Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 10 - LABORATORIES
Chapter 10.10.02 - Medical Laboratories-General
Section 10.10.02.02 - Accredited Laboratory and Accrediting Organization
Universal Citation: MD Code Reg 10.10.02.02
Current through Register Vol. 51, No. 19, September 20, 2024
A. Accredited Laboratory-Determination. The Secretary shall accept as meeting the survey requirements of this chapter a laboratory accredited by an organization approved by the Secretary, as set forth in §C of this regulation, if the OHCQ determines that the standards of the laboratory's accrediting organization are equivalent to those under this subtitle.
B. Accredited Laboratory-Requirements. In addition to meeting the requirements for its certificate of accreditation, as set forth by its accrediting organization, an accredited laboratory shall:
(1) Obtain and
maintain a valid license issued by the Secretary; and
(2) Be subject to survey by the OHCQ for the
purpose of investigating complaints or validating findings of the laboratory's
accrediting organization.
C. Accrediting Organization.
(1) A private, nonprofit laboratory
accrediting organization may inspect and accredit laboratories in the State for
the purpose of Maryland State licensure only after applying for and receiving
approval of the OHCQ.
(2) The OHCQ
shall base approval of a laboratory accrediting organization on a review of
that organization, when the review includes but is not limited to an evaluation
of:
(a) Documentation of current accrediting
status issued by CMS and of compliance with CMS reporting
requirements;
(b) Accreditation
policies and standards;
(c) Copies
of survey forms and guidelines;
(d)
Surveying and deficiency writing policies;
(e) Surveyor qualifications;
(f) Complaint investigation
policies;
(g) Proficiency test
monitoring policies;
(h) Procedures
the accrediting organization will follow when notifying the OHCQ that the
organization:
(i) Is denying, withdrawing,
suspending, or revoking a laboratory's accreditation,
(ii) Finds serious patient jeopardy or
identifies a hazard to public safety,
(iii) Accredits a new laboratory,
(iv) Imposes an adverse or corrective action
on a laboratory, or
(v) Is
initiating a complaint investigation; and
(i) The accrediting organization's compliance
with the requirements of §C of this regulation.
(3) In addition to requirements set forth
elsewhere in this regulation, an accrediting organization shall:
(a) Provide to the OHCQ:
(i) Annually, an updated list containing the
names, addresses, and accreditation expiration dates of all accredited
laboratories in the State,
(ii)
Within 30 days after conducting a survey, a certified written or electronic
copy of each survey report covering each laboratory applying for or maintaining
accreditation in the State,
(iii)
Written notice of any proposed change to requirements for laboratory
accreditation, at least 30 days before the effective date of the
change,
(iv) Within 30 days after a
laboratory's certificate of accreditation expires, written or electronic notice
when the laboratory does not renew its certificate, and
(v) Within 24 hours after taking an action,
telephonic or electronic notice whenever an accredited laboratory's certificate
of accreditation is limited, suspended, revoked, or surrendered;
(b) Evaluate compliance, when
applicable, with State regulations pertaining to:
(i) Cholesterol testing,
(ii) Gynecological cytology,
(iii) Dermatopathology,
(iv) Forensic toxicology,
(v) Laboratory reporting of test results
covering contagious disease, blood lead, cancer, and other tests as required by
law or regulation,
(vi) Proficiency
testing,
(vii) Special medical
waste disposal, and
(viii) Testing
performed at a temporary or mobile laboratory;
(c) Evaluate compliance with State
regulations by:
(i) Employing a checklist
provided by the Department,
(ii)
Incorporating an evaluation of compliance with State regulatory requirements
into its own survey process, or
(iii) Demonstrating that its existing survey
process adequately evaluates compliance with State regulations; and
(d) On request, provide to OHCQ a
copy of:
(i) A complaint
investigation,
(ii) Surveyor
qualifications,
(iii) A change in a
laboratory's disciplines, subdisciplines, or specialties, and
(iv) Other information the Secretary may
require relating to approval of a laboratory accrediting
organization.
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