Sec. 10.05.05.05. Personnel

A. Credentialing of Physicians, Dentists, Podiatrists.

(1) As part of the formal written appointment process, the administrator, in consultation with the medical director, shall collect, review, and document the following information concerning a physician, dentist, or podiatrist licensed under the Health Occupations Article, Annotated Code of Maryland:

(a) The physician's, dentist's, or podiatrist's education;

(b) The professional experience of the physician, dentist, or podiatrist, including:

(i) Any board certification or specialty training of the physician, dentist, or podiatrist; and

(ii) Any post-graduate training;

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

(d) Whether any license or registration to practice a health occupation ever held by the physician, dentist, or podiatrist has been:

(i) Suspended; or

(ii) Revoked;

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

(i) The name of the hospital;

(ii) The term of appointment or employment; and

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

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

(i) The physician's, dentist's, or podiatrist's present carrier;

(ii) The physician's, dentist's, or podiatrist's current limits of coverage;

(iii) The physician's, dentist's, or podiatrist's current types of coverage; and

(iv) Restrictions on the physician's, dentist's, or podiatrist's coverage;

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

(h) Any physical or mental condition that currently impairs the physician's, dentist's, or podiatrist's ability to exercise privileges;

(i) 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

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

(2) The administrator shall consider the delineation of services requested by each physician, dentist, or podiatrist and approve, deny, or modify the request as the administrator deems appropriate.

B. For a physician, dentist, or podiatrist who has privileges in a licensed Maryland hospital, the administrator may verify, through the hospital, the credentials described in §A(1) of this regulation.

C. The administrator shall establish a procedure for the biennial reappointment of each physician, dentist, or podiatrist. The procedures shall include an evaluation of the following for all physicians, dentists, or podiatrists:

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

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

(a) Complaints filed with the freestanding ambulatory surgical facility;

(b) Malpractice claims filed;

(c) Utilization, quality, and risk data;

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

(e) Physician, dentist, or podiatrist practice patterns as reviewed through the freestanding ambulatory surgical facility's quality assurance program.

D. Credentialing of Allied Health Professionals.

(1) Direct Hires.

(a) The Administrator, in consultation with the medical director, shall collect, review, and verify evidence of the following information for all licensed or certified allied health professionals that are employed by the freestanding ambulatory surgical 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 each allied health professional.

(2) Nondirect Hires. When a licensed physician, dentist, or podiatrist uses an allied health practitioner to provide services at the freestanding ambulatory surgical facility, and that person is not employed by the facility, the licensed physician, dentist, or podiatrist who employs the allied health practitioner is responsible for verifying the information required in §D(1) of this regulation.

E. Medical Director.

(1) The freestanding ambulatory surgical facility shall have a medical director who:

(a) Is responsible for the overall medical care that is provided by the facility; and

(b) Advises and consults with the staff of the facility on all medical issues relating to services provided by the facility.

(2) The medical director shall be a physician, dentist, or podiatrist licensed to practice in the general areas for which the freestanding ambulatory surgical facility provides services.