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Chapter 12. Perinatal and Neonatal Referral Center Standards

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Regulation .01 Definitions.Copy Citation

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A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Capability” means having the necessary equipment and supplies as well as staff with the skill and experience in its use.
(2)
“Current” means generally accepted, used, practiced, or prevalent at the moment.
(3)
“Dedicated” means a resource is assigned to or for the exclusive use by a unit and not shared with any other unit
(4)
“E” means the standard is essential.
(5)
“O” means the standard is optional.
(6)
“NA” means the standard does not apply.
(7)
“Programmatic responsibility” means the writing, review, and maintenance of practice guidelines, policies, and procedures; development of the operating budget in collaboration with hospital administration and other program directors; evaluation and guiding of the purchase of equipment; planning, development, and coordinating of educational programs, both in-hospital and outreach; participation in the evaluation of perinatal care; and participation in perinatal quality improvement and patient safety activities.
(8)
“Readily available” means a resource is available for use a short time after it is requested.
(9)
“Telemedicine” means the use of interactive audio, video, or other telecommunications or electronic technology by a licensed health care provider to deliver a health care service within the scope of practice of the health care provider at a site other than the site at which the patient is located, in compliance with COMAR 10.32.05.and including at least two forms of communication.
(10)
“Thirty (30) minutes” means in-house within thirty (30) minutes under normal driving conditions which include, but are not limited to, weather, traffic, and other circumstances which may be beyond the individual’s control.

Regulation .02 Types of Perinatal Referral Centers.Copy Citation

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A.
“III” is a Level III perinatal referral center.
B.
“IV” is a Level a Level IV perinatal referral center.

Regulation .03 Organization.Copy Citation

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III IV
A. The hospital’s Board of Directors, administration, and medical and nursing staffs shall demonstrate commitment to its specific level of perinatal center designation and to the care of perinatal patients. This commitment shall be demonstrated by:
(1) A Board resolution that the hospital agrees to meet the current Maryland Perinatal System Standards for its specific level of designation and assures that all perinatal patients shall receive medical care commensurate with that designation; E E
(2) Submission of patient care data to the Maryland Department of Health (MDH) and the Maryland Institute for Emergency Medical Services Systems (MIEMSS), for system and quality management; and E E
(3) A Board resolution, bylaws, contracts, and budgets indicating the hospital’s commitment to the financial, human, and physical resources and to the infrastructure that are necessary to support the hospital’s level of perinatal center designation. E E
B. The hospital shall be licensed by the Maryland Department of Health (MDH) as an acute care hospital. E E
C. The hospital shall be accredited by an organization that has been granted deeming authority by the Centers for Medicare & Medicaid Services and approved by the Maryland Department of Health to accredit hospitals in the State. E E
D. The hospital shall have an agreement with the Health Services Cost Review Commission that addresses how the cost of neonatal intensive care services will be incorporated into the hospital’s population health budget, and the hospital shall have a certificate of need (CON) from the Maryland Health Care Commission (MHCC) in order to provide neonatal intensive care services, defined as a Level III or IV perinatal program, unless establishment of the hospital’s neonatal intensive care services preceded this requirement. A hospital shall obtain a CON in order to establish Level III or IV perinatal program or to expand a Level III perinatal program to Level IV. E E
E. The hospital shall obtain and maintain current equipment and technology, as described in these standards, to support optimal perinatal care for the level of the hospital’s perinatal center designation. E E
F. If maternal or neonatal air transports are accepted, then the hospital shall have a heliport, helipad, or access to a helicopter landing site near the hospital. E E
G. The hospital shall provide specialized maternal and neonatal transport capability and have extensive Statewide perinatal educational outreach programs in both specialties in collaboration with the Maryland Institute for Emergency Medical Services Systems (MIEMSS) and the Maryland Department of Health (MDH). O E

Regulation .04 Obstetrical Unit Capabilities.Copy Citation

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III IV
A hospital shall:
A. Demonstrate its capability of providing obstetrical care through written standards, protocols, or guidelines, including those for the following:
(1) Management of uncomplicated pregnancy; E E
(2) Detection, stabilization, and initiation of management of unanticipated maternal-fetal problems; E E
(3) Fetal monitoring, including internal scalp electrode monitoring; E E
(4) Ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits with the provision of emergency care; and E E
(5) Selection and management of obstetrical patients at a maternal risk level appropriate to its capability. E E
B. Have an on-site intensive care unit that accepts obstetrical patients and has critical care providers on-site to actively collaborate with obstetricians or maternal-fetal medicine specialists at all times. E E

Regulation .05 Neonatal Unit Capabilities.Copy Citation

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III IV
A hospital shall demonstrate its capability of providing neonatal care through written standards, protocols, or guidelines, including those for the following:
A. Resuscitation and stabilization of the neonate according to the current American Academy of Pediatrics/American Heart Association (AAP/AHA) Neonatal Resuscitation Program (NRP) guidelines at every delivery; E E
B. Detection, stabilization, and initiation of management of unanticipated neonatal problems; E E
C. Evaluation and care of stable term newborn infants. E E

Regulation .06 Obstetric Personnel.Copy Citation

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III IV
A hospital shall have:
A. A physician board-certified in obstetrics/gynecology shall be a member of the medical staff and have programmatic responsibility for obstetrical services; E NA
B. A physician board-certified in maternal-fetal medicine shall be a member of the medical staff and have programmatic responsibility for obstetrical services; O E
C. A physician board-certified in maternal-fetal medicine shall be a member of the medical staff and have programmatic responsibility for high-risk obstetrical services; E E
D. A physician board-certified in anesthesiology shall be a member of the medical staff and have programmatic responsibility for obstetrical anesthesia services; E E
E. A physician board-certified or an active candidate for board certification in maternal-fetal medicine on the medical staff, in active practice available at all times and, if needed, in-house within 30 minutes; and E E
F. A physician board-certified or an active candidate for board-certification in obstetrics/gynecology shall be present in-house 24 hours a day and immediately available to the delivery area when a patient is in active labor. E E

Regulation .07 Pediatric Personnel.Copy Citation

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III IV
A hospital shall have:
A. A physician board-certified in pediatrics, neonatal-perinatal medicine, or family medicine shall be a member of the medical staff and have privileges for neonatal care and have programmatic responsibility for neonatal services in the newborn nursery and/or the mother-baby unit; E E
B. A physician board-certified in neonatal-perinatal medicine shall be a member of the medical staff and have programmatic responsibility for neonatal services in the special care nursery or NICU; E E
C. Neonatal Resuscitation Program (NRP) trained professional(s) with experience in acute care of the depressed newborn and skilled in neonatal endotracheal intubation and resuscitation shall be immediately available to the delivery and neonatal units; E E
D. A physician who has completed postgraduate pediatric training, a nurse practitioner, or a physician assistant with privileges for neonatal care appropriate to the level of the nursery and who shall be present in-house 24 hours a day and assigned to the delivery area and neonatal units and not shared with other units in the hospital; E E
E. A physician board-certified or an active candidate for board certification in neonatal-perinatal medicine shall be on the medical staff, in active practice, available at all times, and, if needed, in-house within 30 minutes; E E
F. An ophthalmologist with experience in neonatal retinal examination and an organized program for the monitoring, treatment, and follow up of retinopathy of prematurity; E E
G. The following pediatric subspecialists on staff, in active practice, and, if needed, readily available in-house or via telemedicine:
(1) Cardiology;
(2) Neurology; and
(3) General Pediatric Surgery;		 E NA
H. The following pediatric subspecialties on staff, in active practice, available at all times, and, if needed, in-house within 30 minutes: cardiology, endocrinology, gastroenterology, genetics, hematology, nephrology, neurology, and pulmonology; and O E
I. General Pediatric Surgery and the following pediatric surgical subspecialists on staff, in active practice, available at all times, and, if needed, in-house within 30 minutes:
(1) Neurosurgery;
(2) Cardiothoracic surgery;
(3) Orthopedic surgery;
(4) Plastic surgery; and
(5) Ophthalmology.		 O E

Regulation .08 Other Personnel.Copy Citation

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III IV
A hospital shall have:
A. A physician board-certified or an active candidate for board certification in anesthesiology or nurse-anesthetist who shall be available at all times to provide labor analgesia and surgical anesthesia so that cesarean delivery may be initiated per hospital protocol as required by Regulation .04A of this chapter; E E
B. A physician board-certified or an active candidate for board-certification in anesthesiology who shall be present in-house 24 hours a day, readily available to the delivery area; E E
C. If the hospital performs neonatal surgery, a physician board-certified or an active candidate for board certification in anesthesiology with experience in neonatal anesthesia who shall be present for the surgery; E E
D. A physician on the medical staff with privileges for providing critical interventional radiology services for:
(1) Obstetrical patients; and E E
(2) Neonatal patients; O E
E. On staff, a licensed registered dietician with knowledge of and experience in the management of obstetrical and neonatal parenteral/enteral nutrition; E NA
F. On staff, a licensed registered dietician with knowledge of and experience in the management of obstetrical and neonatal parenteral/enteral nutrition, with one dietician dedicated to the NICU; O E
G. At least one full-time equivalent International Board Certified Lactation Consultant who shall have programmatic responsibility for lactation support services which shall include education and training of additional hospital staff members in order to ensure availability of lactation support 7 days per week; E E
H. A written plan to address lactation consultant/patient ratios recommended in the current Association of Women’s Health, Obstetric, and Neonatal Nurses Guidelines; E E
I. At least one licensed social worker with a Master’s degree (either an LMSW, Licensed Master Social Worker, or an LCSW, Licensed Certified Social Worker) and experience in psychosocial assessment and intervention with women and their families dedicated to the perinatal service; E E
J. At least one licensed social worker with a Master’s Degree (either an LMSW, Licensed Master Social Worker, or an LCSW, Licensed Certified Social Worker) and experience in psychosocial assessment and intervention with women and their families dedicated to the NICU;
K. Respiratory therapists skilled in neonatal ventilator management;
(1) Present in-house 24 hours a day; and E NA
(2) Dedicated to the NICU 24 hours a day; O E
L. At least one occupational or physical therapist with neonatal expertise; E E
M. At least one individual skilled in evaluation and management of neonatal feeding and swallowing disorders such as a speech-language pathologist; E E
N. Genetic diagnostic and counseling services or written consultation and referral agreements for these services in place; E E
O. A pediatric neurodevelopmental follow-up program or written referral agreements for neurodevelopmental follow-up; E E
P. Pharmacy personnel with knowledge of and experience in pediatric pharmacy; E E
Q. Hospital perinatal program shall have on its administrative staff at least one registered nurse with a Master’s degree or higher degree in nursing or a health-related field and experience in high-risk obstetrical and/or neonatal nursing who shall have programmatic responsibility for the obstetrical and neonatal nursing services; E E
R. On its perinatal program staff at least one registered nurse with a Master’s or higher degree in nursing or a health or education-related field and experience in high-risk obstetrical and/or neonatal nursing who shall have programmatic responsibility for the obstetrical and neonatal nursing services; E E
S. Hospital perinatal program shall have on its staff at least one registered nurse with a Master’s or higher degree in nursing or a health or education-related field and experience in high-risk obstetrical and/or neonatal nursing responsible for staff education; E E
T. Obstetrical service shall have continuous availability of adequate numbers of registered nurses with competence in assessment and care of obstetrical patients as well as the recognition and nursing management of obstetrical complications; E E
U. Neonatal service shall have continuous availability of adequate numbers of registered nurses with competence in assessment and care of neonatal patients appropriate to the designated level of care; E E
V. Neonatal service shall have continuous availability of adequate numbers of registered nurses with competence in assessment and care of neonatal patients appropriate to the designated level of care; E E
W. A written plan to address registered nurse/patient ratios recommended in the current Association of Women’s Health, Obstetric, and Neonatal Nurses Guidelines. E E

Regulation .09 Laboratory.Copy Citation

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III IV
A hospital shall:
A. The programmatic leaders of the perinatal service and the hospital laboratory shall establish laboratory processing and reporting times that are appropriate for samples drawn from obstetrical and neonatal patients with specific consideration for the acuity of the patient and the integrity of the samples. E E
B. Demonstrate the capability to immediately receive, process, and report urgent/emergent obstetric and neonatal laboratory requests. E E
C. Have a process in place to report critical results to the obstetric and neonatal services. E E
D. Make laboratory results from standard maternal antepartum testing available to the providers caring for the mother and the neonate prior to discharge. If test results are not available or if testing was not performed prior to admission, such testing shall be performed during the hospitalization of the mother and results available prior to discharge of the newborn. E E
E. Have the capacity to conduct rapid HIV testing 24 hours a day. E E
F. Have available the equipment and trained personnel to perform newborn hearing screening prior to discharge on all infants born at or transferred to the institution as required by COMAR 10.11.02. E E
G. Have available the equipment and trained personnel to perform critical congenital heart disease screening between 24 and 48 hours of age on all well infants born at or transferred to the institution and report screening results as required by COMAR 10.52.15. E E
H. Have a protocol to perform critical congenital heart disease screening on all infants in the special care nursery or neonatal intensive care unit born at or transferred to the institution and to report screening results as required by COMAR 10.52.15. E E
I. Have available the equipment and trained personnel to collect newborn blood-spot screening on all infants born at or transferred to the institution at the appropriate time/intervals and to transport blood-spot specimens to the Maryland State Newborn Screening Laboratory as required by COMAR 10.52.12 and 10.10.13.14. E E
J. Have blood bank technicians present in-house 24 hours a day. E E
K. Have molecular, cytogenetic, and biochemical genetic testing. E E

Regulation .10 Diagnostic Imaging Capabilities.Copy Citation

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III IV
A hospital shall have:
A. The capability of providing emergency ultrasound imaging and interpretation for obstetrical patients 24 hours per day; E E
B. The capability of providing detailed ultrasonography and fetal assessment, including Doppler studies, with interpretation for obstetrical patients 24 hours a day; E E
C. The capability of providing maternal echocardiology with interpretation for obstetrical patients 24 hours a day; E E
D. The capability of providing portable x-ray imaging with interpretation for neonatal patients 24 hours a day; E E
E. The capability of providing portable head ultrasound with interpretation for neonatal patients; E E
F. The capability on campus of providing computerized tomography (CT) and magnetic resonance imaging (MRI) with interpretation; O E
G. Neonatal echocardiography equipment and an experienced technician shall be available on campus as needed with interpretation by a pediatric cardiologist; E E
H. A pediatric cardiac catheterization laboratory and appropriate staff; and O E
I. The capability of providing interventional radiology services for:
(1) Obstetrical patients; and E E
(2) Neonatal patients. O E

Regulation .11 Equipment.Copy Citation

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III IV
A hospital shall have:
A. All of the following equipment and supplies immediately available for existing patients and for the next potential patient:
(1) O2 analyzer, stethoscope, intravenous infusion pumps;
(2) Radiant heated bed in delivery room and available in the neonatal units;
(3) Oxygen hood with humidity;
(4) Bag and masks and/or T-piece resuscitator capable of delivering a controlled concentration of oxygen to the infant;
(5) Orotracheal tubes;
(6) CO2 detector;
(7) Aspiration equipment;
(8) Laryngoscope;
(9) Bowel bags;
(10) Umbilical vessel catheters and insertion tray;
(11) Cardiac monitor;
(12) Pulse oximeter;
(13) Transilluminator;
(14) Phototherapy unit;
(15) Doppler blood pressure for neonates;
(16) Cardioversion/defibrillation capability for obstetrical patients and neonates;
(17) Resuscitation equipment for obstetrical patients;
(18) Resuscitation equipment for neonates including equipment outlined in the current NRP;
(19) Individual oxygen, air, and suction outlets for obstetrical patients and neonates; and
(20) Emergency call system for both obstetrical and neonatal units as well as an emergency communication system among units.		 E E
B. Special equipment and facilities needed to accommodate the care and services needed for obese women. E E
C. A neonatal stabilization bed set up and equipment available at all times for an emergency admission; E E
D. Fetal diagnostic testing and monitoring equipment for:
(1) Fetal heart rate monitoring; E E
(2) Ultrasound examinations; and E E
(3) Amniocentesis; E E
E. The capability to monitor neonatal intra-arterial pressure; E E
F. The capability on campus of providing laser coagulation for retinopathy of prematurity; E E
G. The capability on campus of providing a full range of invasive maternal monitoring including equipment for central venous pressure and arterial pressure monitoring; E E
H. Appropriate equipment, including back-up equipment, for neonatal respiratory care as well as protocols for the use and maintenance of the equipment as required by its level of neonatal care; E E
I. The capability of providing advanced ventilatory support, beyond conventional mechanical ventilation, for neonates of all birth weights; and O E
J. The capability of providing continuing therapeutic hypothermia. O E

Regulation .12 Medications.Copy Citation

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III IV
A hospital shall have:
A. Emergency medications, as listed in the current Neonatal Resuscitation Program (NRP) guidelines, shall be immediately available in the delivery area and neonatal units; E E
B. The following medications shall be immediately available to the neonatal units:
(1) Antibiotics, anticonvulsants, and emergency cardiovascular drugs; and E E
(2) Surfactant, prostaglandin E1; E E
C. All emergency resuscitation medications to initiate and maintain resuscitation, in accordance with current Advanced Cardiac Life Support (ACLS) guidelines of the American Heart Association (AHA), shall be immediately available in the delivery area; E E
D. The following medications shall be immediately available for management of obstetrical hemorrhage in the delivery area and postpartum floor:
(1) Oxytocin (Pitocin);
(2) Methylergonovine (Methergine);
(3) Misoprostol (Cytotec);
(4) Carboprost tromethamine (Hemabate);
(5) Tranezamic acid (TXA); and		 E E
E. The following medications shall be immediately available for management of hypertensive crisis in all obstetrical care areas:
(1) Hydralazine;
(2) Labetalol; and
(3) Nifedipine.		 E E

Regulation .13 Education Programs.Copy Citation

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III IV
A hospital shall:
A. Identify minimum competencies for obstetrical and neonatal clinical staff, not otherwise credentialed, that are assessed prior to independent practice and on a regular basis thereafter; E E
B. Provide continuing education programs available to all obstetrical and neonatal clinical staff concerning the treatment and care of obstetrical and neonatal patients; E E
C. Conduct multidisciplinary clinical drills or simulations including post-drill debriefs to help prepare obstetrical and neonatal staff for high risk, high complexity, low frequency events; E E
D. Provide evidence-based education every two years to all staff caring for newborns (nurses, respiratory therapist, technicians, etc.) that includes at a minimum stabilization after immediate resuscitation to address glucose metabolism, thermoregulation, respiratory support hemodynamic monitoring and stability, risk and treatment of infection, and support for the family; and E E
E. Accept maternal or neonatal primary transports and provide the following to the referring hospital/providers:
(1) Guidance on indications for consultation and referral of patients at high risk;
(2) Information about the accepting hospital’s response times and clinical capabilities;
(3) Information about alternative sources for specialized care not provided by the accepting hospital;
(4) Guidance on the pre-transport stabilization of patients; and
(5) Feedback on the pre-transport and post-transport care of patients.		 E E

Regulation .14 Quality Improvement.Copy Citation

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III IV
A hospital shall:
A. Have a multi-disciplinary Perinatal Quality Improvement Program which meets at least quarterly to evaluate maternal and neonatal health outcomes and to identify process changes to improve patient safety and perinatal outcomes. E E
B. The Perinatal Quality Improvement Program shall conduct internal case reviews, collect and analyze perinatal program data, conduct trend analyses, set quality improvement goals annually, and use data to assess progress toward those goals. E E
C. The Perinatal Quality Improvement Program shall conduct reviews of all cases of the following as well as cases related to other patient safety and systems issues identified:
(1) Maternal, intrapartum fetal, and neonatal deaths;
(2) Transports to a higher or comparable level of care; and
(3) Elective delivery at less than 39 weeks gestation.		 E E
D. Participate with the Maryland Department of Health and local health department Fetal and Infant Mortality Review program. E E
E. Participate in the collaborative collection and assessment of data with the Maryland Department of Health and/or the Maryland Institute for Emergency Medical Services Systems, for the purpose of improving perinatal health outcomes. E E
F. Maintain membership in the Vermont Oxford Network. E E

Regulation .15 Policies and Protocols.Copy Citation

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III IV
A hospital shall have:
A. Written policies and protocols for the initial stabilization and continuing care of all obstetrical and neonatal patients appropriate to the designated level of care; E E
B. Maternal and neonatal resuscitation protocols; E E
C. A medical staff credentialing process that shall include documentation of competency to perform obstetrical and neonatal invasive procedures appropriate to its designated level of care; E E
D. A written protocol for the initiating maternal and neonatal transports to an appropriate level of care; E NA
E. A written protocol for the acceptance of maternal and neonatal transports; E E
F. Written protocols for accepting or transferring obstetrical patients or neonates as “back transports”; E E
G. A licensed neonatal transport service or written agreement with a licensed neonatal transport service; E E
H. Policies that allow families (including siblings) to be together in the hospital following the birth of an infant and that promote parental involvement in the care of the neonate including those in the NICU; E E
I. A policy to eliminate deliveries by induction of labor or by cesarean section prior to 39 weeks gestation without a medical indication with a systematic internal review process to evaluate any occurrences and a plan for corrective action;
J. Written protocols and capabilities in place for the following:
(1) Assessment of risk for obstetrical hemorrhage;
(2) Maximizing accuracy in determining obstetrical blood loss;
(3) Massive transfusion;
(4) Emergency release of blood products before full compatibility testing is complete; and
(5) Management of multiple component therapy;		 E E
K. Written protocol to evaluate all infants born at or transferred to the institution for birth defects and to report findings to the Birth Defects Reporting and Information System as required by Health-General Article, §18-206, Annotated Code of Maryland; E E
L. Written policy for the management of obstetrical patients with opioid use and opioid use disorder that addresses the following and other relevant issues:
(1) Universal screening of obstetrical patients for opioid use;
(2) Pharmacotherapy of the pregnant, laboring, and postpartum patient;
(3) Breastfeeding;
(4) Linkages to appropriate postpartum psychosocial support services including substance use treatment and relapse prevention program; and
(5) Reproductive health planning;		 E E
M. Written policy for the identification and management of neonatal abstinence syndromes; E E
N. Written policy for optimizing post-delivery care of obstetrical patients that addresses the following and other relevant issues:
(1) Identification of postpartum patients at risk for poor health outcomes;
(2) Breastfeeding support;
(3) Linkages to appropriate medical and psychosocial services; and
(4) Reproductive health planning;		 E E
O. Written policy to address infant safety issues including safe sleep, abusive head trauma (shaken baby) and car seat safety. E E
Chapter annotations
Authority: Education Article, §13-509, Annotated Code of Maryland
History: Effective date: March 24, 1997 (24:6 Md. R. 488)
History: Regulation .03A, D amended effective July 1, 2002 (29:12 Md. R. 934)
History: Regulation .04A, C amended effective August 7, 2000 (27:15 Md. R. 1403)
History: Regulation .05A amended effective August 7, 2000 (27:15 Md. R. 1403)
History: Regulation .06 repealed and new Regulation .06 adopted effective August 7, 2000 (27:15 Md. R. 1403)
History: Regulation .07A—D amended effective August 7, 2000 (27:15 Md. R. 1403)
History: Regulation .08 amended effective August 7, 2000 (27:15 Md. R. 1403)
History: Regulation .09A amended effective August 7, 2000 (27:15 Md. R. 1403)
History: Regulation .10 amended effective August 7, 2000 (27:15 Md. R. 1403)
History: Regulation .11 amended effective August 7, 2000 (27:15 Md. R. 1403)
History: Chapter revised effective May 15, 2005 (32:9 Md. R. 850)
History: Regulations .01—.15 repealed and new Regulations .01—.15 adopted effective January 13, 2011 (38:1 Md. R. 12)
History: Regulations .01—.15 amended effective March 30, 2015 (42:6 Md. R. 514)
History: Regulation .01B amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .03 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .03C amended effective July 21, 2025 (52:14 Md. R. 714)
History: Regulation .04 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .05 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .06 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .07 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .08 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .09 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .10 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .11 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .11I amended effective December 10, 2015 (42:24 Md. R. 1506)
History: Regulation .12 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .13 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .14 amended effective October 3, 2022 (49:20 Md. R. 913)
History: Regulation .15 amended effective October 3, 2022 (49:20 Md. R. 913)