Mandated Reports by Employers Requirements

Any person or entity that enters into an arrangement for professional services, whether paid, unpaid, contractual, or otherwise, with an individual licensed under Health Occupations, Title 14 or Title 15, Annotated Code of Maryland. This includes but is not limited to hospitals, private practices, urgent cares, long-term care facilities, HMOs, federally qualified health centers, universities, and any other person or entity that falls under the statutory definition of “employer” in Health Occupations, §14-101, Annotated Code of Maryland.

Mandated reports are required for all health professionals that the Board regulates. This includes: physicians, physician assistants, radiographers, radiology assistants, radiation therapists, nuclear medicine technologists, perfusionists, respiratory care practitioners, naturopathic doctors, and genetic counselors.

Employers must report if they have:

1. Reduced, suspended, revoked, restricted, denied, conditioned, or did not renew the employee's clinical privileges, employment, or other ability to practice or treat patients;
2. Involuntarily terminated or restricted the employee's employment or staff membership; OR
3. Asked the employee to voluntarily resign because of the employee's conduct or while the employee is being investigated;
AND if the action was taken:
4. For reasons that may be grounds for disciplinary action;
5. Because the employee may have engaged in an act that may constitute unprofessional conduct;
6. Because the employee may be unable to practice with reasonable skill and safety because of a physical or mental condition or professional incompetence; OR
7. Because the employee may have harmed or placed one or more patients or the public at unreasonable risk of harm by engaging in an act that created an immediate or continuing danger.

One or more conditions from each list must occur to trigger a mandated report. (Health Occupations, §§ 14-5A-18, 14-5B-15, 14-5C-18, 14-5D-11.5, 14-5E-18, 14-5F-19, 14-5G-20, and 15-103).

As of April 18, 2017, employers are no longer required to submit a list to the Board every six months of individuals employed by, granted privileges by, or applying for privileges at the hospital.

No. These requirements are no longer in effect.

No. Employers do not determine if an action violates the Maryland Medical Practice Act. If a reportable action occurs, the Board will determine if it violated the Maryland Medical Practice Act after a mandated report is filed and reviewed.

No. The employer must report the reportable action within ten business days of occurrence. Employers are not required to characterize the underlying conduct.

No. The employer must report the reportable action within ten business days of occurrence.

No. The employer must report the reportable action within ten business days of occurrence.

Yes. A voluntary leave of absence by an employee in good standing may be non-reportable. This may include, but is not limited to:

1. Employer-approved Family Medical Leave
2. Family problems of a medical or other personal nature
3. Medical problems that do not implicate the health care professional's mental or emotional ability to provide competent care
4. Employer-approved leave as a reasonable accommodation under the Americans with Disabilities Act, State law, or the employer's sick leave policy
5. Military deployment
6. Sabbaticals
7. Extended vacations
8. Initial denial of employment or privileges not due to disciplinary reasons
9. Administrative suspensions of less than 30 cumulative calendar days

Do not file a report on an action that is not reportable. The Board will dismiss the case.

1. Dr. Jane Doe and Hospital A mutually terminated Dr. Doe's employment contract. After the contract was terminated, Dr. Doe resigned her clinical privileges, which were in good standing.
2. Dr. John Doe voluntarily relinquished his clinical privileges at Hospital B and decided to focus on teaching and research activities.
3. Dr. Jane Doe's practice group did not renew its contract with Hospital C, leading to the automatic termination of her clinical privileges there.

An administrative suspension is non-reportable if it is less than 30 cumulative calendar days. The Board may impose an administrative suspension due to the employee's failure to:

1. Acquire mandated vaccinations or required serum titers for infections;
2. Attend required meetings;
3. Complete medical records;
4. Complete required training; or
5. Maintain or submit a certificate of professional insurance.

Yes. A medical committee, medical board, or any other entity within an employer is considered part of the employer.

The statute requires each employer to file a report. Any entity that meets the statutory definition of employer for a health care professional must submit a mandated report.

Yes, if the action meets the reporting requirement under statute, the hospital or other employer must report it regardless of any root cause analysis.

If the employer advised the applicant to withdraw the application, this must be reported. However, if the applicant simply withdrew on his or her own accord and without any suggestion or recommendation from the employer, or if the application is withdrawn due to a non-reportable action, this does not need to be reported.

The employer must submit a report if the termination was due to disciplinary reasons and if the action meets the reporting requirement under statute (Health Occupations, §15-103, Annotated Code of Maryland).

An employer must submit the required report through the Board's online portal within ten business days after the reportable action occurs.

An employer may upload a blank cover sheet if they have no other documentation to provide.