means the State Board of Physicians. “Certifying board” means the Board of Certification, Inc., or its successor. “Committee” means the Athletic Trainer Advisory Committee of the Board. “Dry needling” means an intramuscular therapy that: Involves the insertion of one or more solid needles into the muscle and related tissues to effect change in the muscle and related tissues; Requires ongoing evaluation, assessment, and reevaluation of an impairment; Is used only in parts of the body with neuromuscular or musculoskeletal links to an impairment; and Is not performed for: The purpose of acupuncture as defined in Health Occupations Article, §1A-101, Annotated Code of Maryland; or Any purpose outside of the scope of practice of athletic trainers. “Evaluation and treatment protocol” means a document that is executed by a physician and an athletic trainer that meets the requirements in Regulation .06 of this chapter. “Immediately available instruction” means instruction provided by the supervising physician to the athletic trainer in person, by telephone, or by other electronic means. “Licensed athletic trainer” means an individual licensed by the Board to practice athletic training. “Licensed health care practitioner” means an individual licensed, certified, or otherwise authorized to practice a health occupation under Health Occupations Article, Annotated Code of Maryland. “Nonsupervising physician” means a physician licensed by the Board who is not the supervising physician of the athletic trainer. “Outside referral” means a request for treatment from a nonsupervising physician or licensed health care practitioner. “Physician” means an individual licensed to practice medicine in Maryland under Health Occupations Article, Title 14, Annotated Code of Maryland. Practice Athletic Training. “Practice athletic training” means application of the following principles and methods for managing athletic injuries for athletes in good overall health under the supervision of a licensed physician: Prevention; Clinical evaluation and assessment; Immediate care; and Treatment, rehabilitation, and reconditioning. “Practice athletic training” includes: Organization and administration of an athletic training program; and Instruction to coaches, athletes, parents, medical personnel, and community members regarding the care and prevention of athletic injuries. “Practice athletic training” does not include any of the following: The practice of chiropractic, including adjustments, manipulation, or high-velocity mobilizations of the spine or extremities; The practice of massage therapy; The practice of medicine; The practice of occupational therapy; The practice of physical therapy; The practice of podiatry; The reconditioning of systemic neurologic injuries, conditions, or disease; or Except for the conditioning of an athlete under the supervision of a treating physician, the treatment, rehabilitation, or reconditioning of nonathletic injuries or disease. “Setting” means a: Location where an athletic activity, as defined in §B(4) of this regulation, is being held; Health or fitness club; Clinic or hospital; Corporation; or Government agency. “Supervising physician” means a physician who has been approved by the Board to supervise one or more athletic trainers. “Supervision” means the responsibility of a physician to provide ongoing and immediately available instruction, in person, by telephone, or by other electronic means, that is adequate to ensure the safety and welfare of a patient and is appropriate to the setting. “Supervision mechanism” means continuous availability to the athletic trainer of a supervising physician by one or more of the following means: On-site supervision; Written instructions; Electronic means; Verbal orders; and Designation of an alternate supervising physician. Therapeutic Modalities. “Therapeutic modalities” means a variety of physical agents used to treat athletic injuries in an effort to decrease pain, reduce inflammation, decrease swelling, decrease muscle spasm, and provide a proper environment for the healing process to take place. “Therapeutic modalities” does not include the use of a prescription or nonprescription drug. The Board shall establish a committee composed of the following individuals: Three licensed physicians meeting the following criteria: At least one physician shall be a specialist in orthopedic or sports medicine; and At least two of the physicians shall currently be or in the past have been partnered with or directed an athletic trainer; Three athletic trainers who meet the following criteria: Have at least 5 years of clinical experience as an athletic trainer; If appointed or serving before October 1, 2011, be certified by the certifying board; and If appointed or serving on or after October 1, 2011, be licensed as an athletic trainer; One licensed chiropractor with sports medicine experience; One licensed physical therapist; One licensed occupational therapist; and Two consumers meeting the criteria specified in Health Occupations Article, §14-5D-05(c), Annotated Code of Maryland. Selection of Athletic Trainers. The Board may appoint the athletic trainer members from a list of qualified individuals submitted to the Board by the Maryland Athletic Trainers Association, Inc. Tenure. The term of a member is 3 years. The terms of the members are staggered. At the end of a term, a member continues to serve until a successor is appointed. An individual may be reappointed for a second term, but the individual may not serve more than two full, consecutive terms. Vacancy. If a vacancy occurs, the Board shall appoint a new member to serve, as provided in this chapter. The successor member shall serve only for the remainder of the term, unless reappointed. Chair. The Committee shall elect a chair from among its members. The chair shall serve for 2 years. The Committee shall: Make recommendations to the Board regarding: Regulations governing athletic trainers; Continuing education requirements for license renewal; and The practice of athletic training; Develop and recommend to the Board an evaluation and treatment protocol for use by an athletic trainer and the physician with whom the athletic trainer practices; Upon request of the Board, provide advice and recommendations to the Board on individual evaluation and treatment protocols; and Keep a record of the Committee’s proceedings. An applicant for licensure as an athletic trainer shall: Complete an application on a form supplied by the Board; Pay an application fee as specified in Regulation .08 of this chapter; and Submit all documentation which the Board requires to evaluate the application. To qualify, an applicant shall meet all of the following requirements: Be 18 years old or older; Be of good moral character; Demonstrate oral and written competency in English by any of the following: Graduation from a recognized English-speaking high school or undergraduate school after at least 3 years of enrollment; Graduation from a recognized English-speaking professional school with acceptable proof of proficiency in the oral and written communication of English; or Receiving a grade of: At least 26 on the “Speaking Section” of the Internet-based Test of English as a Foreign Language; and At least 79 on the Internet-based Test of English as a Foreign Language; Meet the following education requirements: A bachelor’s or master’s degree from an accredited athletic training educational program; or Exemption from the education requirement because the applicant: Was certified by the certifying board on or before October 1, 2012; and Is in good standing with the certifying board at the time of the application; Has passed the certification examination of the certifying board; and Has been certified and maintains current certification from the certifying board at the time of application. The scope of practice of an athletic trainer in the domain of injury prevention and wellness protection includes the following: Minimization of risk of injury of athletes through awareness and education; Monitoring of environmental conditions to facilitate individual and group safety of athletes; Maintenance or enhancement of physical conditioning of athletes; and Promotion of a healthy lifestyle of athletes using appropriate education and communication strategies to enhance wellness and minimize the risk of injury and illness. The scope of practice of an athletic trainer in the domain of clinical evaluation and assessment includes the following with respect to athletes: Obtaining athlete’s health history through observation, interview, and records review; Examining athlete’s body to assess the type and extent of the athletic injury; Formulating a clinical assessment; and Communicating information about the athletic injury to appropriate persons including the athlete. The scope of practice of an athletic trainer in the domain of immediate and emergency care includes the following with respect to athletes: Immediate and emergency procedures including: CPR; Applying ice; Splinting; Elevation; Pressure; Bandaging for bleeding; Proper immobilization of spine or other body parts; and Dry needling; and Making appropriate referrals so that the athlete will obtain appropriate follow-up. The scope of practice of an athletic trainer in the domain of treatment and rehabilitation includes the following activities, performed in an approved setting, with respect to athletes with athletic injuries: Administering therapeutic and conditioning exercises as identified by the evaluation and treatment protocols of the supervising physician; Administering therapeutic modalities as identified by the evaluation and treatment protocols of the supervising physician; Applying braces, splints, or other assistive devices as identified by the evaluation and treatment protocols of the supervising physician; Reassessing the status of injuries, illnesses, or conditions using appropriate techniques and documentation strategies to: Determine appropriate treatment, rehabilitation, or reconditioning for injuries; and Evaluate readiness to return to desired level of activity with respect to injuries, illnesses, or conditions; and Administering dry needling therapy under the direction and guidance of a supervising physician who has training and experience in dry needling. The scope of practice of an athletic trainer in the domain of organization and management includes the following activities: Maintenance of medical records with respect to all athletes who receive emergency care, assessment, or treatment; Planning and organization of an athletic training program; and Instructing others in prevention of and care for athletic injuries. The athletic trainer may accept an outside referral from a nonsupervising physician or licensed health care practitioner if: The supervising physician specifies in the evaluation and treatment protocol that the athletic trainer may accept referrals from nonsupervising physicians or other licensed health care practitioners; The nonsupervising physician or licensed health care practitioner has seen the athlete and has written an order for the care; and The duties are: Within the scope of practice of an athletic trainer; and Among the duties delegated in the evaluation and treatment protocol. Contents. The evaluation and treatment protocol shall include the following: Identification, licensure information, and signature of the: Licensed athletic trainer; and Licensed supervising physician; Information about where the athletic trainer practices, including: Addresses of the primary employer and supervising physician; and Identification of the settings where the athletic trainer may practice; Description of the supervision mechanism that applies to each setting; Description of the delegated processes and procedures that the athletic trainer may use in each of the following areas: Injury or illness prevention and wellness; Clinical evaluation and assessment; Immediate and emergency care; Treatment, rehabilitation, and reconditioning; and Organizational and professional well-being; Descriptions of tasks which the athletic trainer may not perform; Description of specialized tasks the supervising physician is delegating to the athletic trainer to perform with documentation of competencies, certification, credentials, or any other requirements established by the Board to support the delegation of the specialized tasks; A statement of whether or not the supervising physician will permit the athletic trainer to accept outside referrals meeting the requirements stated in Regulation .05F of this chapter; If applicable, the name and other relevant information about an alternate supervising physician; and An attestation that states that the supervising physician will be responsible for providing ongoing and immediately available instruction that is adequate to ensure the safety and welfare of a patient and is appropriate to the setting. Process and Approval. A licensed athletic trainer shall: Submit an evaluation and treatment protocol on a form approved by the Board; and Pay the fee as specified in Regulation .08 of this chapter. A licensed athletic trainer may practice athletic training after receiving written approval from the Committee. The Committee shall conditionally approve an evaluation and treatment protocol if: The evaluation and treatment protocol does not include specialized tasks; or The evaluation and treatment protocol includes specialized tasks that have been previously approved by the Board. If an evaluation and treatment protocol includes a specialized task that has not been previously approved by the Board, the athletic trainer may perform the specialized task only after receiving written approval from the Board. After consideration by the Committee, the Board shall either: Approve the evaluation and treatment protocol and any specialized tasks; or Disapprove the evaluation and treatment protocol or a specialized task if the Board determines that the evaluation and treatment protocol or specialized task does not meet the requirements in Health Occupations Article, §14-5D-11.3(b), Annotated Code of Maryland. If the Board disapproves an evaluation and treatment protocol or a specialized task included in an evaluation and treatment protocol, the Board shall send written notice of the disapproval to the: Primary supervising physician; and Athletic trainer. An athletic trainer who receives notice of a disapproval of an evaluation and treatment protocol from the Board shall immediately cease: Practicing under the evaluation and treatment protocol; or Performing the specialized task. An individual member of the Board is not civilly liable for any act or omission relating to the approval, modification, or disapproval of an evaluation and treatment protocol. Termination of Evaluation and Treatment Protocol. If the athletic trainer or the supervising physician terminates the evaluation and treatment protocol, the athletic trainer shall cease practicing until another evaluation and treatment protocol is approved by the Board. The supervising physician shall report the termination of an evaluation and treatment protocol for any reason to the Board within 10 days of the termination and provide the following information: Name and license number of supervising physician and athletic trainer; and Reason for termination, including a description of conduct or incident that resulted in the termination. Emergency Evaluation and Treatment Protocol. In the event of a sudden departure, incapacity, or death of a supervising physician, a designated alternate may assume the role of the supervising physician by submitting a new evaluation and treatment protocol to the Board within 15 days. Dry Needling Protocol. The practice of dry needling by a licensed athletic trainer shall require approval from the Board as a specialized task. The Board shall issue approval to perform dry needling to a licensed athletic trainer who provides proof of completion of at least 80 hours of instruction in a continuing education course approved by: The National Athletic Trainers’ Association; The Board of Certification for the Athletic Trainer; or The United States Armed Forces. Course Requirements. Of the 80 hours of instruction required under §E(2) of this regulation, at least 40 hours of instruction shall be in the following content areas: Theory and application of dry needling; Dry needling technique, including spine and extremities; Dry needling indications and contraindications; Infection control, the Occupational Safety and Health Administration’s Bloodborne Pathogen Protocol, and safe handling of needles; Emergency preparedness and response procedures related to complications associated with dry needling; and Appropriate documentation of dry needling. Of the 80 hours of instruction required under §E(2) of this regulation, at least 40 hours shall be practical, hands-on instruction in the application and technique of dry needling that is completed under the guidance of a licensed health care practitioner who: Is approved to perform dry needling; and Has practiced dry needling for at least 5 years. The instruction required under §E of this regulation shall include an assessment of the licensed athletic trainer’s competency to perform dry needling that is performed by the instructor of the approved course. Renewal. The Board may not renew a license until the Comptroller of Maryland has verified that the individual has paid all undisputed taxes and unemployment insurance contributions, or arranged for repayment, as required by COMAR 10.31.02. An individual who has been licensed by the Board as an athletic trainer may renew the license every 2 years on the date specified by the Board by: Completing a renewal application on a form supplied by the Board; Paying the required renewal fee specified in Regulation .08 of this chapter; Attesting to the completion of at least 50 hours of approved continuing education credits, earned during the 2-year period preceding the expiration of the license for athletic training, in accordance with the requirements specified in §C of this regulation; and Meeting any other requirement established by the Board. The continuing education requirement applies to all renewal applications after the first renewal. Reinstatement. The Board shall reinstate the license of an athletic trainer if the athletic trainer: Completes a reinstatement application on a form supplied by the Board; Pays the required reinstatement fee and any other fees specified in Regulation .08 of this chapter; Documents evidence of at least 50 hours of approved continuing education credits during the 2-year period preceding the date of the submission of the application for reinstatement; Meets any additional requirements set by the Board for reinstatement of a license; and Is currently registered with the certifying board. Continuing Education. The following activities are approved continuing education experiences: Programs presented by providers approved by the certifying board; Professional development activities approved by the certifying board; and Courses offered for undergraduate or graduate degree credit by colleges or universities. Documentation. An athletic trainer shall obtain documentation of completion of continuing education and retain the documentation for 4 years. The documentation for a program provided by a provider approved by the certifying board shall contain, at a minimum, the following information: Program title; Sponsor’s name; Athletic trainer’s name; Inclusive date or dates and location of the program; Number of continuing education hours earned; and Documented verification that the athletic trainer attended the program by stamp, signature, printout, or other official proof. Documentation for professional development activities shall be as specified by the certifying board. Documentation of credits earned through college or university courses shall be an official transcript from the college or university. Proof of maintenance of certification by the certifying board may be used to document compliance with the continuing education requirement. Change in Name or Address. A licensee shall notify the Board in writing of a change in name or address within 60 days after the change. Licensees who fail to notify the Board of name or address changes as required by §D(1) of this regulation are subject to an administrative penalty of $100. The following fees are applicable to athletic trainers. Initial licensure fee — $200; License renewal fees: License renewal fee — $135; and Maryland Health Care Commission (MHCC) fee — as determined by MHCC under COMAR 10.25.03; Reinstatement fee — $200; Evaluation and treatment protocol — $100; Written verification fee — $25; and Replacement of license fee — $25. Subject to the hearing provisions of Health Occupations Article, §14-405, Annotated Code of Maryland, the Board may deny a license to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the applicant or licensee: Fraudulently or deceptively obtains or attempts to obtain a license for the applicant, for the licensee, or for another; Fraudulently or deceptively uses a license; Is guilty of unprofessional or immoral conduct in the practice of athletic training; Is professionally, physically, or mentally incompetent; Abandons a patient; Habitually is intoxicated; Is addicted to, or habitually abuses, any narcotic or controlled dangerous substance as defined in Criminal Law Article, §5-101, Annotated Code of Maryland; Provides professional services while: Under the influence of alcohol; or Using: Any narcotic or controlled dangerous substance as defined in Criminal Law Article, §5-101, Annotated Code of Maryland; or Any other drug that is in excess of therapeutic amounts or without valid medical indication; Promotes the sale of services, drugs, devices, appliances, or goods to a patient so as to exploit the patient for financial gain; Willfully makes or files a false report or record in the practice of athletic training; Willfully fails to file or record any report as required under law, willfully impedes or obstructs the filing or recording of the report, or induces another to fail to file or record the report; Breaches patient confidentiality; Pays or agrees to pay any sum or provide any form of remuneration or material benefit to any for bringing or referring a patient or accepts or agrees to accept any sum or any form of remuneration or material benefit from an individual for bringing or referring a patient; Knowingly makes a misrepresentation while practicing athletic training; Knowingly practices athletic training with an unauthorized individual or aids an unauthorized individual in the practice of athletic trainer services; Offers, undertakes, or agrees to cure or treat disease by a secret method, treatment, or medicine; Is disciplined by a licensing, certifying, or disciplinary authority or is convicted or disciplined by a court of any state or country or is disciplined by any branch of the United States uniformed services or the Veterans Administration for an act that would be grounds for disciplinary action under Health Occupations Article, §15-5D-14, Annotated Code of Maryland; Fails to meet appropriate standards for delivery of athletic training services; Knowingly submits false statements to collect fees for which services have not been provided; Has been subject to investigation or disciplinary action by a licensing or disciplinary authority or by a court of any state or country for an act that would be grounds for disciplinary action under the Board’s disciplinary statutes and the licensed individual: Surrendered the license issued by the state or country; or Allowed the license issued by the state or country to expire or lapse; Knowingly fails to report suspected child abuse in violation of Family Law Article, §5-704, Annotated Code of Maryland; Sells, prescribes, gives away, or administers drugs for illegal or illegitimate medical purposes; Practices or attempts to practice beyond the authorized scope of practice; Refuses, withholds from, denies, or discriminates against an individual with regard to the provision of professional services for which the licensee is licensed and qualified to render because the individual is HIV positive; Practices or attempts to practice an athletic training procedure or uses or attempts to use athletic training equipment if the applicant or licensee has not received education and training in the performance of the procedure or the use of the equipment; Fails to cooperate with a lawful investigation conducted by the Board; Fails to practice under the supervision of a physician or violates the approved evaluation and treatment protocol; Violates an order of the Board, including any condition of probation; or Performs dry needling without the approval of the Board issued under Regulation .06E of this chapter. Crimes of Moral Turpitude. On the filing of certified docket entries with the Board by the Office of the Attorney General, the Board shall order the suspension of a license if the licensee is convicted of or pleads guilty or nolo contendere with respect to a crime involving moral turpitude, whether or not any appeal or other proceeding is pending to have the conviction or plea set aside. After completion of the appellate process, if the conviction has not been reversed or the plea has not been set aside with respect to a crime involving moral turpitude, the Board shall order the revocation of a license on the certification by the Office of the Attorney General. Complaints alleging prohibited conduct shall be referred to the Board to be investigated according to the Board’s procedures. A hearing on charges issued under Regulation .09A of this chapter or Health Occupations Article, §14-5D-14(a), Annotated Code of Maryland, shall be held in accordance with the hearing provisions of Health Occupations Article, §§14-405 and 14-5D-15, Annotated Code of Maryland. Proceedings for crimes of moral turpitude, under Health Occupations Article, §14-5D-14(b), Annotated Code of Maryland, or Regulation .09B of this chapter shall be held in accordance with COMAR 10.32.02.08. All other hearings shall be held in accordance with the Administrative Procedure Act. Appeals from a final Board decision shall be taken in accordance with Health Occupations Article, §14-5D-15, Annotated Code of Maryland. An individual who violates any provision of Health Occupations Article, Title 14, Subtitle 5D, Annotated Code of Maryland, is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000, or imprisonment not exceeding 1 year, or both. The Board may impose a civil fine of not more than $5,000 on an individual who violates any provision of Health Occupations Article, Title 14, Subtitle 5D, Annotated Code of Maryland. The Board shall deposit a penalty collected under §B of this regulation into the Board of Physicians fund. General Application of Sanctioning Guidelines. Sections D and E of this regulation and Regulation .12 of this chapter do not apply to offenses for which a mandatory sanction is set by statute or regulation. Except as provided in §E of this regulation, for violations of the sections of the Maryland Athletic Trainers Act listed in the sanctioning guidelines, the Board shall impose a sanction not less severe than the minimum listed in the sanctioning guidelines nor more severe than the maximum listed in the sanctioning guidelines for each offense. Ranking of Sanctions. For the purposes of this regulation, the severity of sanctions is ranked as follows, from the least severe to the most severe: Reprimand; Probation; Suspension; and Revocation. A stayed suspension in which the stay is conditioned on the completion of certain requirements is ranked as probation. A stayed suspension not meeting the criteria for §D(3)(b) of this regulation is ranked as a reprimand. A fine listed in the sanctioning guidelines may be imposed in addition to but not as a substitute for a sanction. The addition of a fine does not change the ranking of the severity of the sanction. The Board may impose more than one sanction, provided that the most severe sanction neither exceeds the maximum nor is less than the minimum sanction permitted in the chart. Any sanction may be accompanied by conditions reasonably related to the offense or to the rehabilitation of the offender. The inclusion of conditions does not change the ranking of the sanction. If a licensee has violated more than one ground for discipline as set out in the sanctioning guidelines: The sanction with the highest severity ranking should be used to determine which ground will be used in developing a sanction; and The Board may impose concurrent sanctions based on other grounds violated. Notwithstanding the sanctioning guidelines set forth in Regulation .12 of this chapter, in order to resolve a pending disciplinary action, the Board and the licensee may agree to a surrender of license or a consent order with terms, sanction, and fine agreed to by the Board, the administrative prosecutor, and the licensee. Depending on the facts and circumstances of each case, and to the extent that the facts and circumstances apply, the Board may consider the aggravating and mitigating factors set out in §E(4) and (5) of this regulation and may in its discretion determine, based on those factors, that an exception should be made and that the sanction in a particular case should fall outside the range of sanctions listed in the sanctioning guidelines. If the Board imposes a sanction that departs from the sanctioning guidelines as set forth in Regulation .12 of this chapter, the Board shall state its reasons for doing so in its final decision and order. Aggravating and Mitigating Factors. Depending on the facts and circumstances of each case, and to the extent that the facts and circumstances apply, the Board may consider the aggravating and mitigating factors set out in §E(4) and (5) of this regulation and may in its discretion determine, based on those factors, that an exception should be made and that the sanction in a particular case should fall outside the range of sanctions listed in the sanctioning guidelines. Nothing in this regulation requires the Board or an Administrative Law Judge to make findings of fact with respect to any of these factors. The existence of one or more of these factors does not impose on the Board or an Administrative Law Judge any requirement to articulate its reasoning for not exercising its discretion to impose a sanction outside of the range of sanctions set out in the sanctioning guidelines. Mitigating factors may include, but are not limited to, the following: The absence of a prior disciplinary record; The offender self-reported the incident; The offender voluntarily admitted the misconduct, made full disclosure to the Board and was cooperative during the Board proceedings; The offender implemented remedial measures to correct or mitigate the harm arising from the misconduct; The offender made good faith efforts to make restitution or to rectify the consequences of the misconduct; The offender has been rehabilitated or exhibits rehabilitative potential; The misconduct was not premeditated; There was no potential harm to patients or the public or other adverse impact; or The incident was isolated and is not likely to recur. Aggravating factors may include, but are not limited to, the following: The offender has a previous criminal or administrative disciplinary history; The offense was committed deliberately or with gross negligence or recklessness; The offense had the potential for or actually did cause patient harm; The offense was part of a pattern of detrimental conduct; The offender committed a combination of factually discrete offenses adjudicated in a single action; The offender pursued his or her financial gain over the patient’s welfare; The patient was especially vulnerable; The offender attempted to hide the error or misconduct from patients or others; The offender concealed, falsified or destroyed evidence or presented false testimony or evidence; The offender did not cooperate with the investigation; or Previous attempts to rehabilitate the offender were unsuccessful. A departure from the sanctioning guidelines set forth in Regulation .12 of this chapter is not a ground for any hearing or appeal of a Board action. Offenses Related to Continuing Medical Education Credits. First Offense of Failure to Document Credits. Except as provided in §F(2) or (3) of this regulation, if a licensee has submitted an application claiming the completion of continuing medical education credits and the licensee fails to document the completion of such continuing medical education credits when audited by the Board, the Board may impose a civil fine under Health Occupations Article, §14-5D-12, Annotated Code of Maryland, of up to $100 per missing continuing medical education credit in lieu of a sanction under Health Occupations Article, §14-5D-14, Annotated Code of Maryland. Section F(1)(a) of this regulation does not limit the Board's authority to require completion of the missing continuing medical education credits. Willful Falsification. If a licensee has willfully falsified an application with respect to continuing medical education credits, the licensee may be charged under one or more of the following, as appropriate: Health Occupations Article, §14-5D-14(a)(3), Annotated Code of Maryland; Health Occupations Article, §14-5D-14(a)(10), Annotated Code of Maryland; and Health Occupations Article, §14-5D-14(a)(11), Annotated Code of Maryland. Upon a finding of a violation, the Board may impose any discipline authorized under Health Occupations Article, §14-5D-14, Annotated Code of Maryland, and the sanctioning guidelines. Licensees Previously Disciplined Under §I(1) or (2) of this regulation. If a licensee has been previously fined or otherwise disciplined under §F(1) or (2) of this regulation, the Board may, for a subsequent offense relating to continuing medical education credits, charge a licensee under one or more of the following, as appropriate: Health Occupations Article, §14-5D-14(a)(3), Annotated Code of Maryland; Health Occupations Article, §14-5D-14(a)(10), Annotated Code of Maryland; and Health Occupations Article, §14-5D-14(a)(11), Annotated Code of Maryland. Upon a finding of a violation, the Board may impose any discipline authorized under Health Occupations Article, §14-5D-14, Annotated Code of Maryland, and the sanctioning guidelines for a subsequent offense. The Board may not apply the sanction described in §F(1) of this regulation in determining a sanction for a licensee previously fined or disciplined for an offense related to continuing medical education credits. The Board shall pay all monies collected pursuant to this section into the Board of Physicians Fund. Payment of Fines. An individual shall pay to the Board any fine imposed under this regulation within 15 calendar days of the date of the order, unless the order specifies otherwise. Filing an appeal under State Government Article, §10-222, Annotated Code of Maryland, does not stay payment of a fine imposed by the Board pursuant to this regulation. If an individual fails to pay, in whole or in part, a fine imposed by the Board pursuant to this regulation, the Board may not restore, reinstate, or renew a license until the fine has been paid in full. 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. Subject to provisions of Regulation .11D—E of this chapter, the Board may impose sanctions as outlined in §B of this regulation on athletic trainers for violations of Health Occupations Article, §14-5D-14, Annotated Code of Maryland. Range of Sanctions. Health Occupations Article, §§1-213, 1-606, 14-205 and 14-5D-01—14-5D-20, Annotated Code of Maryland Effective date: July 22, 2013 (40:14 Md. R. 1176) Regulation .01A amended effective January 19, 2026 (53:1 Md. R. 21) Regulation .02B amended effective January 19, 2026 (53:1 Md. R. 21) Regulation .05C, D amended effective January 19, 2026 (53:1 Md. R. 21) Regulation .06A amended effective August 15, 2016 (43:16 Md. R. 900) Regulation .06B amended effective July 31, 2017 (44:15 Md. R. 760) Regulation .06E adopted effective January 19, 2026 (53:1 Md. R. 21) Regulation .07 amended effective January 2, 2017 (43:26 Md. R. 1446) Regulation .09A amended effective January 19, 2026 (53:1 Md. R. 21) Regulation .12B amended effective January 19, 2026 (53:1 Md. R. 21)