1. A. The facility shall plan and implement a quality assurance program which includes:

   1. (1) Monitoring and evaluation of the quality of patient care;
   2. (2) Identification, evaluation, and resolution of care problems; and
   3. (3) A peer review process.
2. B. The facility shall conduct ongoing quality assurance activities and document the activities on a continuous basis, but not less than quarterly.

3. C. Peer Review. The facility shall establish a peer review process that includes:

   1. (1) A mechanism to evaluate the clinical performance of each health care practitioner on a continuous basis, but not less than annually;
   2. (2) Procedures, approved by a supervising physician, to identify and minimize risks to the patient; and
   3. (3) Documentation of each health care practitioner's annual evaluation.

4. D. Equipment Quality Control.

   1. (1) The facility shall develop and implement a quality control procedure to monitor the safety and performance of all biomedical equipment.

   2. (2) In developing its procedures, the facility shall consider:

      1. (a) FDA recommendations; and
      2. (b) The equipment manufacturer's recommendations.

5. E. Quality Assurance Records. The facility shall document the following information for all quality assurance activities:

   1. (1) A description of identified problems;
   2. (2) Findings;
   3. (3) Conclusions;
   4. (4) Recommendations;
   5. (5) Actions taken;
   6. (6) Results; and
   7. (7) Follow-up.

Authority: Health-General Article, §§19-301, 19-307, 19-307.1, 19-308, 19-319, 19-320, and 19-323, Annotated Code of Maryland

Effective date:

Regulations .01—.06 adopted as an emergency provision effective August 23, 1985 (12:19 Md. R. 1842); emergency status expired November 21, 1985; adopted permanently effective December 2, 1985 (12:24 Md. R. 2348)

Chapter, Freestanding Emergency Facilities, repealed as an emergency provision effective July 1, 2000 (27:16 Md. R. 1519); repealed permanently effective October 30, 2000 (27:21 Md. R. 1975)

Chapter, Limited Service Hospital, Regulations .01—.10 adopted as an emergency provision effective July 1, 2000 (27:16 Md. R. 1519); adopted permanently effective October 30, 2000 (27:21 Md. R. 1975)

Regulation .03A amended effective March 13, 2017 (44:5 Md. R. 292)

Regulation .04A amended effective March 13, 2017 (44:5 Md. R. 292)