10.12.01.06

.06 Personnel.

A. Qualifications of Physicians and Staff. A facility shall ensure that all physicians and other health professionals who are employees or contractual staff have been appropriately trained and licensed or certified under the Health Occupations Article, Annotated Code of Maryland.

B. Credentialing of Physicians. The facility shall collect, review, and document the following information concerning a physician licensed under Health Occupations Article, Title 14, Annotated Code of Maryland:

(1) The physician's education;

(2) The professional experience of the physician, including:

(a) Any board certification or specialty training of the physician; and

(b) Any post-graduate training;

(3) Any license or registration to practice a health occupation ever held by the physician, including DEA registration;

(4) Any hospital where the physician was appointed or employed during the last 10 years, including:

(a) The name of the hospital;

(b) The term of appointment or employment; and

(c) Privileges held and any disciplinary action taken, including suspension, revocation, limitation, or voluntary surrender;

(5) The physician's professional liability insurance for the last 5 years, including:

(a) The physician's present carrier;

(b) The physician's current limits of coverage;

(c) The physician's current types of coverage; and

(d) Restrictions on the physician's coverage;

(6) Any claim that has been made against the physician in the practice of a health occupation in the last 5 years, and the status of the claim;

(7) Any physical or mental condition that currently impairs the physician's ability to exercise privileges;

(8) Any complaint or report, permitted to be disclosed by law, which has been filed with any state licensing or disciplinary body, or comparable body of the armed forces; and

(9) Data provided by the National Practitioner Data Bank.

C. For a physician who has privileges in a licensed Maryland hospital, the administrator may verify, through the hospital, the credentials described in žB of this regulation.

D. The administrator shall establish a procedure for the biennial reappointment of a physician which includes:

(1) An update of the information required in §B of this regulation; and

(2) An assessment of the physician's performance pattern based on an analysis of:

(a) Complaints filed with the facility;

(b) Malpractice claims filed;

(c) Utilization, quality, and risk data;

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

(e) Physician practice patterns as reviewed through the facility's quality assurance program.

E. Credentialing of Health Professionals.

(1) Direct Hires.

(a) The facility shall collect, review, and verify evidence of the following information for all licensed or certified health professionals that are employed by the facility:

(i) A current license or certificate to practice in this State; and

(ii) Malpractice insurance, if required by the facility.

(b) The administrator shall approve the delineation of services to be provided by the health professional.

(2) Nondirect Hires. When a licensed physician uses a health professional to provide services at the facility, and that person is not employed by the facility, the licensed physician who employs the health professional is responsible for verifying the information required in §E(1) of this regulation.