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<regulation prefix="Regulation" num=".05" citation="COMAR 30.08.02.05" title_num="30" subtitle_num="08" chapter_num="02" heading="On-Site Review for Initial Trauma Center Designation.">
  <paragraph num="A.">
    <text>After a hospital's application for designation has been accepted, MIEMSS shall conduct an on-site review of a hospital that has applied to be a Primary Adult Resource Center, or a Level I, II, or III trauma center.</text>
  </paragraph>
  <paragraph num="B.">
    <text>On-Site Review Teams.</text>
    <paragraph num="(1)">
      <text>MIEMSS shall establish multidisciplinary on-site review teams composed of individuals knowledgeable in trauma or specialty care and trauma or specialty care systems.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The composition of the team shall be appropriate to the level of designation sought.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>For trauma center designation, MIEMSS shall select a team which, at a minimum, shall include MIEMSS staff and representatives from three of the following categories:</text>
      <paragraph num="(a)">
        <text>Trauma surgeon;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Emergency physician;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Trauma nurse coordinator;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Administrator.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>A staff person from MIEMSS shall accompany and coordinate the functions of the review team.</text>
    </paragraph>
    <paragraph num="(5)">
      <text>A team shall consist of professionals who do not have any conflict or competitive interest with the applicant.</text>
    </paragraph>
    <paragraph num="(6)">
      <text>If a hospital can demonstrate a reasonable basis for concern, MIEMSS shall consider allegations that conflicts of interest exist between an on-site reviewer and an applicant.</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Contact with Members of On-Site Review Team.</text>
      <paragraph num="(a)">
        <text>Except as authorized by MIEMSS, an applicant's administration, faculty, medical staff, employees, and representatives may not have any contact with an on-site review team member relating to the review process after the team members are announced and before the on-site review is conducted.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A violation of §B(7)(a) of this regulation may be grounds for denial by MIEMSS of the hospital's application.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(8)">
      <text>The on-site review team shall:</text>
      <paragraph num="(a)">
        <text>Evaluate the appropriateness and capability of the applicant to provide trauma care services, according to the designation standards described in COMAR 30.08.05;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Verify the hospital's ability to meet the:</text>
        <paragraph num="(i)">
          <text>Responsibilities of, and the resources, equipment, and performance standards for, the level of designation sought, and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Overall needs of the trauma system in that region;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>Familiarize themselves with the hospital's application and the designation standards;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Inspect the hospital's physical plant;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Interview trauma team members and management personnel;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Examine the hospital's trauma-related documents, including patient care records;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>Review other materials considered appropriate by MIEMSS;</text>
      </paragraph>
      <paragraph num="(h)">
        <text>Provide an exit interview of preliminary findings to the applicant upon completion of the on-site review; and</text>
      </paragraph>
      <paragraph num="(i)">
        <text>Provide a brief written summary of preliminary findings upon completion of the on-site review.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(9)">
      <text>Confidentiality of On-Site Review Records.</text>
      <paragraph num="(a)">
        <text>MIEMSS shall require and maintain confidentiality of an on-site review record.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An on-site review record is confidential and exempt from public disclosure under General Provisions Article, Title 4, Subtitle 3, Annotated Code of Maryland.</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Except as provided in Health Occupations Article, Title 1, Subtitle 4, Annotated Code of Maryland, an on-site review record is not discoverable or admissible in evidence.</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A member of the on-site review team may not divulge, and may not be compelled to divulge, any information obtained or included in on-site review records submitted to MIEMSS relating to the on-site review, including in any civil action resulting from MIEMSS' designation process.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Notwithstanding §§A and B of this regulation, instead of conducting an on-site review, MIEMSS may take into consideration or coordinate with verification surveys by the American College of Surgeons or other specialty medical organizations.</text>
  </paragraph>
</regulation>