As part of the report, state health officials outline several recommendations for improving the way temporary workers are regulated in Maryland. Legislation pending before the General Assembly would require that health care staffing agencies be licensed. Currently, only nursing staffing agencies are regulated.
The report cites Maxim specifically for failing to divulge problems with Kwiatkowski. The report said Maxim acknowledged fabricating an email that appeared to come from the Maryland Board of Physicians in 2009, saying the board had received notification from Maxim about unprofessional conduct by Kwiatkowski.
Maxim declined to comment about details of the report, but said it is cooperating with any investigation.
"We have reviewed the department's report and take their recommendations seriously," the company said in an email. "We do, however, believe that certain representations in the report regarding our company require additional detail and clarification. Given its breadth, we are continuing to review the report in greater detail and will follow up with the state directly."
The report also recommended that the Board of Physicians augment its licensing of contract health workers with background checks and better verification processes.
"We have spent the last year making many improvements in our operations," said Carole Catalfo, the board's executive director. "We will certainly take time to carefully review and discuss the report and its recommendations.
Kwiatkowski was able to continue practicing because many co-workers, as well as staffing agencies and hospital supervisors, failed to report concerns about his conduct. The report said many feared being sued if they turned in a fellow worker.
State officials recommended legislation that would expand immunity laws to health care workers.
The report also called for standardizing drug-diversion programs at hospitals and recommended that the federal government expand its national data bank to include more information about contract health workers.
Local hospitals say they have many safeguards in place, but welcome other ways to improve the system.
"We embrace any ideas that help ensure public safety, and we look forward to working together to prevent something like this from ever happening again," a Johns Hopkins spokeswoman said in a statement.
Jim Reiter, a spokesman for the Maryland Hospital Association, said hospitals have checks and balances in place, but on rare occasions determined individuals will find loopholes.
"When you have the assumption that somebody has been cleared and certified by the board and an agency, there is no reason to believe they are not going to do what they're supposed to do," he said.