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<chapter num="05" heading="Quality Assurance" title_num="10" subtitle_num="51">
  <regulation prefix="Regulation" num=".01" heading="Quality Assurance — General.">
    <text>To obtain or maintain a permit to operate a forensic laboratory, a person or licensee shall ensure that the forensic laboratory:</text>
    <paragraph num="A.">
      <text>Establishes and follows policies and procedures for a comprehensive quality assurance program designed to monitor and evaluate the ongoing and overall quality and safety of the total examination and forensic analysis process;</text>
    </paragraph>
    <paragraph num="B.">
      <text>Maintains a quality assurance program that:</text>
      <paragraph num="(1)">
        <text>Continually evaluates the effectiveness of the laboratory’s policies and procedures;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Routinely revises policies and procedures based on the results of ongoing evaluation;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Identifies and corrects problems;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Assures:</text>
        <paragraph num="(a)">
          <text>Accurate, complete, and reliable reporting of results of examinations and analyses;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Technical procedures are validated and are accepted practice in the forensic discipline; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Adequate and competent employees;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(5)">
        <text>Requires documentation of all quality assurance and quality control activities; and</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Includes policies and procedures for:</text>
        <paragraph num="(a)">
          <text>Handling and preservation of evidence;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Calibration and maintenance of equipment;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Handling, maintaining, and securing laboratory records including case records and reports;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Evaluation and approval of employees;</text>
        </paragraph>
        <paragraph num="(e)">
          <text>Laboratory security;</text>
        </paragraph>
        <paragraph num="(f)">
          <text>Identifying and implementing corrective actions;</text>
        </paragraph>
        <paragraph num="(g)">
          <text>Documenting and investigating complaints;</text>
        </paragraph>
        <paragraph num="(h)">
          <text>The operation of individual characteristic databases, where appropriate; and</text>
        </paragraph>
        <paragraph num="(i)">
          <text>Data integrity and ethics;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>Develops and maintains:</text>
      <paragraph num="(1)">
        <text>An organizational chart of all employees;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Job requirements and a job description for each contractor; and</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Employee records that include, but are not limited to:</text>
        <paragraph num="(a)">
          <text>Job requirements and a job description for each employee;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Educational background and qualifications;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Curriculum vitae;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Court testimony evaluations and a record that the evaluations are reviewed with each examiner and analyst;</text>
        </paragraph>
        <paragraph num="(e)">
          <text>Documentation of successful completion of a training program set forth by the laboratory, including competency testing;</text>
        </paragraph>
        <paragraph num="(f)">
          <text>Authorization to perform independent casework; and</text>
        </paragraph>
        <paragraph num="(g)">
          <text>Performance evaluations;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="D.">
      <text>Establishes and maintains a forensic laboratory safety program;</text>
    </paragraph>
    <paragraph num="E.">
      <text>Employs appropriately trained employees and possesses equipment to conduct the scope of forensic services offered;</text>
    </paragraph>
    <paragraph num="F.">
      <text>Maintains reference literature in physical or electronic form that covers all disciplines and subdisciplines for which services are offered;</text>
    </paragraph>
    <paragraph num="G.">
      <text>Designates an individual as the quality assurance manager;</text>
    </paragraph>
    <paragraph num="H.">
      <text>Defines and maintains a document retention policy;</text>
    </paragraph>
    <paragraph num="I.">
      <text>Maintains a facility that is designed to ensure the integrity of the forensic analyses and the evidence;</text>
    </paragraph>
    <paragraph num="J.">
      <text>Conducts:</text>
      <paragraph num="(1)">
        <text>Administrative review of all cases and reports before issuing a report; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Technical review, of no less than 5 percent of cases as determined by the laboratory director or designee, to ensure conclusions and supporting data are within the constraints of scientific knowledge; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="K.">
      <text>Establishes a mechanism to address unresolved discrepant conclusions between an analyst and the technical reviewer.</text>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".02" heading="Quality Assurance — Specific.">
    <paragraph num="A.">
      <text>Policies and Procedure.</text>
      <paragraph num="(1)">
        <text>A licensee shall develop, establish, maintain, implement, and follow quality assurance policies and procedures that ensure that the laboratory’s quality system is maintained.</text>
      </paragraph>
      <paragraph num="(2)">
        <text>A licensee shall ensure that the laboratory has a clear procedure describing the process to uniquely identify evidence.</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Chain of Custody. The licensee shall:</text>
        <paragraph num="(a)">
          <text>Maintain a record of chain of custody in written or electronic form in order to maintain accurate tracking of all evidence; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Document each transfer of evidence with the date of transfer and the signature of the person receiving the evidence at the time of transfer.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>Identifying and Handling Evidence. A licensee shall:</text>
      <paragraph num="(1)">
        <text>Ensure that each item of evidence received by the forensic laboratory:</text>
        <paragraph num="(a)">
          <text>Is permanently marked and includes a unique identifier either on the:</text>
          <paragraph num="(i)">
            <text>Evidence itself; or</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Proximal container of the evidence; and</text>
          </paragraph>
        </paragraph>
        <paragraph num="(b)">
          <text>Has a documented record that includes the:</text>
          <paragraph num="(i)">
            <text>Identity of the evidence submitter;</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Date the item of evidence was submitted; and</text>
          </paragraph>
          <paragraph num="(iii)">
            <text>Description of the item of evidence submitted;</text>
          </paragraph>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>Establish and follow a procedure to identify evidence that cannot be marked or identified as set forth in §B(1) of this regulation;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Ensure all items produced during a forensic analysis or examination are:</text>
        <paragraph num="(a)">
          <text>Marked with a unique identifier that can be traced back to the original evidence;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Appropriately packaged;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Documented in case notes, reports, and the evidence tracking system; and</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Packed with the original evidence when applicable or a disposition will be noted;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(4)">
        <text>Ensure documentation of the date of receipt of each test item and evidence;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Establish, maintain, and follow a procedure to define proper packaging and sealing of evidence requiring that:</text>
        <paragraph num="(a)">
          <text>Evidentiary seals:</text>
          <paragraph num="(i)">
            <text>Are initialed or marked by the person sealing the evidence; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Prevent the evidence from being removed, lost, altered, or contaminated; and</text>
          </paragraph>
        </paragraph>
        <paragraph num="(b)">
          <text>Evidence is protected from:</text>
          <paragraph num="(i)">
            <text>Loss;</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Cross-contamination; and</text>
          </paragraph>
          <paragraph num="(iii)">
            <text>Any harmful change; and</text>
          </paragraph>
        </paragraph>
      </paragraph>
      <paragraph num="(6)">
        <text>Consider evidence containers properly sealed only if:</text>
        <paragraph num="(a)">
          <text>The contents cannot readily escape; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Entering the container results in obvious damage or alteration to the container or the container’s seal.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>Deficiencies, Errors, and Corrective Actions. A licensee shall have:</text>
      <paragraph num="(1)">
        <text>A procedure for corrective actions to be taken when a deficiency or error is identified with:</text>
        <paragraph num="(a)">
          <text>A forensic analysis procedure or method; or</text>
        </paragraph>
        <paragraph num="(b)">
          <text>The casework or proficiency testing of a forensic analyst or examiner; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>The procedure and required documentation for the corrective actions include:</text>
        <paragraph num="(a)">
          <text>A determination of the cause of the deficiency or error;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>An evaluation of the deficiency or error to determine if the deficiency or error causes or has caused an adverse effect on the quality of a forensic analysis;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>An indication of the individual responsible for corrective action;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>A timeline of corrective action or actions; and</text>
        </paragraph>
        <paragraph num="(e)">
          <text>Verification that the corrective action was:</text>
          <paragraph num="(i)">
            <text>Implemented; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Monitored for effectiveness in correcting the deficiency or error.</text>
          </paragraph>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="D.">
      <text>A licensee shall designate a quality assurance manager to oversee and ensure that the quality assurance program is implemented, maintained, and routinely evaluated.</text>
    </paragraph>
    <paragraph num="E.">
      <text>A licensee shall ensure that a change to an entry on an examination document, whether written or electronic, is:</text>
      <paragraph num="(1)">
        <text>Trackable to the person who made the change; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Not erased, hidden, obscured, disguised, or obliterated.</text>
      </paragraph>
    </paragraph>
    <paragraph num="F.">
      <text>A licensee shall establish and follow a procedure to document any:</text>
      <paragraph num="(1)">
        <text>Evidence discrepancies;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Compromise of evidence integrity; or</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Lost or misplaced evidence.</text>
      </paragraph>
    </paragraph>
    <paragraph num="G.">
      <text>A licensee shall document all quality assurance and quality control activities as set forth in this subtitle.</text>
    </paragraph>
    <paragraph num="H.">
      <text>A licensee shall establish a procedure to:</text>
      <paragraph num="(1)">
        <text>Investigate, resolve, and document a forensic analysis discrepancy; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Allow for a request and approval from the director or designee for a deviation from standard operating procedures.</text>
      </paragraph>
    </paragraph>
    <paragraph num="I.">
      <text>Public Record.</text>
      <paragraph num="(1)">
        <text>A licensee shall establish and follow a procedure to make discrepancy logs, contamination records, and test results available to the public within 30 days of a written request.</text>
      </paragraph>
      <paragraph num="(2)">
        <text>A contamination record shall include the following information:</text>
        <paragraph num="(a)">
          <text>Unique case identifier;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Encoded sample identification;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Description of results; and</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Identifiers that led to an incident report.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".03" heading="Quality Assurance — Specific for Postmortem Forensic Toxicology.">
    <paragraph num="A.">
      <text>In addition to any applicable requirement in this chapter, a forensic laboratory performing postmortem forensic toxicology shall establish a:</text>
      <paragraph num="(1)">
        <text>Procedure for responding to requests for the laboratory’s information and documentation; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Policy for:</text>
        <paragraph num="(a)">
          <text>Retention and release of laboratory information;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Addressing the confidentiality of laboratory data; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Identifying:</text>
          <paragraph num="(i)">
            <text>The extent to which interpretations may be provided with test results; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Who is authorized to provide interpretations.</text>
          </paragraph>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>Specimen Collection and Handling.</text>
      <paragraph num="(1)">
        <text>A laboratory director shall develop and provide, to all agencies or parties that submit or request postmortem toxicology analyses, instructions that include the specific requirements for the:</text>
        <paragraph num="(a)">
          <text>Type and minimum amount of specimen needed to perform the:</text>
          <paragraph num="(i)">
            <text>Requested analysis; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Subsequent interpretations;</text>
          </paragraph>
        </paragraph>
        <paragraph num="(b)">
          <text>Type and size of specimen container;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Type and amount of preservative to be added to biological fluids, when applicable;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Labeling of each individual specimen container;</text>
        </paragraph>
        <paragraph num="(e)">
          <text>Packaging and transport of a specimen;</text>
        </paragraph>
        <paragraph num="(f)">
          <text>Submission of relevant medical history on decedents who may carry a highly infectious disease, such as tuberculosis, hepatitis, or human immunodeficiency virus (HIV);</text>
        </paragraph>
        <paragraph num="(g)">
          <text>Labeling of each specimen as to type and source, if applicable; and</text>
        </paragraph>
        <paragraph num="(h)">
          <text>Proper sealing of containers to prevent:</text>
          <paragraph num="(i)">
            <text>Leakage of the specimen container; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Cross-contamination between specimens.</text>
          </paragraph>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>A licensee shall ensure that a specimen submitted for postmortem toxicology testing includes documentation that provides pertinent case information, including the:</text>
        <paragraph num="(a)">
          <text>Name of decedent;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Date of specimen collection; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Pertinent history of the case.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(3)">
        <text>For a specimen received for postmortem toxicology testing, a laboratory shall maintain a written or electronic record documenting the:</text>
        <paragraph num="(a)">
          <text>Condition of the specimen;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Handwritten initials or electronic signature of the individual who received the specimen;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Date the specimen was received;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Name of the decedent;</text>
        </paragraph>
        <paragraph num="(e)">
          <text>Unique identifier assigned to the specimen;</text>
        </paragraph>
        <paragraph num="(f)">
          <text>Specimen type;</text>
        </paragraph>
        <paragraph num="(g)">
          <text>Date the specimen was collected; and</text>
        </paragraph>
        <paragraph num="(h)">
          <text>Identification of the individual who collected the specimen.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(4)">
        <text>A licensee shall develop and follow a policy for the retention, release, and disposal of specimens submitted for postmortem toxicology testing.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".04" heading="Quality Control Program.">
    <paragraph num="A.">
      <text>A licensee shall:</text>
      <paragraph num="(1)">
        <text>Develop, establish, maintain, implement, and follow quality control policies and procedures that ensure accurate and reliable:</text>
        <paragraph num="(a)">
          <text>Forensic analysis results; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Case reports;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>Ensure that all quality control activities set forth in this chapter are documented;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Ensure that the quality control program is able to detect shifts and trends that could result in an adverse impact on the quality of forensic analysis results;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Ensure that quality control data are evaluated routinely and when found to be contaminated, out of range, incorrect, or otherwise unacceptable:</text>
        <paragraph num="(a)">
          <text>Corrective actions are taken; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Incorrect results are not reported;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(5)">
        <text>Ensure that quality control material and reference standards are specified in the SOPM and the results of quality control testing are documented in the case record;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Ensure that a reagent used for a forensic analysis:</text>
        <paragraph num="(a)">
          <text>Is tested for reliability before being put into use;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Is identified with the:</text>
          <paragraph num="(i)">
            <text>Name of the reagent;</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Lot number or date the reagent was prepared; and</text>
          </paragraph>
          <paragraph num="(iii)">
            <text>Expiration date;</text>
          </paragraph>
        </paragraph>
        <paragraph num="(c)">
          <text>Is checked for reliability on a cycle determined by the technical leader;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Has a record documenting:</text>
          <paragraph num="(i)">
            <text>Who prepared the reagent; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Completion of a reliability check before use; and</text>
          </paragraph>
        </paragraph>
        <paragraph num="(e)">
          <text>Has storage, safety, and handling requirements specified;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(7)">
        <text>Ensure that a reagent that is not used for a forensic analysis on a regular basis is tested for reliability before each use;</text>
      </paragraph>
      <paragraph num="(8)">
        <text>Discard a reagent, make a new reagent, and check the new reagent’s reliability before any casework being performed, if the reagent reliability is found to be compromised;</text>
      </paragraph>
      <paragraph num="(9)">
        <text>Use reagents that are suitable for the forensic analysis methods employed;</text>
      </paragraph>
      <paragraph num="(10)">
        <text>Have procedures for tracking the receipt and use of commercial reagents;</text>
      </paragraph>
      <paragraph num="(11)">
        <text>Have procedures for the formulation of in-house reagents in the SOPM; and</text>
      </paragraph>
      <paragraph num="(12)">
        <text>Test the forensic analysis method, before reporting a forensic analysis result, using:</text>
        <paragraph num="(a)">
          <text>A positive and negative external control for a qualitative forensic analysis; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Known levels of external controls for each analyte in a quantitative forensic analysis.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>Postmortem Forensic Toxicology. In addition to applicable requirements of this regulation, a laboratory performing postmortem forensic toxicology shall meet the requirements of this section.</text>
      <paragraph num="(1)">
        <text>Screening Tests. A licensee shall:</text>
        <paragraph num="(a)">
          <text>Ensure a postmortem toxicology screening test is appropriate and validated for the type of biological specimen being analyzed; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Perform and document precision studies for a method that uses cut-off values for analyte concentrations.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>Confirmatory Tests. A licensee shall:</text>
        <paragraph num="(a)">
          <text>Confirm, if possible, the detection or initial identification of controlled dangerous substances or other toxicants by a second method based on a different chemical principle; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Ensure the confirmatory test is more specific than the initial test for the target analyte, if possible.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(3)">
        <text>Immunoassay. A laboratory shall:</text>
        <paragraph num="(a)">
          <text>Be able to demonstrate sufficient separation in the response between a negative and positive specimen at the cut-off concentration of the immunoassay;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Validate the use of an immunoassay method or procedure on a specimen if the method or procedure is not recommended by the manufacturer of the immunoassay; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Use matrix-matched quality control materials for each batch of specimens analyzed with the immunoassay.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(4)">
        <text>Chromatography. A laboratory shall:</text>
        <paragraph num="(a)">
          <text>Analyze calibrators or controls with each batch of specimens for qualitative and quantitative chromatography assays;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Establish an acceptable range for each quantitative quality control material; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Use a suitable internal reference standard, when available.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(5)">
        <text>Spectrophotometry. A laboratory shall maintain cuvettes used for spectrophotometry in good optical condition.</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Mass Spectrometry. A laboratory shall:</text>
        <paragraph num="(a)">
          <text>Establish and adhere to criteria for acceptable mass spectrometric tune;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Have written criteria for full scan mass spectrometric identification through library searching; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Compare ion ratios and retention times between reference standards, calibrators, quality control materials, and case specimens when using selected ion monitoring or selected reaction monitoring.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".05" heading="Standard Operating Procedures Manual (SOPM).">
    <paragraph num="A.">
      <text>Policies and Procedures. A licensee shall ensure that all policies and procedures affecting the scope of activities performed in the laboratory are:</text>
      <paragraph num="(1)">
        <text>Documented; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Communicated to, understood by, available to, and implemented by employees performing the activities.</text>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall ensure that:</text>
      <paragraph num="(1)">
        <text>Documents issued to employees are reviewed and approved for use by authorized employees before issue;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>The current revision status and distribution of documents is established to preclude use of archived documents;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Authorized documents are available at all locations where casework is performed;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Archived documents are promptly removed from access or otherwise identified to ensure against unintended use;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Documents are uniquely identified, including date of issue or version, page numbering, total number of pages or a mark to signify the end of the document, and the issuing authority;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Changes to documents are approved by the same authority that issued the document and altered or new text is clearly identified; and</text>
      </paragraph>
      <paragraph num="(7)">
        <text>Documents in computerized systems have equivalent procedures.</text>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>A licensee shall develop, establish, maintain, implement, and require that technical procedures meet the following:</text>
      <paragraph num="(1)">
        <text>The procedures included are:</text>
        <paragraph num="(a)">
          <text>Generally accepted in the appropriate forensic field or supported by data gathered and recorded in a scientific manner;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Available to all appropriate employees;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Able to produce valid and accurate results; and</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Reviewed annually by the director or the director’s designee and this review shall be documented;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>All procedures include, at a minimum:</text>
        <paragraph num="(a)">
          <text>Sample or specimen preparation, as needed for the method;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Required quality control, standard, and reference material;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Calibration requirements and instructions;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Interfering substances and potential sources of error;</text>
        </paragraph>
        <paragraph num="(e)">
          <text>Literature references;</text>
        </paragraph>
        <paragraph num="(f)">
          <text>Special analytical and safety precautions;</text>
        </paragraph>
        <paragraph num="(g)">
          <text>Step-by-step instructions; and</text>
        </paragraph>
        <paragraph num="(h)">
          <text>Calculations, if required;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(3)">
        <text>The laboratory has a document control procedure to determine when the technical procedure has been discontinued or retired.</text>
      </paragraph>
      <paragraph num="(4)">
        <text>A laboratory procedure identifies which documents are to be maintained in the case file;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>All changes to a procedure are approved and signed by the director;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>The SOPM is available to all forensic analysts and examiners;</text>
      </paragraph>
      <paragraph num="(7)">
        <text>A departure from the SOPM is:</text>
        <paragraph num="(a)">
          <text>Approved by the laboratory director or qualified designee before implementation;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Scientifically validated before implementation;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Written; and</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Communicated to the quality assurance manager;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(8)">
        <text>The laboratory has a procedure for determining the reasons, criteria, or conditions for when a report is not produced;</text>
      </paragraph>
      <paragraph num="(9)">
        <text>The laboratory has a procedure or policy for technical review of reports that:</text>
        <paragraph num="(a)">
          <text>Defines criteria for the technical review, for example, number or percent of case reports reviewed or corrective action protocol if discrepancies are found;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Ensures that a review cannot be performed by the examiner or analyst who prepared the report; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Ensures that a technical review of a one-individual unit is performed at a review percentage determined by the laboratory director by an analyst or examiner of another licensed forensic laboratory, who is qualified within the same disciplines or subdisciplines; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(10)">
        <text>The laboratory has a procedure for administrative review that:</text>
        <paragraph num="(a)">
          <text>Requires that reviews be performed on all case reports;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Specifies who may perform the administrative review;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Clearly defines how the administrative review is documented; and</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Requires that reviews be performed before case reports are issued.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="D.">
      <text>A licensee shall ensure that the laboratory has a policy and procedure for the handling of written or oral complaints received from customers, laboratory employees, or other parties.</text>
    </paragraph>
    <paragraph num="E.">
      <text>Postmortem Forensic Toxicology. In addition to applicable sections of this regulation, a laboratory performing postmortem forensic toxicology shall have:</text>
      <paragraph num="(1)">
        <text>A record of sample signatures and initials of all employees handling specimens and performing analytical work; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>A procedure:</text>
        <paragraph num="(a)">
          <text>For periodically monitoring the purity of chemicals used as reference standards; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>That defines which postmortem forensic toxicology tests are to be performed on each type of case.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".06" heading="Calibration — General.">
    <paragraph num="A.">
      <text>A licensee shall develop, establish, implement, maintain, and follow calibration procedures.</text>
      <paragraph num="(1)">
        <text>If computers or automated equipment are used for the processing, recording, reporting, storage, or retrieval of calibration data, the licensee shall ensure that:</text>
        <paragraph num="(a)">
          <text>Computer software is performance checked after updates occur or validated;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Procedures are established, maintained, and followed to protect and secure the data; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Computers and automated equipment are maintained to ensure proper functioning.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>A licensee shall ensure that:</text>
        <paragraph num="(a)">
          <text>Reference standards are calibrated by an entity that can provide traceability;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Measuring devices including rulers, weights, pipettes, balances, thermometers, and other devices that affect a forensic analysis result are calibrated against a reference standard traceable to the International System of Units, if available, as required by the manufacturer or forensic laboratory’s quality assurance program;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Calibration, if applicable, is performed:</text>
          <paragraph num="(i)">
            <text>Before initial use and before the recalibrated item is returned to service;</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Following service or maintenance; and</text>
          </paragraph>
          <paragraph num="(iii)">
            <text>At intervals specified by the manufacturer or more frequently as determined by the technical leader or quality assurance manager; and</text>
          </paragraph>
        </paragraph>
        <paragraph num="(d)">
          <text>All calibration activities are documented.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>Postmortem Forensic Toxicology. In addition to applicable sections of this regulation, a laboratory performing postmortem forensic toxicology shall:</text>
      <paragraph num="(1)">
        <text>Include in the method calibration:</text>
        <paragraph num="(a)">
          <text>A sufficient number of calibrators and quality control samples in each batch that are consistent with the analysis being performed; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Analyses being performed on unusual specimens that:</text>
          <paragraph num="(i)">
            <text>Use appropriate matrix-matched calibrators, when possible; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Are prepared and tested concurrently with the specimen; and</text>
          </paragraph>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>Have a policy that defines a specimen that has a unique matrix.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".07" heading="Validation and Performance Checks.">
    <paragraph num="A.">
      <text>The licensee shall:</text>
      <paragraph num="(1)">
        <text>Separately perform a validation or conduct a performance check on standard methods before use;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Validate non-standard methods, laboratory designed methods, laboratory designed tests, and modifications of standard methods before use; and</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Maintain documentation of all method validation and performance check activities.</text>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall ensure that validation includes, but is not limited to:</text>
      <paragraph num="(1)">
        <text>Literature references;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Limitations of the method;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Sources of error;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Specificity;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Sensitivity;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Accuracy; and</text>
      </paragraph>
      <paragraph num="(7)">
        <text>Reproducibility.</text>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>A licensee shall ensure that performance checks, if applicable, are performed:</text>
      <paragraph num="(1)">
        <text>Before:</text>
        <paragraph num="(a)">
          <text>Initial use of computers and automated equipment; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Computers or automated equipment are returned to use for casework;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>Following servicing or maintenance;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>At intervals specified by the manufacturer; and</text>
      </paragraph>
      <paragraph num="(4)">
        <text>As needed as determined by the laboratory director or the laboratory director’s designee.</text>
      </paragraph>
    </paragraph>
    <paragraph num="D.">
      <text>A technical leader and a laboratory director shall approve all testing methods before the testing methods are put into use.</text>
    </paragraph>
    <paragraph num="E.">
      <text>A licensee shall ensure that:</text>
      <paragraph num="(1)">
        <text>Reference samples are used for method validation and performance checks;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Validation and performance checks include a statement as to whether the method is fit for the intended use; and</text>
      </paragraph>
      <paragraph num="(3)">
        <text>All new procedures and modifications of current procedures are validated and documented before being used in case work.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".08" heading="Examination and Analysis.">
    <paragraph num="A.">
      <text>A licensee shall develop, establish, maintain, implement, and follow examination and analysis procedures.</text>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall:</text>
      <paragraph num="(1)">
        <text>Ensure that all evidence is given a unique identifier;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Ensure that, when computers or automated equipment are used for the processing, recording, reporting, storage, or retrieval of examination or analysis data:</text>
        <paragraph num="(a)">
          <text>Computer software is validated;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Procedures are established and maintained to protect and secure the data; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Computers and automated equipment are maintained to ensure proper functioning;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(3)">
        <text>Have a policy for securing short-term and long-term storage of documents, evidence, and reports, which includes:</text>
        <paragraph num="(a)">
          <text>Limited access; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Environmental controls;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(4)">
        <text>Ensure each individual sub-sample has a unique identifier, when evidentiary samples are subdivided;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Ensure that all positive comparative analyses are verified by a second independent qualified examiner or analyst who has documented expertise in the examination that was performed, and the verification is documented; and</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Have a policy for securing evidence that is in the process of being examined or analyzed.</text>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>Examinations and Analysis by Subcontractors.</text>
      <paragraph num="(1)">
        <text>All subcontractors shall be licensed as a forensic laboratory in the State, regardless of location, unless a waiver has been obtained for a rare or unique test as required by COMAR 10.51.03.01A(4).</text>
      </paragraph>
      <paragraph num="(2)">
        <text>A licensee shall ensure:</text>
        <paragraph num="(a)">
          <text>The customer who ordered the analyses is notified of the laboratory’s intention to subcontract specific services for testing;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>All subcontractors issue reports only to the forensic laboratory that ordered the testing; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>All remaining evidence is returned to the forensic laboratory by the subcontractor.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".09" heading="Test Reports — General.">
    <paragraph num="A.">
      <text>A licensee shall ensure that a test report includes but is not limited to the following:</text>
      <paragraph num="(1)">
        <text>Name and physical address of the laboratory;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>A unique identifier on each page of the report;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Identification of the forensic analysis method used;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>A clear identification of each item tested including a description of the item’s condition;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>The date each forensic analysis was completed;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Units of measurement, if applicable;</text>
      </paragraph>
      <paragraph num="(7)">
        <text>The name and written or electronic signature of the examiner or analyst responsible for:</text>
        <paragraph num="(a)">
          <text>Performance of the forensic analysis;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Interpretations of forensic analysis results; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Opinions;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(8)">
        <text>Opinions and interpretations;</text>
      </paragraph>
      <paragraph num="(9)">
        <text>When applicable, a statement of uncertainty of measurement if the uncertainty of measurement may affect the interpretation of the results of the forensic analysis;</text>
      </paragraph>
      <paragraph num="(10)">
        <text>The date report was generated;</text>
      </paragraph>
      <paragraph num="(11)">
        <text>The indication of the end of the report on the report’s last page; and</text>
      </paragraph>
      <paragraph num="(12)">
        <text>If applicable, a statement that the analysis was performed by another laboratory and identifies the facility that actually performed the analysis.</text>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall ensure that any information from §A(1)—(12) of this regulation that is not included in the test report is documented in the case record.</text>
    </paragraph>
    <paragraph num="C.">
      <text>A licensee shall ensure that test reports:</text>
      <paragraph num="(1)">
        <text>Are produced when analytical testing is performed on evidence;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Contain opinions and conclusions and the name of the report’s author;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Report results accurately, clearly, unambiguously, and objectively; and</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Utilize a page numbering system that includes either the total number of pages or a mark to signify the end of the document.</text>
      </paragraph>
    </paragraph>
    <paragraph num="D.">
      <text>A licensee shall ensure that amended reports:</text>
      <paragraph num="(1)">
        <text>Clearly state that the report has been amended;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Reference the original report;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Are placed or associated with the original report in the case file; and</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Are provided to the customers.</text>
      </paragraph>
    </paragraph>
    <paragraph num="E.">
      <text>Reports — Postmortem Forensic Toxicology. In addition to applicable sections of this regulation, a laboratory performing postmortem forensic toxicology shall:</text>
      <paragraph num="(1)">
        <text>Have a procedure or policy for technical review of reports, which includes at a minimum:</text>
        <paragraph num="(a)">
          <text>Chain of custody documentation;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Validity of analytical data; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Quality control data;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>Include on the test report the name of the submitting agency or individual;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Indicate qualitative test results using the:</text>
        <paragraph num="(a)">
          <text>Term “Positive” if the test result is positive for the presence of the substance tested; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Term “None detected” if the test result is negative for the presence of the substance tested;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(4)">
        <text>Have quantitative results identified using correct nomenclature;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Have preliminary reports clearly indicate that the:</text>
        <paragraph num="(a)">
          <text>Results are unconfirmed and subject to verification;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Testing is incomplete; and</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Subsequent results, where appropriate, may affect the final report and interpretation of the report;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(6)">
        <text>Clearly identify test results performed by a subcontractor;</text>
      </paragraph>
      <paragraph num="(7)">
        <text>Clearly identify revised reports or addenda using the same identifying information as the original report, for reports that contain additional testing after the original test results were reported; and</text>
      </paragraph>
      <paragraph num="(8)">
        <text>Indicate on the final report the name of the laboratory that actually performed the test if specimens were referred to another laboratory for analysis.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".10" heading="Employee Training and Competency.">
    <paragraph num="A.">
      <text>A licensee shall develop, establish, maintain, implement, and follow a written training program for all technical skills in each discipline and subdiscipline for each new or untrained employee and employees who need remedial training.</text>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall ensure that available to all technical employees is a discipline-specific training program that includes:</text>
      <paragraph num="(1)">
        <text>All aspects of the work being performed by the laboratory for each discipline and subdiscipline in which the laboratory performs case work;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Ethics and data integrity;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Criminal and civil law procedures;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Criteria or requirements to demonstrate competence;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Moot court training if court testimony may be required; and</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Expert witness training if expert witness testimony may be required.</text>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>A licensee shall ensure that training records include at least:</text>
      <paragraph num="(1)">
        <text>Competency assessments;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Proficiency testing results;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Documentation of all training;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Documentation of training that occurred at a previous job, if applicable;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Written authorization by the laboratory director and technical leader to conduct independent casework in each type of testing assigned; and</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Documentation of all continuing education.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".11" heading="Equipment Maintenance.">
    <paragraph num="A.">
      <text>General. The laboratory shall develop, establish, maintain, implement, and follow an equipment calibration and maintenance procedure and policy.</text>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall ensure that equipment, before being placed into use, is calibrated or checked to establish that the equipment meets either the laboratory’s or manufacturer’s specifications, or both, as determined by the director.</text>
    </paragraph>
    <paragraph num="C.">
      <text>A licensee shall ensure that records are maintained on all items of equipment including at a minimum:</text>
      <paragraph num="(1)">
        <text>Identity of the item of equipment and the equipment’s ancillary parts;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Manufacturer’s name and serial number or other unique identifier;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Performance checks ensuring the equipment complies with the manufacturer’s specifications;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Current location, if applicable;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Manufacturer’s instructions or operating manual;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Dates and results of calibrations, adjustments, and service and date of next calibration;</text>
      </paragraph>
      <paragraph num="(7)">
        <text>Documentation of all maintenance performed, including date and signature of the individual performing the maintenance; and</text>
      </paragraph>
      <paragraph num="(8)">
        <text>Documentation of any damage, malfunction, modification, or repair to the equipment.</text>
      </paragraph>
    </paragraph>
    <paragraph num="D.">
      <text>A licensee shall ensure that any equipment that gives questionable results or is not functioning properly is immediately taken out of use and the equipment:</text>
      <paragraph num="(1)">
        <text>Is clearly labeled as out of service;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Is examined and repaired or retired;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Is calibrated or shown to perform correctly before being put back into service; and</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Has forensic analysis results on previously examined evidence evaluated for accuracy back to the previous calibration.</text>
      </paragraph>
    </paragraph>
    <paragraph num="E.">
      <text>A licensee shall ensure that the equipment, including both hardware and software, is safeguarded from adjustments that invalidate or alter calibrations or test examinations and analyses.</text>
    </paragraph>
    <paragraph num="F.">
      <text>A licensee shall ensure that operator’s manuals for all equipment and instruments are available to all examiners and analysts who use the equipment or instruments.</text>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".12" heading="Case Records.">
    <paragraph num="A.">
      <text>A licensee shall create and maintain a unique identifier system for all administrative and examination documents originating from or received by the laboratory for each case by:</text>
      <paragraph num="(1)">
        <text>Writing all documents in permanent ink and defining exceptions in the laboratory SOPM;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Using electronic signatures only if a security protocol is in place;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Having a tracking policy and system for electronic record changes, when the electronic document is complete; and</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Identifying all administrative documents with a unique identifier and signing or initialing by the individual who prepared or received the document.</text>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>In regard to examination documents, a licensee shall ensure that:</text>
      <paragraph num="(1)">
        <text>If information is recorded on both sides, each side of a page is considered a separate page;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>If examination documents consist of multiple pages, a page numbering system that includes either the total number of pages or a mark signifying the end of the document is used;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>In the absence of the examiner or analyst, another competent examiner or analyst is able to evaluate and interpret the data;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>An examination document:</text>
        <paragraph num="(a)">
          <text>Includes details to support the conclusions and opinions reported by each examiner or analyst;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Is free of erasures or obliterations;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Is marked with a unique identifier and the examiner’s or analyst’s handwritten initials or electronic signature; and</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Includes each date casework or an analysis was performed;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(5)">
        <text>If an individual in addition to the examiner or analyst interprets or reports the results, both individuals initial or electronically sign each page of the examination documents;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Abbreviations and symbols are defined in the SOPM;</text>
      </paragraph>
      <paragraph num="(7)">
        <text>Erroneous results, corrections, and amendments:</text>
        <paragraph num="(a)">
          <text>Are crossed out with a single line, not erased, and not deleted or made illegible; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Have corrections entered beside the erroneous result;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(8)">
        <text>All corrections and amendments are initialed and dated;</text>
      </paragraph>
      <paragraph num="(9)">
        <text>If electronically signed, measures are taken to ensure the signature is secure; and</text>
      </paragraph>
      <paragraph num="(10)">
        <text>There is no loss or change of the original documents.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".13" heading="Complaints.">
    <paragraph num="A.">
      <text>A licensee shall retain all complaint records and documentation of the investigations and corrective actions taken by the laboratory.</text>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall ensure that complaint documents include at least the:</text>
      <paragraph num="(1)">
        <text>Name and organization of complainant, if applicable;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Date of complaint;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Details of complaint;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Corrective action and resolution; and</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Notification of the complainant as to the resolution of the complaint.</text>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>A licensee shall forward all complaints to the laboratory director.</text>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".14" heading="Subcontractors.">
    <text>A licensee shall:</text>
    <paragraph num="A.">
      <text>Maintain a list of all subcontractors to which forensic analyses are referred;</text>
    </paragraph>
    <paragraph num="B.">
      <text>Be responsible for the subcontractor’s forensic analysis or examination;</text>
    </paragraph>
    <paragraph num="C.">
      <text>Ensure that forensic analysis results from the subcontractor are written or in a secured electronic form;</text>
    </paragraph>
    <paragraph num="D.">
      <text>Ensure that if alternative methods are used, the customer is notified before performing the examination or analysis;</text>
    </paragraph>
    <paragraph num="E.">
      <text>Establish and use appropriate review procedures to ensure the integrity of:</text>
      <paragraph num="(1)">
        <text>Outsourced samples; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Data received from the subcontractor; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="F.">
      <text>Establish and use appropriate review procedures to verify compliance with applicable State regulations.</text>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".15" heading="Facilities.">
    <paragraph num="A.">
      <text>Facility Administration. A licensee shall ensure that a laboratory:</text>
      <paragraph num="(1)">
        <text>Is adequate for the testing services offered;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Has lighting, plumbing, wiring, ventilation, heat, air conditioning, and humidity to meet the laboratory’s requirements; and</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Has the required safety equipment as defined by the laboratory SOPM.</text>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>Security. A licensee shall:</text>
      <paragraph num="(1)">
        <text>Control and limit access to areas of the laboratory to those persons who regularly work in an area or are designated by the laboratory director as having access to an area; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Ensure that:</text>
        <paragraph num="(a)">
          <text>Entrances and exits have adequate security measures;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Internal areas that are required to have controlled or limited access are protected by a locked system;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>The distribution of all keys, magnetic cards, and entry devices is documented and authorized by the director;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>The facility is secure; and</text>
        </paragraph>
        <paragraph num="(e)">
          <text>All short-term and long-term storage areas have controlled or limited access and have a lock system in place.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>Safety. A licensee shall:</text>
      <paragraph num="(1)">
        <text>Have a safety policy and procedure, that is reviewed annually;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Designate an employee as the safety officer with responsibilities defined by the licensee;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Have appropriate safety policies and procedures;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Demonstrate appropriate safety policies and procedures;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Have appropriate safety devices and equipment available and in close proximity to the appropriate areas; and</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Be in compliance with all federal, State, and local regulations regarding the handling and disposal of infectious materials, chemicals, radioactive materials, sharps, and glassware.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".16" heading="Ethics and Data Integrity Policy — Requirement.">
    <paragraph num="A.">
      <text>A licensee shall:</text>
      <paragraph num="(1)">
        <text>Establish and maintain a written ethics and data integrity policy to be followed by all forensic laboratory employees, which includes the items set forth in §B of this regulation;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Provide access to the information, training, and resources needed by all forensic laboratory employees to comply with applicable federal and State laws, including ethics laws and regulations and the ethics and data integrity policy required in §A(1) of this regulation;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Provide formal ethics and data integrity training:</text>
        <paragraph num="(a)">
          <text>As part of new employee orientation; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>On an annual basis for all current employees;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(4)">
        <text>Develop and utilize an employee ethics and data integrity agreement, for each employee to sign annually after training, acknowledging, and certifying that the employee has read, understands, and will follow the forensic laboratory ethics and data integrity policy; and</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Provide a working environment in the forensic laboratory that:</text>
        <paragraph num="(a)">
          <text>Prevents employees from being subject to inappropriate pressures, coercion, intimidation, unethical laboratory dilemmas, or bribery from internal or external sources; and</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Promotes and maintains effective bilateral communication through the chain-of-command, regarding concerns, inquiries, and allegations pertaining to:</text>
          <paragraph num="(i)">
            <text>Suspected or actual unethical conduct;</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Data integrity issues;</text>
          </paragraph>
          <paragraph num="(iii)">
            <text>Questionable practices; or</text>
          </paragraph>
          <paragraph num="(iv)">
            <text>Questions concerning forensic analysis procedures or results.</text>
          </paragraph>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="B.">
      <text>A licensee shall ensure that a licensee’s ethics and data integrity policy includes at least the following topics, requirements, and procedures:</text>
      <paragraph num="(1)">
        <text>An employee’s responsibility to report any activity or behavior by any other employee, subcontractor, or vendor that the employee has reason to believe violates applicable laws, rules, and regulations or the forensic laboratory’s ethics and data integrity policy;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>The disciplinary action an employee will be subject to if the employee:</text>
        <paragraph num="(a)">
          <text>Makes or produces a report that the employee knows to be false or misleading;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Is found falsifying, short-cutting, camouflaging, or misrepresenting any information or facts about forensic analysis procedure, result, reports, or data management; or</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Otherwise engages in conduct or behavior that violates the:</text>
          <paragraph num="(i)">
            <text>Forensic laboratory’s ethics and data integrity policy; or</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Established forensic laboratory practices;</text>
          </paragraph>
        </paragraph>
      </paragraph>
      <paragraph num="(3)">
        <text>Procedures for reporting, handling, and investigating complaints of unethical conduct and violations or suspected violations of the forensic laboratory’s ethics and data integrity policy;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Requiring employees to:</text>
        <paragraph num="(a)">
          <text>Act impartially and not give preferential treatment to any person;</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Exhibit exemplary conduct and use honest efforts in the performance of duties and responsibilities;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Perform a forensic analysis in a manner that:</text>
          <paragraph num="(i)">
            <text>Is independent of internal and external influences;</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Is objective; and</text>
          </paragraph>
          <paragraph num="(iii)">
            <text>Assures that results are accurate, precise, and of known and documented quality; and</text>
          </paragraph>
        </paragraph>
        <paragraph num="(d)">
          <text>Understand the:</text>
          <paragraph num="(i)">
            <text>Serious implications and consequences of unethical conduct, intent to defraud, or any impropriety in performing forensic analyses; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Zero tolerance policy regarding an employee who engages in any form of conduct or behavior that is a violation of the ethics and data integrity policy required in §A of this regulation or any forensic laboratory practice that is not authorized by a licensee’s established procedures; and</text>
          </paragraph>
        </paragraph>
      </paragraph>
      <paragraph num="(5)">
        <text>Prohibiting an employee from:</text>
        <paragraph num="(a)">
          <text>Soliciting or accepting any gift of goods or services or other benefit of value from a person or entity:</text>
          <paragraph num="(i)">
            <text>Seeking action from or doing business with the forensic laboratory; or</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Whose interests may be substantially affected by the performance or nonperformance of the employee’s duties and responsibilities;</text>
          </paragraph>
        </paragraph>
        <paragraph num="(b)">
          <text>Holding a financial or personal interest that conflicts with the conscientious and ethical performance of duties and responsibilities;</text>
        </paragraph>
        <paragraph num="(c)">
          <text>Engaging in a transaction allowing the improper use of confidential information to further a private interest;</text>
        </paragraph>
        <paragraph num="(d)">
          <text>Conducting an action that violates the standards and requirements set forth in this subtitle or the licensee’s ethics and data integrity policy; and</text>
        </paragraph>
        <paragraph num="(e)">
          <text>Engaging in outside employment or activities that conflict with the conscientious and ethical performance of duties and responsibilities.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".17" heading="Nonretaliation.">
    <paragraph num="A.">
      <text>A licensee shall establish, maintain, and follow a nonretaliation policy that ensures that an employee who in good faith reports to the Secretary or the Department an issue related to data integrity or unethical or fraudulent conduct will not be subject to any form of discrimination or retaliation.</text>
    </paragraph>
    <paragraph num="B.">
      <text>An employee who works in a forensic laboratory may disclose information to the Secretary that the employee believes evidences a violation or possible violation of a standard or requirement set forth in this subtitle or Health-General Article, Title 17, Subtitle 2A, Annotated Code of Maryland, including a standard or requirement related to data integrity or unethical or fraudulent conduct.</text>
    </paragraph>
    <paragraph num="C.">
      <text>A licensee shall post the document developed by the Secretary and approved by the Department informing employees of a forensic laboratory of the procedures to report instances of noncompliance or other violations of the standards and requirements set forth in this subtitle or Health-General Article, Title 17, Subtitle 2A, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="D.">
      <text>The Department shall develop a forensic laboratory noncompliance document that:</text>
      <paragraph num="(1)">
        <text>Has contact information for reporting violations of standards and requirements for forensic laboratories, including address, phone numbers, fax number, and website;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Has a statement about nonretaliation and nondiscrimination against anyone reporting noncompliance or other violations for forensic laboratories; and</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Is signed by the director of the Office of Health Care Quality.</text>
      </paragraph>
    </paragraph>
    <paragraph num="E.">
      <text>The Department shall distribute to each quality assurance manager of a forensic laboratory the document referenced in §D of this regulation.</text>
    </paragraph>
    <paragraph num="F.">
      <text>A licensee shall ensure that the document referenced in §D of this regulation is posted in a conspicuous place visible to all forensic laboratory employees.</text>
    </paragraph>
    <paragraph num="G.">
      <text>A licensee may not discriminate or retaliate against an employee of a forensic laboratory who:</text>
      <paragraph num="(1)">
        <text>In good faith makes a report to the Secretary as set forth in this regulation; or</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Has agreed to cooperate with an investigation of the forensic laboratory.</text>
      </paragraph>
    </paragraph>
    <paragraph num="H.">
      <text>A licensee may be subject to the sanctions set forth in this subtitle and Health-General Article, Title 17, Subtitle 2A, Annotated Code of Maryland, if the licensee discriminates or retaliates against an employee who in good faith makes a report to the Secretary as set forth in this regulation, including:</text>
      <paragraph num="(1)">
        <text>Failing to promote the employee or provide an employment-related benefit for which the employee would otherwise be eligible;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Making an adverse evaluation or decision in relation to accreditation, certification, credentialing, or licensing of the employee; or</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Taking a personnel action that is retaliatory to the employee.</text>
      </paragraph>
    </paragraph>
    <paragraph num="I.">
      <text>An employee of a forensic laboratory who has been discriminated or retaliated against in violation of this regulation or Health-General Article, §17–2A–10, Annotated Code of Maryland, may initiate an action within 2 years of the discrimination or retaliation that is the basis for the action, and, on prevailing, shall be entitled to:</text>
      <paragraph num="(1)">
        <text>Reinstatement;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Reimbursement for lost wages;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Work benefits lost as a result of the unlawful acts of the licensee; and</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Reasonable attorney’s fees and costs associated with pursuing the action.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <annotations>
    <annotation type="Authority">Health-General Article, Title 17, Subtitle 2A, Annotated Code of Maryland</annotation>
    <annotation type="History" subtype="Administrative History">Effective date: May 28, 2012 (39:10 Md. R. 660)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .01K amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .02A, B amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .05C amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .07C amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .09C, D amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .10B amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .12B amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .15A, C amended effective July 20, 2015 (42:14 Md R. 880)</annotation>
  </annotations>
</chapter>