10.07.11.07

.07 Personnel.

A. When applicable, each staff member of the HMO shall be licensed as required by State and local law, and meet acceptable professional qualifications or have qualified by means of an occupational proficiency examination or through acceptable training. Provider staff patterns shall be designed to meet enrollee needs.

B. The HMO shall provide orientation for all new employees and require continuing education of all professional and supportive personnel which reflects advances in medical knowledge and enrollee health education.

C. The HMO shall establish a formal written process for:

(1) Appointment of a physician or certified nurse practitioner to the clinical staff of the HMO;

(2) Employment of a physician or certified nurse practitioner by the HMO; or

(3) Selection of a physician or certified nurse practitioner to provide services to the enrollees under contract with the HMO.

D. Information Concerning a Physician's or Certified Nurse Practitioner's Background and Training.

(1) As part of the formal written process in §C of this regulation, the HMO shall collect, review, and verify the information concerning a physician's or certified nurse practitioner's background and training in §D(2) and (3) of this regulation.

(2) Information that shall be collected, reviewed, and verified for a physician or certified nurse practitioner includes:

(a) Evidence of education;

(b) Evidence of current license to practice in the State;

(c) Evidence of internship, residency training, or other pertinent training;

(d) Evidence of specialty certification;

(e) Evidence of Drug Enforcement Administration or Controlled Dangerous Substances registration;

(f) Evidence of malpractice insurance coverage;

(g) Physical and mental status;

(h) List of all hospitals where the physician or certified nurse practitioner has current privileges or is employed;

(i) Evidence of any adverse action or restriction of privileges imposed by any hospital or Board;

(j) Delineation of services to be provided to patients at the HMO;

(k) Past malpractice claims history;

(l) Verification of status through the federal National Practitioner Data Bank; and

(m) Cooperative arrangement with a physician for each certified nurse practitioner.

(3) For a physician who has privileges in a licensed Maryland hospital, the HMO may verify, through the hospital, the credentials described in §D(2)(a)—(f) of this regulation.

E. Reevaluation of Physicians or Certified Nurse Practitioners.

(1) The HMO shall establish a formal written process for the reevaluation of appointment, employment, or selection of a physician or certified nurse practitioner.

(2) The reevaluation shall include an ongoing process for verifying:

(a) Current State Licensure;

(b) Current Controlled Dangerous Substances or Drug Enforcement Administration registration; and

(c) Evidence of current malpractice insurance.

(3) Every 3 years, the reevaluation also shall include the following for all physicians and certified nurse practitioners:

(a) An update of the requirements of §D of this regulation;

(b) An assessment of the performance pattern based on an analysis of:

(i) Complaints filed through the grievance system;

(ii) Malpractice claims filed;

(iii) Utilization, quality, and risk data;

(iv) Adherence to policies, bylaws, and procedures; and

(v) Physician and certified nurse practitioner practice patterns as reviewed through the HMO's quality assurance program.

F. Administrator.

(1) At least one administrator shall be appointed by the governing body and delegated the responsibility for the internal operation of the HMO according to established policies. The administrator's responsibility for procurement and direction of personnel shall be clearly defined. An individual competent and authorized to act in the absence of the administrator shall be designated.

(2) The HMO shall notify the Department of the name of the person appointed administrator and of any change in the appointment.

G. Medical Director. The HMO shall have a medical director who is licensed to practice medicine in the State. A physician authorized to act in the absence of the medical director shall be designated. The medical director shall oversee the quality of care provided to the HMO's patients. If the medical director becomes aware of unethical or unprofessional conduct on the part of any health provider, the medical director shall take appropriate action to prevent future occurrences of this conduct.

H. The HMO shall have a licensed registered nurse present to perform nursing services at all times that these services are required.