Maryland Health - General Section 19-308

      (a)      The Secretary shall adopt reasonable rules and regulations that set standards of services for related institutions, nonaccredited hospitals, and nonaccredited residential treatment centers in the following areas:

            (1)      The care of patients;

            (2)      The medical supervision of patients;

            (3)      The physical environment;

            (4)      Disease control;

            (5)      Sanitation;

            (6)      Safety; and

            (7)      Dietary matters.

      (b)      (1)      To assure compliance with the standards adopted under this subtitle, the Secretary shall have an inspection made:

                  (i)      Of each related institution, each nonaccredited hospital, and each nonaccredited residential treatment center for which a license is sought; and

                  (ii)      Periodically of each related institution, each nonaccredited hospital, and each nonaccredited residential treatment center for which a license has been issued.

            (2)      An accredited hospital and an accredited residential treatment center shall be subject to inspections under this subtitle by the Department to:

                  (i)      Investigate a complaint in accordance with § 19-309 of this part;

                  (ii)      Review compliance with a written progress report or other documentation of corrective action in response to a focused survey submitted by the hospital or residential treatment center to the Joint Commission on Accreditation of Healthcare Organizations in response to a Type I finding that the hospital or residential treatment center is only in partial compliance with the patient care standards established by the Joint Commission on Accreditation of Healthcare Organizations; or

                  (iii)      Monitor corrective action, in accordance with § 19-360 of this subtitle, for any serious or life-threatening patient care deficiency identified by the Joint Commission on Accreditation of Healthcare Organizations, the Centers for Medicare and Medicaid Services, or the Department.

            (3)      In addition to other provisions of this subsection, an accredited hospital shall be subject to inspections under this subtitle by the Department for reviewing compliance with licensure requirements for risk management, utilization review, and physician credentialing under § 19-319 of this subtitle.

            (4)      When conducting an inspection of an accredited hospital or accredited residential treatment center, the Department shall use the current applicable standards of the Joint Commission on Accreditation of Healthcare Organizations.

            (5)      At least 2 inspections a year of each related institution shall be unannounced.

            (6)      The part of a building that contains part of a hospital, residential treatment center, or related institution and any outbuilding are considered part of the facility and are subject to inspection to determine occupancy status for licensing purposes.

            (7)      Subject to § 2-1246 of the State Government Article, during each regular session of the General Assembly, the Department shall submit to the General Assembly a report on the inspections.

            (8)      (i)      An employee of the Department may not inform a hospital, residential treatment center, or related institution of any proposed inspection activity, unless the chief of the employee's division directs the employee to do so.

                  (ii)      An employee who violates any provision of this paragraph is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 or imprisonment not exceeding 1 year or both.

      (c)      (1)      An accredited hospital or accredited residential treatment center shall submit the survey findings of the Joint Commission on Accreditation of Healthcare Organizations within 30 days of receipt by the hospital or the residential treatment center to the Department.

            (2)      Except as provided in paragraph (5) of this subsection, an accredited hospital's or accredited residential treatment center's official accreditation report and any summary of the report, written progress reports, or plans of correction which are submitted to the Secretary are confidential and are not discoverable or admissible as evidence in any civil action.

            (3)      The Secretary shall refer any request for public inspection of a survey report made by the Joint Commission on Accreditation of Healthcare Organizations for an accredited hospital or accredited residential treatment center directly to the hospital or residential treatment center.

            (4)      Upon the written request of any person, within 15 working days, the accredited hospital or accredited residential treatment center shall make available for public inspection the most recent accreditation letter and any Type I recommendations if the Joint Commission on Accreditation of Healthcare Organizations has made a final decision on any appeal by the hospital or residential treatment center of the Type I recommendations.

            (5)      If information is released in accordance with paragraph (4) of this subsection, that information is no longer confidential, but is not discoverable or admissible in any civil action.

            (6)      An accreditation report, including any summary of the report and any information contained in the report, disclosed by a hospital or residential treatment center, the Joint Commission on the Accreditation of Healthcare Organizations, or the Department is not admissible or discoverable in any civil action.

            (7)      If an accredited hospital or accredited residential treatment center willfully fails to comply with the provisions of this subsection, the Secretary may impose a penalty not to exceed $1,000 a day for each day the violation continues.