10.32.22.03

.03 Mandated Reports.

A. Subject to the limitations set out in §§B, C and E of this regulation, the reporting entity shall report to the Board in writing any change made with respect to a health care provider:

(1) Whom the reporting entity employs;

(2) Who works with the reporting entity under contract; or

(3) To whom the reporting entity has granted privileges.

B. A reporting entity shall inform the Board of any change that has been made, in whole or in part, because the reporting entity had reason to believe that the health care provider:

(1) Abandoned a patient;

(2) Provided patient care of questionable quality;

(3) Disrupted the workplace;

(4) Committed unethical or unprofessional conduct;

(5) Committed billing or coding fraud;

(6) Used the reporting entityís employment or privileges to commit illegal or unethical business practices;

(7) Suffers from a physical, a mental, or an emotional condition or impairment that affects the health care providerís ability to perform the individualís medical or surgical duties;

(8) Is habitually intoxicated by alcohol or a controlled dangerous substance;

(9) Provided care while under the influence of alcohol or while abusing or misusing any controlled dangerous substance or mood-altering substance;

(10) Has not complied with the requirements of an alcohol or a drug treatment program;

(11) With respect to allied health providers, failed to notify the reporting entity of the health care providerís decision to enter into an alcohol or a drug treatment program;

(12) Performed care beyond the scope of licensure or privileges or delegated duties, or delegated duties to an individual not authorized to perform those duties;

(13) Repeatedly failed to complete medical records;

(14) Repeatedly violated hospital bylaws, rules, policies, or procedures after warning; or

(15) Committed any other act or suffered from any other condition which the reporting entity had reason to believe may constitute a violation of the Acts.

C. Specific Changes Not Reportable. The following changes do not require reporting by a reporting entity:

(1) Voluntary leaves of absence that:

(a) Are not involuntary leaves of absence as defined in Regulation .02 of this chapter;

(b) Are taken by a health care provider who is in good standing; and

(c) May be caused by, for example:

(i) Maternity leave;

(ii) Family problems of a medical or other personal nature;

(iii) Medical problems that do not implicate the health care providerís physical, mental, or emotional ability to provide competent care;

(iv) Military deployment;

(v) Sabbaticals;

(vi) Extended vacations; or

(vii) Absences for professional training;

(2) Voluntary resignations that:

(a) Are not involuntary resignations as defined in Regulation .02 of this chapter;

(b) Are submitted by a health care provider who is in good standing; and

(c) May be caused by, for example:

(i) A job or career change;

(ii) The health care providerís desire to relocate from Maryland;

(iii) The health care providerís desire to retire; or

(iv) A decision by an individual in a postgraduate training program to leave the program to pursue another specialty before the expiration of the term of the training program originally contemplated;

(3) Voluntary alterations in practice that:

(a) Are not involuntary alterations in practice as defined in Regulation .02 of this chapter;

(b) Are submitted by a health care provider who is in good standing; and

(c) May be caused by, for example, a health care providerís desire to:

(i) Switch from active practice to consulting;

(ii) Reduce workload; or

(iii) Alter a specialty or scope of practice;

(4) With respect to allied health providers, the initial denial of employment or privileges;

(5) With respect to physicians, an involuntary alteration in practice that:

(a) Results solely from an FPPE or a focused review;

(b) Does not by itself or in combination with any other involuntary alteration in practice exceed 90 days in any one calendar year;

(c) Consists solely of one or more of the following:

(i) A program of additional training or monitoring or heightened scrutiny of the individualís practice; or

(ii) A requirement that the individual successfully perform a skill, an activity, or a procedure a specific number of times, or within a specific time period; and

(d) Does not result from inappropriate sexual behavior, harassment, or any other unprofessional conduct in the workplace;

(6) With respect to physicians, the initial denial of employment or privileges due solely to the applicantís:

(a) Inability to fulfill on-call requirements because of other time commitments;

(b) Lack of a board certification required by the reporting entity; or

(c) Lack of experience in conducting a particular medical procedure;

(7) Administrative suspensions, if the sum total does not cumulatively exceed 30 days in any one calendar year, imposed on or agreed to by the health care provider, solely for the health care providerís failure to:

(a) Acquire mandated vaccinations or required serum titers for infections;

(b) Attend required meetings;

(c) Complete medical records;

(d) Complete required training; or

(e) Maintain or submit a certificate of professional insurance;

(8) With respect to an individual in a postgraduate training program:

(a) The expiration of the postgraduate training program contract at the end of its term as originally contemplated and while the individual is in good standing with the program; or

(b) Academic probation, unless imposed for any of the reasons set out in §B(3), (4), (8), or (9) of this regulation.

(9) With respect to allied health providers and subject to the requirements of §E(1) and (2) of this regulation, entrance into an alcohol or a drug treatment program:

(a) That is accredited by the Joint Commission;

(b) That is certified by the Maryland Department of Health;

(c) To which the allied health provider is referred by the Maryland Physician Health Program or the Maryland Healthcare Professionals Program; or

(d) Provided by a health care practitioner who is competent and capable of dealing with alcoholism and drug abuse.

(10) With respect to physicians and subject to the requirements of §E(3) and (4) of this regulation, entrance into an alcohol or a drug treatment program:

(a) That is accredited by the Joint Commission;

(b) That is certified by the Maryland Department of Health; or

(c) To which the physician is referred by the Maryland Physician Health Program.

D. With respect to physicians, each reporting entity shall file a report with the Board that contains the name of each licensed physician who, during the 6 months preceding the report, was employed by, had privileges with, or applied for privileges with that entity.

E. Exceptions to §C(9) and (10) of this Regulation.

(1) Section C(9) of this regulation applies only where:

(a) The allied health provider notified the reporting entity at the time the allied health provider decided to enter the program;

(b) The reporting entity is able to verify that the allied health provider remains continually in the program until properly discharged; and

(c) The action or condition of the allied health provider had not caused injury to any individual during the provision of health care by the allied health provider.

(2) Section C(9) of this regulation does not apply to:

(a) Any change made by a reporting entity relating to the discharge of an allied health provider from an alcohol or a drug treatment program, when that discharge was for non-attendance or non-compliance with the program;

(b) Additional changes made by the reporting entity, other than minor scheduling changes made solely to accommodate participation in the program; or

(c) Any change made by the reporting entity based on events set out in Regulation .03B which occurred subsequent to the providerís entrance into the alcohol or drug treatment program;

(3) Section C(10) of this regulation applies only where:

(a) The physician notified the reporting entity at the time the physician decided to enter the program;

(b) The reporting entity is able to verify that the physician remains continually in the program until properly discharged; and

(c) The action or condition of the physician had not resulted in injury to any individual during the provision of health care by the physician.

(4) Section C(10) of this regulation does not apply to:

(a) Any change made by a reporting entity relating to the discharge of a physician by an alcohol or a drug treatment program, when that discharge was for non-attendance or non-compliance with the program;

(b) Additional changes made by the reporting entity, other than minor scheduling changes made solely to accommodate participation in the program; or

(c) Any change made by the reporting entity relating to events set out in §B of this regulation which occurred subsequent to the physicianís entrance into the alcohol or drug treatment program.