<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 10.32.22.03" title_num="10" subtitle_num="32" chapter_num="22" heading="Mandated Reports.">
  <paragraph num="A.">
    <text>Subject to the limitations set out in §§B, C and D of this regulation, the reporting entity shall report to the Board in writing any change made with respect to a health care provider:</text>
    <paragraph num="(1)">
      <text>Whom the reporting entity employs;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Who works with the reporting entity under contract; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>To whom the reporting entity has granted privileges.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>A reporting entity shall inform the Board of any change that has been made, in whole or in part, because the reporting entity had reason to believe that the health care provider:</text>
    <paragraph num="(1)">
      <text>Abandoned a patient;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provided patient care of questionable quality;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Disrupted the workplace;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Committed unethical or unprofessional conduct;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Committed billing or coding fraud;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Used the reporting entity’s employment or privileges to commit illegal or unethical business practices;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Suffers from a physical, a mental, or an emotional condition or impairment that affects the health care provider’s ability to perform the individual’s medical or surgical duties;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Is habitually intoxicated by alcohol or a controlled dangerous substance;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Provided care while under the influence of alcohol or while abusing or misusing any controlled dangerous substance or mood-altering substance;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Has not complied with the requirements of an alcohol or a drug treatment program;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>With respect to allied health providers, failed to notify the reporting entity of the health care provider’s decision to enter into an alcohol or a drug treatment program;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Performed care beyond the scope of licensure or privileges or delegated duties, or delegated duties to an individual not authorized to perform those duties;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Repeatedly failed to complete medical records;</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Repeatedly violated hospital bylaws, rules, policies, or procedures after warning; or</text>
    </paragraph>
    <paragraph num="(15)">
      <text>Committed any other act or suffered from any other condition which the reporting entity had reason to believe may constitute a violation of the Acts.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Specific Changes Not Reportable. The following changes do not require reporting by a reporting entity:</text>
    <paragraph num="(1)">
      <text>Voluntary leaves of absence that:</text>
      <paragraph num="(a)">
        <text>Are not involuntary leaves of absence as defined in Regulation .02 of this chapter;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Are taken by a health care provider who is in good standing; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>May be caused by, for example:</text>
        <paragraph num="(i)">
          <text>Maternity leave;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Family problems of a medical or other personal nature;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Medical problems that do not implicate the health care provider’s physical, mental, or emotional ability to provide competent care;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Military deployment;</text>
        </paragraph>
        <paragraph num="(v)">
          <text>Sabbaticals;</text>
        </paragraph>
        <paragraph num="(vi)">
          <text>Extended vacations; or</text>
        </paragraph>
        <paragraph num="(vii)">
          <text>Absences for professional training;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Voluntary resignations that:</text>
      <paragraph num="(a)">
        <text>Are not involuntary resignations as defined in Regulation .02 of this chapter;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Are submitted by a health care provider who is in good standing; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>May be caused by, for example:</text>
        <paragraph num="(i)">
          <text>A job or career change;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The health care provider’s desire to relocate from Maryland; or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>The health care provider’s desire to retire;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Voluntary alterations in practice that:</text>
      <paragraph num="(a)">
        <text>Are not involuntary alterations in practice as defined in Regulation .02 of this chapter;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Are submitted by a health care provider who is in good standing; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>May be caused by, for example, a health care provider’s desire to:</text>
        <paragraph num="(i)">
          <text>Switch from active practice to consulting;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Reduce workload; or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Alter a specialty or scope of practice;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>With respect to allied health providers, the initial denial of employment or privileges;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>With respect to physicians, an involuntary alteration in practice that:</text>
      <paragraph num="(a)">
        <text>Results solely from an FPPE or a focused review;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Does not by itself or in combination with any other involuntary alteration in practice exceed 90 days in any one calendar year;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Consists solely of one or more of the following:</text>
        <paragraph num="(i)">
          <text>A program of additional training or monitoring or heightened scrutiny of the individual’s practice; or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>A requirement that the individual successfully perform a skill, an activity, or a procedure a specific number of times, or within a specific time period; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(d)">
        <text>Does not result from inappropriate sexual behavior, harassment, or any other unprofessional conduct in the workplace;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>With respect to physicians, the initial denial of employment or privileges due solely to the applicant’s:</text>
      <paragraph num="(a)">
        <text>Inability to fulfill on-call requirements because of other time commitments;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Lack of a board certification required by the reporting entity; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Lack of experience in conducting a particular medical procedure;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(7)">
      <text>Administrative suspensions, if the sum total does not cumulatively exceed 30 days in any one calendar year, imposed on or agreed to by the health care provider, solely for the health care provider’s failure to:</text>
      <paragraph num="(a)">
        <text>Acquire mandated vaccinations or required serum titers for infections;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Attend required meetings;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Complete medical records;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Complete required training; or</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Maintain or submit a certificate of professional insurance;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(8)">
      <text>With respect to allied health providers and subject to the requirements of §D(1) and (2) of this regulation, entrance into an alcohol or a drug treatment program:</text>
      <paragraph num="(a)">
        <text>That is accredited by the Joint Commission;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>That is certified by the Maryland Department of Health;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>To which the allied health provider is referred by the Maryland Physician Health Program or the Maryland Healthcare Professionals Program; or</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Provided by a health care practitioner who is competent and capable of dealing with alcoholism and drug abuse; or</text>
      </paragraph>
    </paragraph>
    <paragraph num="(9)">
      <text>With respect to physicians and subject to the requirements of §D(3) and (4) of this regulation, entrance into an alcohol or a drug treatment program:</text>
      <paragraph num="(a)">
        <text>That is accredited by the Joint Commission;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>That is certified by the Maryland Department of Health; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>To which the physician is referred by the Maryland Physician Health Program.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Exceptions to §C(8) and (9) of This Regulation.</text>
    <paragraph num="(1)">
      <text>Section C(8) of this regulation applies only where:</text>
      <paragraph num="(a)">
        <text>The allied health provider notified the reporting entity at the time the allied health provider decided to enter the program;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The reporting entity is able to verify that the allied health provider remains continually in the program until properly discharged; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The action or condition of the allied health provider had not caused injury to any individual during the provision of health care by the allied health provider.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Section C(8) of this regulation does not apply to:</text>
      <paragraph num="(a)">
        <text>Any change made by a reporting entity relating to the discharge of an allied health provider from an alcohol or a drug treatment program, when that discharge was for non-attendance or non-compliance with the program;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Additional changes made by the reporting entity, other than minor scheduling changes made solely to accommodate participation in the program; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Any change made by the reporting entity based on events set out in Regulation .03B which occurred subsequent to the provider’s entrance into the alcohol or drug treatment program.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Section C(9) of this regulation applies only where:</text>
      <paragraph num="(a)">
        <text>The physician notified the reporting entity at the time the physician decided to enter the program;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The reporting entity is able to verify that the physician remains continually in the program until properly discharged; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The action or condition of the physician had not resulted in injury to any individual during the provision of health care by the physician.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Section C(9) of this regulation does not apply to:</text>
      <paragraph num="(a)">
        <text>Any change made by a reporting entity relating to the discharge of a physician by an alcohol or a drug treatment program, when that discharge was for non-attendance or non-compliance with the program;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Additional changes made by the reporting entity, other than minor scheduling changes made solely to accommodate participation in the program; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Any change made by the reporting entity relating to events set out in §B of this regulation which occurred subsequent to the physician’s entrance into the alcohol or drug treatment program.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>