reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part II - Administrative Services › Section 12VAC5-408-190 - Covered person education and communication

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCHIP licensee shall make available to
				  each covered person at the time of enrollment or at the time the contract or
				  evidence of coverage is issued, as required by law and upon request thereafter,
				  policies and procedures applicable to the covered person including, but not
				  limited to:
1. A statement of covered
				  person's rights and responsibilities;
2. Procedures for obtaining care including:
a. Referral and authorization
				  requirements;
b. Primary care
				  services;
c. Specialty care and
				  hospital services;
d. Behavioral
				  services, when the complexity of the covered person's condition requires the
				  knowledge base and expertise beyond those of the primary care
				  provider;
e. Emergency services and
				  after-hours coverage, including access to emergency care, and any requirements
				  for prior authorization and payment for out-of-service areas;
f. Care and coverage when out of the service
				  area;
g. Out-of-network services;
				  and
h. Pharmacy services;
3. Procedures concerning the
				  complaint process and the process for appealing adverse decisions affecting
				  covered person coverage benefits;
4. To the extent there are coverage
				  restrictions for changing primary care providers, procedures for changing
				  primary care and specialty care providers including any restrictions on
				  changing providers;
5. All
				  necessary mailing addresses and telephone numbers for seeking information or
				  authorization;
6. The toll-free
				  number for the complaint unit of the center; and
7. Notice of the right to obtain information
				  on types of provider payment arrangements used to compensate providers for
				  health care services rendered to covered persons, including, but not limited
				  to, withholds, bonus payments, capitation, processing fees, and fee-for-service
				  discounts.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part II - Administrative Services › Section 12VAC5-408-200 - Data management

Current through Register Vol. 40, No. 24, July 15, 2024
A. The data
				  management system shall be reasonable and adequate to assess, measure and
				  evaluate the functions of the quality assurance program.
B. If the MCHIP licensee has healthcare data
				  and information, the data management system, which includes medical records,
				  shall comply with federal and state law and regulations, including the Virginia
				  Health Records Privacy Act (§ 32.1-127.1:03 of the Code of
				  Virginia).
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part II - Administrative Services › Section 12VAC5-408-210 - Medical records

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCHIP
				  licensee shall require that an organized medical record system be maintained by
				  providers that assures the availability of information required for effective
				  and continuous covered person care and for quality received.
B. Medical records shall be confidential.
				  Only authorized personnel shall have access as specified in §
				  32.1-127.1:03 of the Code of Virginia. Written procedures shall govern the use
				  and removal of medical records and the conditions for release of information.
				  The covered person's written consent shall be required for release of
				  information as required by law.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part III - Quality Improvement Program › Section 12VAC5-408-220 - Purpose

Current through Register Vol. 40, No. 24, July 15, 2024
The MCHIP licensee shall have a comprehensive, systematic,
					 and organized quality assurance program for the purpose of:
1. Improving covered person's health
				  outcomes;
2. Assuring the quality
				  of the services provided to covered persons;
3. Increasing covered person
				  satisfaction;
4. Maximizing
				  opportunities for MCHIP improvements and minimizing opportunities for
				  errors;
5. Monitoring, measuring
				  and evaluating quality activities; and
6. Satisfying all federal and state reporting
				  requirements.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part III - Quality Improvement Program › Section 12VAC5-408-230 - Program requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  MCHIP licensee shall be structured operationally to administer the quality
				  assurance program. The quality assurance operations shall include, but not be
				  limited to:
1. Establishing performance goals
				  designed to improve the quality of health care services provided by the MCHIP
				  licensee and governed by the certificate;
2. Developing a quality assurance plan to
				  implement the goals;
3. Measuring
				  and assessing the MCHIP licensee's performance in meeting the goals;
4. Implementing activities based upon the
				  assessments to improve and maintain performance;
5. Integrating the quality assurance
				  activities of appropriate organizational units, providers, delegated service
				  providers, and the governing body into the quality assurance program and
				  providing feedback to those entities;
6. Enlisting covered person input through
				  sources such as satisfaction surveys, reviews of complaints, appeals, and
				  requests to change providers;
7.
				  Maintaining and documenting the licensee's compliance with state and federal
				  laws, as well as private accreditation requirements, if applicable, that govern
				  the MCHIP licensee's quality assurance program; and
8. Ensuring that the MCHIP licensee's quality
				  assurance goals are communicated to all appropriate organizational units of the
				  MCHIP licensee and delegated health service entities and made available to
				  covered persons and providers upon request.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part III - Quality Improvement Program › Section 12VAC5-408-240 - Quality assurance plan

Current through Register Vol. 40, No. 24, July 15, 2024
Each MCHIP licensee shall have a written quality assurance
					 plan. The plan shall include:
1. The
				  quality assurance performance expectations for the MCHIP licensee for the year
				  and an explanation as to the rationale for targeting these
				  expectations;
2. Delineation of the
				  expected outcomes for the performance expectations;
3. The performance activities to implement
				  the plan and the specific lines of authority and accountability for
				  implementation;
4. The data
				  collection and analysis methodologies to be used to evaluate the quality of
				  services;
5. For MCHIP licensees
				  that have access to clinical data, clinical studies, applicable to the type of
				  MCHIP, that target clinical diagnosis and treatments with the requirement that
				  those diagnoses focused upon are pertinent to a substantial number of its
				  covered persons, or have been identified as major public health risks. The plan
				  shall also include studies that are pertinent to the covered persons of the
				  product lines that the MCHIP manages or that address major public health
				  risks;
6. Strategies to evaluate
				  provider performance and systems, request corrective action when patterns are
				  identified, and act when corrective action has not been taken;
7. Methods to assess covered person
				  satisfaction so as to identify opportunities for improvement and set
				  improvement goals;
8. For MCHIP
				  licensees that have access to clinical data, evaluations of the actual outcomes
				  of care provided to selected groups of covered persons with an analysis of
				  variations in care;
9. For MCHIP
				  licensees that have access to clinical data, amendment of treatment protocols
				  and clinical practice guidelines, as necessary, to make them current and the
				  development of new protocols and clinical practice guidelines, as necessary, to
				  address clinical conditions;
10.
				  Strategies to evaluate the continuity of care that covered persons receive;
				  and
11. Analysis of the
				  accessibility of covered person services including emergency services and
				  after-hour care within the licensee's geographic service area. Compliance may
				  be demonstrated by evidence of contract language with providers stipulating
				  after-hour care, customer satisfaction surveys, and complaint
				  reviews.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part IV - Coordination and Continuity of Care › Section 12VAC5-408-250 - Continuity of care

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCHIP
				  licensee shall provide, arrange, pay for, or reimburse the basic health care
				  services it provides in such a way that:
1.
				  Covered persons' individual needs are assessed on an ongoing basis through
				  their physician or staff and matched with the appropriate level of medical,
				  psychological, or medical social services care. The MCHIP licensee shall
				  monitor the continuity and coordination of care a covered person receives with
				  other facets of care;
2. Covered
				  persons' transition through the system of care are facilitated by the MCHIP
				  licensee and its components;
3. The
				  MCHIP licensee does not impede covered persons' involvement in determining care
				  and treatment;
4. Information
				  necessary to support the provision of care from one plan component to another
				  is provided in a timely manner to covered persons and providers to support the
				  continuity of the covered person's care; and
5. The MCHIP licensee advises its physicians
				  of their responsibility to share specific information with covered persons
				  concerning their illness, condition or treatment, in order for the covered
				  person to follow his plan of care and receive follow-up care when
				  needed.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part IV - Coordination and Continuity of Care › Section 12VAC5-408-260 - Network adequacy

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  MCHIP licensee shall provide a sufficient number and mix of services,
				  specialists, and practice sites to meet covered persons' health care needs,
				  including providers serving high risk populations or those specializing in the
				  treatment of costly conditions, and its contractual obligations with reasonable
				  promptness.
B. The MCHIP licensee
				  shall ensure covered persons telephone access 24 hours a day, 7 days a week, to
				  responsible and knowledgeable health care practitioners capable of assessing
				  the covered persons' conditions and, as necessary, providing for appropriate
				  services.
C. The MCHIP licensee
				  shall incorporate strategies into its access procedures to facilitate
				  utilization of the licensee's health care services by covered persons with
				  physical, mental, language or cultural barriers.
D. If the MCHIP licensee does not have a
				  health care provider within its network capable of providing care to covered
				  persons, the licensee shall cover such care out of network. The covered person
				  shall not be responsible for any additional costs incurred by the MCHIP as a
				  result of this referral, consistent with the evidence of coverage, other than
				  any applicable copayment, coinsurance or deductible.
E. The MCHIP licensee shall make provisions
				  for affected covered persons to be notified about the termination of a provider
				  as soon as it becomes aware of the termination. The MCHIP shall inform the
				  affected covered persons of other participating providers available to assume
				  their care and facilitate the covered persons' transition from a terminating
				  provider to another provider so that the covered person's continuity of care is
				  not interrupted. Covered persons undergoing an active course of treatment shall
				  have continued access to care during the transition period.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part IV - Coordination and Continuity of Care › Section 12VAC5-408-270 - Travel and appointment waiting times

Current through Register Vol. 40, No. 24, July 15, 2024
A. An MCHIP shall set reasonable and adequate
				  standards for the number and geographic distribution of primary care, specialty
				  care, and institutional service sites. Such standards shall address acceptable
				  average travel times or distances to the nearest primary care delivery site,
				  nearest specialty care site, or nearest institutional service site for covered
				  persons in the service area. The standards must be realistic for the community
				  served, the delivery system utilized by the MCHIP, and clinical safety.
Institutional service sites include acute care hospitals,
					 surgical facilities including tertiary care or other specialty hospitals,
					 licensed acute care hospitals and outpatient surgical hospitals, psychiatric
					 inpatient facilities and other sites as determined appropriate by the
					 department.
B. An MCHIP
				  licensee must set reasonable and adequate standards for access to medical care,
				  including quantifiable and measurable standards for preventive care
				  appointments, routine primary care appointments, urgent care, emergency care,
				  and after-hours care. The standards must be realistic for the community served,
				  the delivery system utilized by the MCHIP, and clinical safety.
C. An MCHIP shall, at least annually, collect
				  and analyze data to measure its performance against the standards developed
				  under subsections A and B of this section. The analysis shall be used by the
				  MCHIP to identify opportunities for improvement and undertake interventions to
				  improve performance. An MCHIP shall subsequently measure the effectiveness of
				  such interventions in improving performance against standards.
D. Routine appointments for nonemergency or
				  nonurgent care shall be available within two weeks of the covered person's
				  request. The department may waive this requirement if the MCHIP licensee can
				  successfully demonstrate that the two-week availability requirement is not
				  feasible.
E. Preventive care
				  appointments, including routine physical examinations, shall be available with
				  60 days of the covered person's request. The department may waive this
				  requirement if the MCHIP licensee can successfully demonstrate that the 60-day
				  availability requirement is not feasible.
F. Consultations for specialty services shall
				  be at least as required in § 38.2-3407.11:1 of the Code of
				  Virginia.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part IV - Coordination and Continuity of Care › Section 12VAC5-408-280 - Urgent care and emergency services

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCHIP licensee shall require that
				  participating providers allow its covered persons, on a 24-hour basis, (i)
				  access to medical care or (ii) access by telephone to a physician or licensed
				  health care professional with appropriate medical training who can refer or
				  direct a covered person for prompt medical care in cases where there is a need
				  for urgent care or emergency services.
B. The MCHIP licensee shall provide clear and
				  understandable explanation to covered persons and providers of:
1. What constitutes emergency and urgent
				  care;
2. The process for accessing
				  emergency and urgent care;
3. The
				  responsibility of the covered person for payment for nonemergency services
				  rendered in a hospital emergency facility; and
4. Coverage for out-of-network emergency
				  medical care when a covered person cannot reasonably access network
				  services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part IV - Coordination and Continuity of Care › Section 12VAC5-408-290 - Health promotion

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Annually, the MCHIP licensee shall develop and implement at least one health
				  guideline for the prevention and early detection of illness and disease. Each
				  written guideline shall:
1. Be available to
				  covered persons upon request;
2.
				  Describe the prevention or early detection intervention and the recommended
				  frequency and condition under which the intervention is required; and
3. Document the scientific basis or authority
				  upon which the guideline is based.
Guidelines may be specific to a defined population
					 segment.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part V - Clinical Performance Evaluation › Section 12VAC5-408-300 - Clinical performance evaluation systems

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCHIP licensee shall have a system for
				  the evaluation of the outcomes and processes of clinical care services
				  delivered to the MCHIP's covered persons.
B. The MCHIP licensee shall adopt a
				  nationally recognized clinical performance evaluation system, such as the
				  Health Plan Employer Data and Information Set (HEDIS), that analyzes data based
				  upon selected performance factors or shall establish a clinical performance
				  evaluation system that uses data collection, quantitative measures, and
				  analysis to monitor quality improvement activities.
C. The MCHIP licensee shall notify the
				  department regarding its adoption of a nationally recognized clinical
				  performance evaluation system, such as HEDIS, or that it has chosen to
				  establish its own performance measurement system.
MCHIP licensees that choose not to adopt a nationally
					 recognized system shall provide justification to the department of their choice
					 of performance measurement selections for the department's approval.
D. The MCHIP licensee shall
				  annually evaluate its performance in at least three of the areas of clinical
				  care shown below:
1. Primary care
				  services;
2. High volume specialty
				  services;
3. Behavioral health
				  services; and
4. Institutional
				  health services including inpatient hospital care, home health services,
				  skilled nursing facility services and ambulatory surgery.
If HEDIS measures are used to assess clinical performance,
					 the MCHIP licensee shall substitute the HEDIS "Effectiveness of Care" measures
					 for those areas listed in subdivisions 1 through 4 of this subsection.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part V - Clinical Performance Evaluation › Section 12VAC5-408-310 - Data collection and submission

Current through Register Vol. 40, No. 24, July 15, 2024
A. Data collected and analyzed for clinical
				  service evaluation shall be:
1. From the
				  covered person population areas appropriate for the MCHIP to assess including:
(i) high risk and high volume areas,
(ii) areas where clinical problems
				  are expected or have occurred in the past,
(iii) areas that have the potential for
				  adverse health outcomes, and
(iv)
				  areas where preventive health measures may have an impact;
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part VI - Delegated Services › Section 12VAC5-408-320 - Delegated services

Current through Register Vol. 40, No. 24, July 15, 2024
A. If the
				  MCHIP licensee contracts for any of the following services, it shall retain
				  accountability for the oversight of those services:
1. Quality assurance activities;
2. Credentialing and
				  recredentialing;
3. Covered person
				  education, communication and satisfaction;
4. Utilization management;
5. Health promotion;
6. Records management;
7. Data management;
8. Providers and provider networks;
9. Claims administration; or
10. Pharmacy benefits.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part VI - Delegated Services › Section 12VAC5-408-330 - Written agreement

Current through Register Vol. 40, No. 24, July 15, 2024
A. There
				  shall be a written agreement signed by the MCHIP licensee and the delegated
				  service entity that describes the:
1.
				  Delegated service or services;
2.
				  Responsibilities of the MCHIP and the delegated service entity and the remedies
				  available to the MCHIP if the delegated service entity does not fulfill its
				  obligations; and
3. Frequency of
				  reporting to the MCHIP licensee and the process by which the MCHIP will
				  evaluate the delegated service entity's performance.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part VI - Delegated Services › Section 12VAC5-408-340 - Exchange of information

Current through Register Vol. 40, No. 24, July 15, 2024
A. If
				  the delegated services are health care services, then the delegated services
				  entity or the MCHIP licensee shall make the following information available if
				  requested by the MCHIP's covered persons:
1.
				  The procedures for filing complaints and appeals;
2. The utilization management decision
				  process;
3. The process for
				  appealing claims denials;
4. How to
				  access emergency and urgent care;
5. How to obtain services not covered in the
				  delegated health services' benefit package;
6. The process for changing from one
				  practitioner to another;
7.
				  Orientation process for new covered persons;
8. Covered person participation
				  opportunities; and
9. Participating
				  practitioners and providers.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part VI - Delegated Services › Section 12VAC5-408-350 - Quality assurance program

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  As it pertains to the covered persons, the MCHIP licensee shall integrate
				  monitoring of the delegated service entity with respect to the following
				  activities within its quality assurance program:
1. Quality assurance program
				  activities;
2. Quality assurance
				  plan measures; and
3. Complaint and
				  appeals processes.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part VII - Utilization Review and Management › Form - FORMS (12VAC5-408)

Current through Register Vol. 40, No. 24, July 15, 2024
Application
					 for Certificate of Quality Assurance, OLC-4210-F (eff.
					 11/2019)
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part VII - Utilization Review and Management › Section - DOCUMENTS INCORPORATED BY REFERENCE (12VAC5-408)

Current through Register Vol. 40, No. 24, July 15, 2024
Health Network Standards, Version 3.0, American
					 Accreditation HealthCare Commission/URAC.
1997 Accreditation Manual for Preferred Provider
					 Organizations, Joint Commission on Accreditation of Healthcare
					 Organizations.
Standards for the Accreditation of Managed Care
					 Organizations, effective July 1, 1999, National Committee for Quality
					 Assurance.
Health Utilization Management Standards, Version 3.0,
					 American Accreditation HealthCare Commission/URAC.
Health Plan Standards, Version 3.0, American Accreditation
					 HealthCare Commission/URAC.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 2 - General Information › Section 12VAC5-410-20 - Exceptions; variances

Current through Register Vol. 40, No. 24, July 15, 2024
A. In
					 accordance with the § 32.1-124 of the Code of Virginia the provisions of
					 this chapter shall not be applicable to:
1. A
					 dispensary or first aid facility maintained by any commercial or industrial
					 plant, educational institution or convent;
2. An institution licensed by the State
					 Mental Health, Mental Retardation and Substance Abuse Services Board;
3. An institution or portion thereof licensed
					 by the State Board of Social Services;
4. A hospital owned or operated by an agency
					 of the Commonwealth or of the United States government; or
5. An office of one or more physicians or
					 surgeons unless such office is used principally for performing surgery as
					 defined in
					 12VAC5-410-10 of this
					 chapter.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 2 - General Information › Section 12VAC5-410-30 - Allowable variances

Current through Register Vol. 40, No. 24, July 15, 2024
A. Upon the
					 finding that the enforcement of one or more of these regulations would be
					 clearly impractical, the commissioner shall have the authority to waive, either
					 temporarily or permanently, the enforcement of one or more of these
					 regulations, provided safety and patient care and services are not adversely
					 affected.
B. Modification of any
					 individual standard herein, for experimental or demonstrative purposes, or any
					 other purposes, shall require advance written approval from the OLC.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-40 - General

Current through Register Vol. 40, No. 24, July 15, 2024
No person, as defined in
						12VAC5-410-10, shall establish,
						conduct, maintain, or operate in this State any hospital as defined and
						included within provisions of this chapter without having obtained a license.
						Any person establishing, conducting, maintaining, or operating a hospital
						without a license shall be guilty of a Class 6 felony.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-50 - Classification

Current through Register Vol. 40, No. 24, July 15, 2024
Hospitals to be licensed shall be classified as general
						hospitals, special hospitals or outpatient hospitals defined by
						12VAC5-410-10.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-60 - Separate license

Current through Register Vol. 40, No. 24, July 15, 2024
A. A separate
					 license shall be required by hospitals maintained on separate premises even
					 though they are operated under the same management. Separate license is not
					 required for separate buildings on the same grounds or within the same complex
					 of buildings.
B. Hospitals which
					 have separate organized sections, units, or buildings to provide services of a
					 classification covered by provisions of other state statutes or regulations may
					 be required to have an additional applicable license for that type or
					 classification of service (e.g., psychiatric, nursing home, home health
					 services, and outpatient surgery).
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-70 - Request for issuance

Current through Register Vol. 40, No. 24, July 15, 2024
A. Hospital
					 licenses shall be issued by the commissioner, but all requests for licensing
					 shall be submitted initially to the OLC. The procedure for obtaining the
					 license shall include the following steps:
1.
					 Request for application forms shall be made in writing to the OLC;
2. Application for license or license renewal
					 to establish or maintain a hospital shall be made and submitted to the
					 OLC;
3. All categories of inpatient
					 beds shall be included on the hospital application for licensure in order for
					 the OLC to have an accurate and complete record of the total bed capacity of
					 the facility;
4. Application for
					 initial license, change in license, or license renewal shall be accompanied by
					 a check or money order for the service charge, payable to the OLC;
					 and
5. Application for initial
					 license of a hospital or for additions to an existing licensed hospital must be
					 accompanied by evidence of approval from a representative of the State Fire
					 Marshal and a copy of the occupancy permit issued by the local building
					 official.
6. Application for
					 initial license of a hospital shall include a statement of any agreement made
					 with the commissioner as a condition for Certificate of Public Need approval to
					 provide a level of care at a reduced rate to indigents or accept patients
					 requiring specialized care.
Any initial license issued to any hospital that made such
						agreement as a condition of its Certificate of Public Need approval shall not
						be renewed without demonstrating prior to or at the time of applying for
						license renewal that it is substantially complying with its agreement.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-80 - Service charge

Current through Register Vol. 40, No. 24, July 15, 2024
A. In accordance
					 with § 32.1-130 of the Code of Virginia, the following service charge
					 shall be made:
0 to 50 beds -- $75
51 to 333 beds -- $1.50 per bed
334 or more -- $500
B. The hospital shall not be required to pay
					 a service charge on hospital beds in a category that requires separate license
					 by the OLC or another state agency (i.e., psychiatric, nursing home).
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-90 - License expiration

Current through Register Vol. 40, No. 24, July 15, 2024
Licenses shall expire as specified or at midnight
						December 31 following date of issue, whichever is first, and shall be renewable
						annually, upon filing of application and payment of service charge, unless
						cause appears to the contrary.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-100 - Name

Current through Register Vol. 40, No. 24, July 15, 2024
Every hospital shall be designated by a permanent and
						appropriate name which shall appear on the application for license. Any change
						of name shall be reported to the OLC within 30 days.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-110 - Bed capacity

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each
					 license issued by the commissioner shall specify the maximum allowable number
					 of beds. The number of beds allowed shall be determined by the OLC and shall so
					 appear on the license issued by the OLC.
B. Request for licensed bed increase or
					 decrease shall be made in writing to the OLC. No increase will be granted
					 without an approved Certificate of Public Need.
C. Hospitals shall be exempt from the
					 requirement to obtain a license to add temporary beds, for a period of no more
					 than 30 days, when the commissioner has determined that a natural or man-made
					 disaster has caused the evacuation of a hospital or nursing home and that a
					 public health emergency exists due to a shortage of hospital or nursing home
					 beds.
Statutory Authority: §§
													32.1-12
						  and
						  32.1-127 of the Code
						  of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-120 - Posting of license

Current through Register Vol. 40, No. 24, July 15, 2024
The hospital license issued by the commissioner shall be
						framed and posted conspicuously on the premises either in the main entrance to
						the hospital or in a place visible from that main entrance.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-130 - Return of license

Current through Register Vol. 40, No. 24, July 15, 2024
The OLC shall be notified in writing at least within 30
						working days in advance of any proposed change in location or ownership of the
						facility. A license shall not be transferred from one owner to another or from
						one location to another. The license issued by the commissioner shall be
						returned to the OLC for correction or reissuance when any of the following
						changes occur during the licensing year:
1. Revocation;
2. Change of location;
3. Change of ownership;
4. Change of name;
5. Change of bed capacity, except as provided
					 in
					 12VAC5-410-110 C;
					 or
6. Voluntary closure.
Article 2 Patient Care Services
Statutory Authority: §§
													32.1-12
						  and
						  32.1-127 of the Code
						  of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-140 - Inspection procedure

Current through Register Vol. 40, No. 24, July 15, 2024
A. The OLC
					 may presume that a hospital accredited by the Joint Commission on Accreditation
					 of Healthcare Organizations (JCAHO) and certified for participation in Title
					 XVIII of the Social Security Act (Medicare) generally meets the requirements of
					 Part II (12VAC5-410-170 et seq.) of this
					 chapter provided the following conditions are met:
1. The hospital provides to the OLC, upon
					 request, a copy of the most current accreditation survey findings made by the
					 Joint Commission on Accreditation of Healthcare Organizations; and
2. The hospital notifies the OLC within 10
					 days after receipt of any notice of revocation or denial of accreditation by
					 the Joint Commission on Accreditation of Healthcare Organizations.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-150 - Plan of correction

Current through Register Vol. 40, No. 24, July 15, 2024
A. Upon
					 receipt of a written licensing report each hospital shall prepare a plan for
					 correcting any licensing violations cited at the time of inspection. The plan
					 of correction shall be to the OLC within the specified time limit set forth in
					 the licensing report. The plan of correction shall contain at least the
					 following information:
1. The methods
					 implemented to correct any violations of this chapter; and
2. The date on which such corrections are
					 expected to be completed.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part I - Definitions and General Information and Procedures › Article 3 - Procedures for Licensure or License Renewal › Section 12VAC5-410-160 - Revocation of license

Current through Register Vol. 40, No. 24, July 15, 2024
The commissioner may revoke or suspend the license to
						operate a hospital in accordance with § 32.1-135 of the Code of Virginia
						for the following reasons:
1.
					 Violation of any provision of these rules and regulations. Violations which in
					 the judgment of the commissioner jeopardize the health or safety of patients
					 shall be sufficient cause for immediate revocation or suspension; or
2. Willfully permitting, aiding, or abetting
					 the commission of any illegal act in the hospital.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part II - Organization and Operation of General and Special Hospitals › Article 1 - Organization and Management › Section 12VAC5-410-170 - Ownership

Current through Register Vol. 40, No. 24, July 15, 2024
A. There shall be
					 disclosure of hospital ownership. In the case of corporations, all individuals
					 or entities holding 5.0% or more of the total ownership shall be identified by
					 name and address.
B. When the owner
					 delegates the operation of a hospital to an individual, corporation or other
					 legal entity by management contract or lease agreement, subsection A shall also
					 be applicable to the operator.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part II - Organization and Operation of General and Special Hospitals › Article 1 - Organization and Management › Section 12VAC5-410-180 - Governing body

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 shall have an organized governing body or other legal entity responsible for
					 the management and control of the operation.
The governing body or other legal entity may be an
						individual, group, corporation or governmental agency.
B. The governing body shall be responsible
					 for insuring compliance with these rules and regulations.
C. The governing body shall provide
					 facilities, personnel and other resources necessary to meet patient and program
					 needs.
D. The governing body shall
					 adopt and maintain written bylaws, rules and regulations in accordance with
					 legal requirements. A copy of said bylaws, rules and regulations including
					 amendments or revisions thereto, shall be made available to the OLC on
					 request.
E. The bylaws, rules and
					 regulations shall include:
1. A statement of
					 purpose;
2. A statement of
					 qualifications for membership and method of selecting members of the governing
					 body;
3. Provisions for the
					 establishment, selection, term of office of committee members and
					 officers;
4. Description of the
					 functions and duties of the governing body, officers, and committees;
5. Specifications for the frequency of
					 meetings, attendance requirements, provision for the order of business and the
					 maintenance of written minutes;
6.
					 A statement of the authority and responsibility delegated to the chief
					 executive officer and to the medical staff;
7. Provision for the selection and
					 appointment of medical staff and the granting of clinical privileges including
					 the provision for current license to practice in Virginia.
8. Provision for the adoption of the medical
					 staff bylaws, rules and regulations;
9. Provision of guidelines for the
					 relationships among the governing body, the chief executive officers, and the
					 medical staff.
10. A policy
					 statement concerning the development and implementation of short- and
					 long-range plans in accordance with Part III (12VAC5-410-650 et seq.) of this
					 chapter.
11. A policy statement
					 relating to conflict of interest on the part of members of the governing body,
					 medical staff and employees who may influence corporate decisions.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part II - Organization and Operation of General and Special Hospitals › Article 1 - Organization and Management › Section 12VAC5-410-190 - Chief executive officer

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 The chief executive officer shall be directly responsible to the governing body
					 for the management and operation of the hospital and shall provide liaison
					 between the governing body and the medical staff.
B. The chief executive officer, or his
					 designee, shall ensure that families of patients who are potential donors are
					 informed of the option of organ, tissue, and eye donation.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part II - Organization and Operation of General and Special Hospitals › Article 1 - Organization and Management › Section 12VAC5-410-200 - Organization

Current through Register Vol. 40, No. 24, July 15, 2024
A. The internal
					 hospital organization shall be structured to include appropriate departments
					 and services consonant with its statement of purpose.
B. Each hospital shall maintain clearly
					 written definitions of its organization, authority, responsibility, and
					 relationships.
C. Each hospital
					 department and service shall maintain:
1.
					 Clearly written definitions of its organization, authority, responsibility, and
					 relationships; and
2. Written
					 policies and procedures including:
a. Patient
					 care where applicable;
b. Infection
					 prevention;
c. Disaster
					 preparedness; and
d. Facility
					 security.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part II - Organization and Operation of General and Special Hospitals › Article 1 - Organization and Management › Section 12VAC5-410-210 - Medical staff

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 shall have an organized medical staff responsible to the governing body of the
					 hospital for its own organized governance and all medical care provided to
					 patients. Nothing in this subsection shall prevent hospitals that are a part of
					 a hospital system from having a unified and integrated medical staff as
					 permitted by 42 CFR
					 482.22(b)(4).
B. The medical staff shall be responsible to
					 the hospital governing board and maintain appropriate standards of professional
					 performance through staff appointment criteria, delineation of staff
					 privileges, continuing peer review, and other appropriate mechanisms.
C. The medical staff, subject to approval by
					 the governing body, shall develop bylaws incorporating details of the medical
					 staff organization and governance, giving effect to its general powers, duties,
					 and responsibilities including:
1. Methods of
					 selection, election, or appointment of all officers and other executive
					 committee members and officers;
2.
					 Provisions for the selection and appointment of officers of departments or
					 services specifying required qualifications;
3. The type, purpose, composition, and
					 organization of standing committees;
4. Frequency and requirements for attendance
					 at staff and departmental meetings;
5. An appeal mechanism for denial,
					 revocation, or limitation of staff appointments, reappointments, and
					 privileges;
6. Delineation of
					 clinical privileges in accordance with the requirements of § 32.1-134.2 of
					 the Code of Virginia;
7.
					 Requirements regarding medical records;
8. A mechanism for utilization and medical
					 care review; and
9. Such other
					 provisions as shall be required by hospital or governmental rules and
					 regulations.