reglab/statecodes huggingface dataset:
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 12VAC5-410-220 - Organ donation

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
					 hospital shall develop and implement a routine contact protocol for organ,
					 tissue and eye donation in compliance with federal law and the regulations of
					 the Centers for Medicare and Medicaid Services (CMS), particularly
					 42 CFR
					 482.45.
B. The protocol shall:
1. Ensure that the hospital collaborates with
					 its designated organ procurement organization (OPO) to inform the family of
					 each potential donor of the option of organ, tissue, and eye donation as well
					 as the option to decline to donate;
2. Recite provisions of § 32.1-290.1 of
					 the Code of Virginia specifying family members who are authorized to make an
					 anatomical gift of all or part of the decedent's body for an authorized purpose
					 and the order of priority of those family members who may make such gift;
					 and
3. Include written procedures
					 for organ, tissue, and eye donation. The procedures shall include:
a. Training of staff in organ, tissue, or eye
					 donation;
b. A mechanism for
					 informing the next of kin of the organ, tissue, and eye donation
					 option;
c. Procedures to be
					 employed when the hospital, consistent with the authority granted by §
					 32.1-292.1 of the Code of Virginia, deems it appropriate to conduct a
					 reasonable search for a document of gift or other information identifying the
					 bearer as a donor or as an individual who has refused to make an anatomical
					 gift;
d. Provisions for the
					 procurement and maintenance of donated organs, tissues, and eyes;
e. The name and telephone number of the local
					 organ procurement agency, tissue or eye bank to be notified of potential
					 donors; and
f. Documentation of the
					 donation request in the patient's medical record.
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 2 - Patient Care Services › Section 12VAC5-410-230 - Patient care management

Current through Register Vol. 40, No. 24, July 15, 2024
A. All
					 patients shall be under the care of a member of the medical staff.
B. Each hospital shall have a plan that
					 includes effective mechanisms for the periodic review and revision of patient
					 care policies and procedures.
C.
					 Each hospital shall establish a protocol relating to the rights and
					 responsibilities of patients based on Joint Commission on Accreditation of
					 Healthcare Organizations' 2000 Hospital Accreditation Standards, January 2000.
					 The protocol shall include a process reasonably designed to inform patients of
					 their rights and responsibilities. Patients shall be given a copy of their
					 rights and responsibilities upon admission.
D. No medication or treatment shall be given
					 except on the signed order of a person lawfully authorized by state statutes.
1. Hospital personnel, as designated in
					 medical staff bylaws, rules and regulations, or hospital policies and
					 procedures, may accept emergency telephone and other verbal orders for
					 medication or treatment for hospital patients from physicians and other persons
					 lawfully authorized by state statute to give patient orders.
2. As specified in the hospital's medical
					 staff bylaws, rules and regulations, or hospital policies and procedures,
					 emergency telephone and other verbal orders shall be signed within a reasonable
					 period of time not to exceed 72 hours, by the person giving the order, or, when
					 such person is not available, cosigned by another physician or other person
					 authorized to give the order.
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 2 - Patient Care Services › Section 12VAC5-410-240 - Anesthesia service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 which provides surgical or obstetrical services shall have an organized
					 anesthesia department/service.
The anesthesia department/service shall be directed by a
						physician member of the medical staff.
B. The anesthesia department/service shall be
					 organized under written policies and procedures regarding staff privileges, the
					 administration of anesthetics, the maintenance of safety controls and
					 qualifications, and supervision of anesthetists and trainees.
C. Policies shall include provisions in
					 addition to the above, for at least:
1.
					 Pre-anesthesia evaluation by a medical staff member;
2. Safety of the patient during the
					 anesthesia period;
3. Review of
					 patient's condition prior to induction of anesthesia and post anesthetic
					 evaluation; and
4. Recording of all
					 events related to each phase of anesthesia care.
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 2 - Patient Care Services › Section 12VAC5-410-250 - Sterile supply service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each
					 hospital shall operate a sterile supply service or provide for the processing,
					 sterilizing, storing, and dispensing of clean and sterile supplies and
					 equipment.
B. Facilities shall be
					 provided for the cleaning, preparation, sterilizing, aeration, storage and
					 dispensing of supplies and equipment for patient care.
C. Areas for the processing of clean and
					 soiled supplies and equipment shall be separated by physical
					 barriers.
D. Written procedures
					 shall be established subject to the approval of the Infection Control Committee
					 for all sterile supply service functions including:
1. Procedures for all sterilizing and for the
					 disposal of wastes and contaminated supplies; and
2. Procedures for the safety of personnel and
					 patients.
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 2 - Patient Care Services › Section 12VAC5-410-260 - Dietary service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 shall maintain a dietary service directed by a full-time person, qualified as
					 allowed in 12VAC5-421.
B. Each
					 hospital shall have at least one dietitian, meeting the criteria of §
					 54.1-2731 of the Code of Virginia, employed on either a full-time, part-time or
					 on a consultative basis, to direct nutritional aspects of patient care and to
					 advise on food preparation and service.
C. Space, equipment and supplies shall be
					 provided for the efficient, safe and sanitary receiving, storage,
					 refrigeration, preparation and serving of food.
D. The hospital food service operation shall
					 comply with applicable standards in 12VAC5-421.
E. A diet manual approved by the medical
					 staff shall be maintained by the dietary service. Diets served to patients
					 shall comply with the principles set forth in the diet manual.
F. All patient diets, including therapeutic
					 diets, shall be ordered in writing by a practitioner, or by a dietitian as
					 authorized by the medical staff, responsible for the care of the patient.
1. Hospitals and their medical staffs may
					 grant privileges to dietitians meeting the criteria of § 54.1-2731 of the
					 Code of Virginia to order patient diets, including therapeutic diets, and to
					 order laboratory tests to help determine appropriate diets for the
					 patient.
2. Therapeutic diets
					 include the provision of enteral and parenteral nutrition.
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 2 - Patient Care Services › Section 12VAC5-410-270 - Disaster and mass casualty programs

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital shall develop and maintain a
					 written disaster plan that includes provisions for complete evacuation of the
					 facility and care of mass casualties.
B. The plan shall provide for widespread
					 disasters as well as for disaster occurring within the local community and
					 hospital facility.
C. The disaster
					 plan shall be rehearsed at least twice a year preferably as part of a
					 coordinated drill in which other community emergency service agencies
					 participate. Written reports and evaluation of all drills shall be maintained
					 for at least two years.
D. A copy
					 of the plan and any revision thereto shall be made available to the OLC upon
					 request.
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 2 - Patient Care Services › Section 12VAC5-410-290 - Laboratory service; general

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
					 director of laboratory service shall be a physician member of the medical
					 staff. If the physician director of laboratory service is not a pathologist, a
					 pathologist shall be retained on a consultant basis.
When the pathologist provides services only on a
						consultative basis, these services shall be provided at least on a monthly
						basis. A written evaluation report with recommendations to the medical staff
						and administration shall be provided by the consultant pathologist on a monthly
						basis.
B. Laboratories
					 shall have adequate space, equipment, and supplies and shall be operated
					 according to 42 CFR Part 493.
C.
					 Provisions shall be made to assure continuous availability of emergency
					 laboratory 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 II - Organization and Operation of General and Special Hospitals › Article 2 - Patient Care Services › Section 12VAC5-410-300 - Clinical laboratory services

Current through Register Vol. 40, No. 24, July 15, 2024
Examination in the fields of hematology, chemistry,
						microbiology, seroimmunology, clinical microscopy and other services necessary
						to meet patient care needs shall be provided directly or shall be provided
						through a contractual arrangement with a reference
						laboratory.
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 2 - Patient Care Services › Section 12VAC5-410-310 - Tissue pathology

Current through Register Vol. 40, No. 24, July 15, 2024
A. Tissue
					 pathology services shall be provided either by the hospital or pursuant to
					 contractual arrangements with a laboratory. In the latter instance, written
					 policies and procedures shall be established governing prompt transportation of
					 specimens and submission of reports.
B. In accordance with medical staff bylaws,
					 surgically removed tissues shall be examined by a pathologist and findings
					 shall be included in the patient's medical record.
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 2 - Patient Care Services › Section 12VAC5-410-320 - Quality control

Current through Register Vol. 40, No. 24, July 15, 2024
There shall be a quality control program designed to
						ensure reliability of the laboratory data and shall include provisions for no
						less than:
1. Frequency and method of
					 work performance evaluation;
2.
					 Frequency and method of performance testing of instruments and
					 equipment;
3. A preventive and
					 corrective maintenance program;
4.
					 Participation in appropriate external proficiency testing programs for the
					 services provided.
5. Maintenance
					 for at least two years of records documenting quality control
					 activities.
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 2 - Patient Care Services › Section 12VAC5-410-330 - Autopsy service

Current through Register Vol. 40, No. 24, July 15, 2024
An autopsy service shall be provided either directly by
						the hospital or written contractual agreement with another
						institution.
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 2 - Patient Care Services › Section 12VAC5-410-340 - Blood banks and transfusion services

Current through Register Vol. 40, No. 24, July 15, 2024
A. If the hospital provides facilities for
					 the procurement, extraction and collection of blood and blood products, written
					 policies and procedures for all phases of operation of blood banks and
					 transfusion services shall be established and periodically revised to comply
					 with 42 CFR Part 493, 42 CFR
					 482.27 and 21 CFR Part 606.
B. Each hospital shall provide appropriate
					 facilities and equipment for the storage and administration of whole blood and
					 blood products.
C. For emergency
					 situations, the hospital shall:
1. Make
					 arrangements by which blood can be quickly obtained from community blood
					 sources, or maintain an up-to-date list of available donors, as well as provide
					 the equipment and personnel and obtain blood from the donor; or
2. Maintain a minimum supply of O negative
					 blood, if the hospital provides obstetrical services.
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 2 - Patient Care Services › Section 12VAC5-410-350 - Isolation of special microorganisms

Current through Register Vol. 40, No. 24, July 15, 2024
When a hospital diagnostic laboratory isolates from
						clinical, pathological or environmental specimens, any one of the special
						micro-organisms listed in
						12VAC5-90-80, it shall be reported
						as required pursuant to 12VAC5-90.
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 2 - Patient Care Services › Section 12VAC5-410-360 - Nuclear medicine

Current through Register Vol. 40, No. 24, July 15, 2024
Every hospital that maintains a nuclear medicine service
						within the institution or through contractual arrangements shall ensure that it
						is under the medical supervision of a physician who is a designated authorized
						user of isotopes licensed by the Nuclear Regulatory Commission or the Office of
						Radiologic Health of the Department of Health as required by 12VAC5-480.
1. There shall be quality control procedures
					 governing nuclear medicine services to ensure diagnostic reliability and
					 therapeutic effectiveness.
2.
					 Records of diagnostic or therapeutic services shall be incorporated in the
					 patient's medical record.
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 2 - Patient Care Services › Section 12VAC5-410-370 - Medical records

Current through Register Vol. 40, No. 24, July 15, 2024
A. The medical
					 record department shall be staffed and equipped to facilitate the accurate
					 processing, checking, indexing, filing and retrieval of all medical
					 records.
B. A medical record shall
					 be established and maintained for every person treated on an inpatient,
					 outpatient (ambulatory) or emergency basis, in any unit of the hospital. The
					 record shall be available to all other units.
A separate medical record shall be maintained for each
						newborn infant. Entered on the chart of the newborn shall be notes of
						gestational history, including any pathology and information regarding
						complications of delivery and mother's medication during labor and
						delivery.
C. Written
					 policies and procedures shall be established regarding content and completion
					 of medical records.
D. Entries in
					 the medical record shall be made by the responsible person in accordance with
					 hospital policies and procedures.
E. Provisions shall be made for the safe
					 storage of medical records or accurate and legible reproductions thereof
					 according to § 32.1-127.1:03 of the Code of Virginia and the Health
					 Insurance Portability and Accountability Act, or HIPPA ( 42 USC § 1320d et
					 seq.).
F. All medical records
					 either original or accurate reproductions shall be preserved for a minimum of
					 five years following discharge of the patient.
1. Records of minors shall be kept for at
					 least five years after such minor has reached the age of 18 years.
2. Birth and death information shall be
					 retained for 10 years in accordance with § 32.1-274 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 2 - Patient Care Services › Section 12VAC5-410-380 - Nursing service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 shall have an organized nursing department. A registered nurse qualified on the
					 basis of education, experience and clinical ability shall be responsible for
					 the direction of nursing care provided the patients.
B. The number and type of nursing personnel
					 on all shifts shall be based upon the needs of the patients and the
					 capabilities of the nursing staff assigned to the patient care unit. All
					 registered nurses and licensed practical nurses shall hold a current license
					 issued by the Virginia Board of Nursing or a current multistate licensure
					 privilege to practice nursing in Virginia.
C. All nursing services shall be directly
					 provided by an appropriately qualified registered nurse or licensed practical
					 nurse, except for those nursing tasks that may be delegated by a registered
					 nurse according to
					 18VAC90-20-420 through
					 18VAC90-20-460 of the regulation
					 of the Virginia Board of Nursing with a plan developed and implemented by the
					 hospital.
D. Nursing personnel
					 shall be assigned to patient care units in a manner that minimizes the risk of
					 cross infection and accidental contamination.
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 2 - Patient Care Services › Section 12VAC5-410-390 - Pharmaceutical service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 shall provide pharmaceutical services under the direction of a pharmacist
					 licensed by the Virginia Board of Pharmacy.
B. There shall be evidence of a current
					 pharmacy license pursuant to Chapter 33 (§ 54.1-3300 et seq.) of Title
					 54.1 of the Code of Virginia and 18VAC110-20.
C. Each hospital shall obtain a criminal
					 history record check pursuant to § 32.1-126.02 of the Code of Virginia on
					 any compensated employee, not licensed by the Board of Pharmacy, whose job
					 duties provide access to controlled substances with the hospital
					 pharmacy.
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 2 - Patient Care Services › Section 12VAC5-410-400 - Radiology service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 shall maintain radiology services which are under the medical supervision of a
					 physician who meets the qualifications of the medical staff bylaws.
B. Hospitals maintaining radiotherapy
					 services shall provide for their safe and effective operation under a director
					 qualified by training and experience in therapeutic radiology.
C. Sufficient technical personnel shall be
					 available, consistent with the scope of services provided.
D. Space and equipment shall be provided for
					 radiographic and fluoroscopic X-ray services including facilities for
					 processing and storage of radiographic films and records.
E. Reports of radiological interpretations,
					 consultations and therapy shall be part of the patient's medical
					 record.
F. Reports shall be
					 preserved in accordance with
					 12VAC5-410-370 H.
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 2 - Patient Care Services › Section 12VAC5-410-410 - Social service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Every
					 hospital shall have a plan for the provision of social services to the patient
					 and the patient's family.
B. An
					 employee of the hospital with knowledge of community agencies and other social
					 service resources shall be designated to assume responsibility for said
					 service.
C. Appropriate records
					 shall be maintained.
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 2 - Patient Care Services › Section 12VAC5-410-420 - Surgical service

Current through Register Vol. 40, No. 24, July 15, 2024
A. The surgical
					 department/service shall have a defined organization and shall be governed by
					 written policies and procedures.
B.
					 The surgical department/service shall be under the medical supervision of a
					 physician who meets the requirements of the medical staff bylaws.
C. The operating suite shall be:
1. Under the supervision of a registered
					 professional nurse.
2. Designed to
					 include operating and recovery rooms, proper scrubbing, sterilizing and
					 dressing room facilities, storage for anesthetic agents and shall be equipped
					 as required by the scope and complexity of the services.
3. Provided with prominently posted safety
					 policies and procedures.
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 3 - Special Services › Section 12VAC5-410-430 - Applicability

Current through Register Vol. 40, No. 24, July 15, 2024
If a hospital provides any of the services in this
						article, the requirements of the specific service shall
						apply.
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 3 - Special Services › Section 12VAC5-410-441 - Obstetric service requirements; medical direction; physician consultation and coverage; nurse staffing and coverage; policies and procedures

Current through Register Vol. 40, No. 24, July 15, 2024
A. The governing
					 body shall appoint a physician as medical director of the organized obstetric
					 service who meets the qualifications specified in the medical staff bylaws.
1. If the medical director is not a board
					 certified obstetrician or board eligible in obstetrics, the hospital shall have
					 a written agreement with one or more board-certified or board-eligible
					 obstetricians to provide consultation on a 24-hour basis. Consultation may be
					 by telephone.
2. The duties and
					 responsibilities of the medical director of obstetric services shall include:
a. The general supervision of the quality of
					 care provided patients admitted to the service;
b. The establishment of criteria for
					 admission to the service;
c. The
					 adherence to standards of professional practices and policies and procedures
					 adopted by the medical staff and governing body;
d. The development of recommendations to the
					 medical staff on standards of professional practice and staff
					 privileges;
e. The identification
					 of clinical conditions and medical or surgical procedures that require
					 physician consultation; and
f.
					 Arranging conferences, at least quarterly, to review obstetrical surgical
					 procedures, complications and infant and maternal mortality and morbidity.
					 Infant mortality and morbidity shall be discussed jointly between the obstetric
					 and newborn service staffs.
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 3 - Special Services › Section 12VAC5-410-442 - Obstetric service design and equipment criteria

Current through Register Vol. 40, No. 24, July 15, 2024
A. Renovation or construction of a hospital's
					 obstetric unit shall be consistent with (i) section 2.2-2.9 of Part 2 of the
					 2018 Guidelines for Design and Construction of Hospitals of the Facility
					 Guidelines Institute pursuant to §
											32.1-127.001
					 of the Code of Virginia and (ii) the Virginia Uniform Statewide Building Code
					 (13VAC5-63).
B. Delivery rooms
					 labor, deliver, and recover (LDR) rooms; labor delivery, recovery, and
					 postpartrum (LDRP) rooms; and nurseries shall be equipped to provide emergency
					 resuscitation for mothers and infants.
C. Equipment and supplies shall be assigned
					 for exclusive use in the obstetric and newborn units.
D. The same equipment and supplies required
					 for the labor room and delivery room shall be available for use in the LDR/LDRP
					 rooms during periods of labor, delivery, and recovery.
E. Sterilizing equipment shall be available
					 in the obstetric unit or in a central sterilizing department. Flash sterilizing
					 equipment or sterile supplies and instruments shall be provided in the
					 obstetric unit.
F. Daily monitoring
					 is required of the stock of necessary equipment in the LDR rooms and LDRP rooms
					 and nursery.
G. The hospital shall
					 provide the following equipment in the labor, delivery and recovery rooms and,
					 except where noted, in the LDR/LDRP rooms:
1.
					 Labor rooms.
a. A labor or birthing bed with
					 adjustable side rails.
b.
					 Adjustable lighting adequate for the examination of patients.
c. An emergency signal and intercommunication
					 system.
d. A sphygmomanometer,
					 stethoscope and fetoscope or doppler.
e. Fetal monitoring equipment with internal
					 and external attachments.
f.
					 Mechanical infusion equipment.
g.
					 Wall-mounted oxygen and suction outlets.
h. Storage equipment.
i. Sterile equipment for emergency delivery
					 to include at least one clamp and suction bulb.
j. Neonatal resuscitation cart.
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 3 - Special Services › Section 12VAC5-410-443 - Newborn service requirements; designation of newborn service levels, service levels

Current through Register Vol. 40, No. 24, July 15, 2024
A. If a hospital
					 intends to provide newborn services, it shall make application to the
					 department requesting approval for a level of newborn service as specified in
					 subsection B of this section. Application shall be made at least 60 days prior
					 to the desired date of approval. Approval is required to be renewed annually.
					 Newborn service level approval shall be based upon the hospital's certification
					 and the department's verification that the hospital meets the requirements of
					 this section for the level requested.
1. No
					 approval for a general level newborn service designation will be granted
					 without a Certificate of Public Need (COPN) or without documentation by the
					 applicant that it provided general level newborn services prior to July 1,
					 1992, or that the provision of general level newborn services was found to be
					 exempt from Certificate of Public Need review pursuant to § 32.1-102.11 of
					 the Code of Virginia.
2. No
					 approval for a newborn service level designation higher than general level will
					 be granted without a Certificate of Public Need or without documentation by the
					 applicant that it provided a newborn service level higher than general level
					 prior to July 1, 1992, or that the provision of a newborn service level higher
					 than general level was found to be exempt from Certificate of Public Need
					 review pursuant to § 32.1-102.11 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 3 - Special Services › Section 12VAC5-410-444 - Newborn service medical direction; physician consultation and coverage; nursing direction, nurse staffing and coverage; policies and procedures

Current through Register Vol. 40, No. 24, July 15, 2024
A. The governing
					 body shall appoint a physician as medical director of the organized newborn
					 service who meets the qualifications specified in the medical staff bylaws. In
					 addition, the medical director must meet the qualifications specified for the
					 medical direction of the highest level of newborn service provided by the
					 hospital.
1. If a hospital offers only
					 general level newborn services, the medical director shall be a physician
					 qualified to provide normal newborn care, including the ability to immediately
					 resuscitate and stabilize a sick newborn for transfer to a higher level of
					 service.
2. If a hospital offers
					 intermediate level newborn services, the medical director shall be a
					 board-certified or board-eligible pediatrician with training and experience in
					 the care of preterm neonates, including stabilization and ventilation
					 management.
3. If a hospital offers
					 specialty level newborn services, the medical director shall be a
					 board-certified or board-eligible neonatologist.
4. If a hospital offers subspecialty level
					 newborn services, the medical director shall be a board-certified or
					 board-eligible neonatologist.
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 3 - Special Services › Section 12VAC5-410-445 - Newborn service design and equipment criteria

Current through Register Vol. 40, No. 24, July 15, 2024
A. Construction or renovation of a hospital's
					 nursery shall be consistent with (i) section 2.2-2.10 of Part 2 of the 2018
					 Guidelines for Design and Construction of Hospitals of the Facility Guidelines
					 Institute pursuant to §
											32.1-127.001
					 of the Code of Virginia and (ii) the Virginia Uniform Statewide Building Code
					 (13VAC5-63). Hospitals with higher-level nurseries shall comply with section
					 2.2-2.8 of Part 2 of the 2018 edition of the guidelines as
					 applicable.
B. The hospital shall
					 provide the following equipment in the general level nursery and all higher
					 level nurseries, unless additional equipment requirements are imposed for the
					 higher level nurseries:
1. Resuscitation
					 equipment as specified for the delivery room in
					 12VAC5-410-442
					 G 2 shall be available in the nursery at all times;
2. Equipment for the delivery of 100% oxygen
					 concentration, properly heated, blended, and humidified, with the ability to
					 measure oxygen delivery in fractional inspired concentration (FI02). The oxygen
					 analyzer shall be calibrated every eight hours and serviced according to the
					 manufacturer's recommendations by a member of the hospital's respiratory
					 therapy department or other responsible personnel trained to perform the
					 task;
3. Saturation monitor (pulse
					 oximeter or equivalent);
4.
					 Equipment for monitoring blood glucose;
5. Infant scales;
6. Intravenous therapy equipment;
7. Equipment and supplies for the insertion
					 of umbilical arterial and venous catheters;
8. Open bassinets, self-contained incubators,
					 open radiant heat infant care system or any combination thereof appropriate to
					 the service level;
9. Equipment for
					 stabilization of a sick infant prior to transfer that includes a radiant heat
					 source capable of maintaining an infant's body temperature at
					 99°F;
10. Equipment for
					 insertion of a thoracotomy tube; and
11. Equipment for proper administration and
					 maintenance of phototherapy.
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 3 - Special Services › Section 12VAC5-410-446 - Newborn support services and other resources

Current through Register Vol. 40, No. 24, July 15, 2024
A. The support services and other resources
					 required for the general level newborn service and all higher levels of newborn
					 services shall be as follows:
1. Clinical
					 laboratory services and blood bank services available in the hospital on a
					 24-hour basis. Laboratory and blood bank personnel available on-site or on-call
					 on a 24-hour basis;
2. Group O Rh
					 negative blood available from the blood bank at all times and the blood bank's
					 ability to provide correctly matched blood within 45 minutes of
					 request;
3. Hospital laboratory and
					 blood bank personnel capability to perform the following tests with less than
					 1.0 ml of blood within one hour or less of request if specified:
(i) blood group and Rh type
					 determination/cross-matching,
(ii)
					 arterial blood gases within 20 minutes,
(iii) blood glucose within 20 minutes,
(iv) complete blood count,
(v) total protein and albumin,
(vi) total and direct bilirubin,
(vii) direct Coombs' test,
(viii) electrolytes,
(ix) blood urea nitrogen,
(x) clotting profile (may require more than
					 one ml of blood); and
4.
					 Portable radiological services for basic radiologic studies in the nursery
					 available on-call, within 30 minutes of request, on a 24-hour basis.
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 3 - Special Services › Section 12VAC5-410-450 - Psychiatric service

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
					 psychiatric service shall be under the supervision of a physician, licensed by
					 the Board of Medicine, who meets the qualifications of the medical staff
					 bylaws.
B. Psychiatric units shall
					 conform to the applicable licensure requirements pursuant to
					 12VAC35-105.
C. Every hospital that
					 provides inpatient psychiatric services shall establish written policies for
					 denial of admission of medically stable patients in its psychiatric unit. The
					 policies shall include language that:
1. If a
					 medically stable patient is referred to a hospital's psychiatric unit and
					 denied admission, the referring physician may request direct verbal
					 communication with the on-call physician at the referral hospital;
					 and
2. Prohibits on-call physicians
					 or other hospital staff from refusing a request from the referring physician
					 for direct verbal communication.
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 3 - Special Services › Section 12VAC5-410-460 - Special care units

Current through Register Vol. 40, No. 24, July 15, 2024
A. As used
					 in this section, special care units may be multipurpose or include but not be
					 limited to units for: intensive care, burn care, coronary care, pulmonary care,
					 rehabilitation, and hemodialysis.
B. Special care units shall have a defined
					 organization. Each unit shall be designed and equipped for the defined special
					 functions. Each special care unit shall be governed by written policies and
					 procedures specifically relating to utilization of the service.
C. Each unit shall be under the direction of
					 a physician qualified by training and experience in the specialty care in
					 accordance with medical staff bylaws.
D. Personnel shall be provided based on the
					 scope and complexity of the services provided.
E. The hospital shall have a written plan for
					 a continuing education program developed specifically for personnel of special
					 care units.
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 3 - Special Services › Section 12VAC5-410-470 - Outpatient (ambulatory care)

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 All hospital outpatient (ambulatory care) services shall conform to all
					 applicable rules and regulations herein, since such services are an integral
					 part of the hospital and covered by its licensure.
B. Freestanding outpatient surgical hospitals
					 shall comply with the provisions of Part IV of this chapter.
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 4 - Environmental and Maintenance Services › Section 12VAC5-410-480 - Housekeeping service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Written
					 housekeeping procedures shall be established for the cleaning of all areas in
					 the hospital and copies posted in appropriate areas.
B. All parts of the hospital and its premises
					 shall be kept clean, neat, and free of litter and rubbish.
C. Equipment and supplies shall be provided
					 for cleaning of all surfaces. Such equipment shall be maintained in a safe and
					 sanitary condition.
D. Cleaning
					 solutions and substances shall be labeled, stored in a safe place, and kept
					 separate from food storage and patient care supplies.
E. Cleaning shall be performed in a manner
					 which will minimize the spread of pathogenic organisms in the hospital
					 atmosphere.
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 4 - Environmental and Maintenance Services › Section 12VAC5-410-490 - Infection control

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each hospital
					 shall have an infection control committee to perform at least the following
					 functions:
1. Establish a hospital-wide
					 infection surveillance program and designate an infection control officer to
					 conduct all infection surveillance activities and to maintain appropriate
					 records to include infection rates by body site and clinical service and all
					 hospital acquired blood stream pathogens.
2. Establish written policies governing the
					 admission and isolation, including protective isolation, of patients with known
					 or suspected infectious diseases.
3. Develop, periodically evaluate, and revise
					 as needed, infection control policies, procedures and techniques for all
					 appropriate phases of hospital operation and service in order to protect
					 patients, employees, and visitors. These policies shall include, but are not
					 limited to, appropriate employee health screening and immunization and
					 acceptable techniques and practices for high risk procedures such as parenteral
					 hyperalimentation, urinary tract catheterization, dialysis, and intravenous
					 therapy.
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 4 - Environmental and Maintenance Services › Section 12VAC5-410-500 - Laundry service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Hospitals
					 providing laundry service shall have adequate facilities and equipment for the
					 safe and effective operation of such service. Those areas used for storage and
					 handling of soiled linens shall be negatively pressurized or vented to the
					 outside.
B. Special procedures
					 shall be established for the handling and processing of contaminated
					 linens.
C. All soiled linen shall
					 be placed in closed containers prior to transportation.
D. To safeguard clean linens from
					 cross-contamination, they shall be:
1.
					 Transported in containers used exclusively for clean linens unless such
					 containers are routinely and regularly sanitized before use as a clean linen
					 transport container and shall be kept covered at all times while in transit;
					 and
2. Stored in areas designated
					 exclusively for this purpose.
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 4 - Environmental and Maintenance Services › Section 12VAC5-410-510 to 12VAC5-410-640

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part III - Standards and Design Criteria for New Buildings and Additions, Alterations and Conversion of Existing Buildings › Section 12VAC5-410-650 - General building and physical plant information

Current through Register Vol. 40, No. 24, July 15, 2024
A. All construction of new buildings and
				  additions, renovations, alterations or repairs of existing buildings for
				  occupancy as a hospital shall conform to state and local codes, zoning
				  ordinances, and the Virginia Uniform Statewide Building Code (13VAC5-63).
In addition, hospitals shall be designed and constructed
					 consistent with Part 1 and Part 2 of the 2018 Guidelines for Design and
					 Construction of Hospitals of the Facility Guidelines Institute pursuant to
					 §
											32.1-127.001
					 of the Code of Virginia.
B.
				  Architectural drawings and specifications for all new construction or for
				  additions, alterations, or renovations to any existing building shall be dated,
				  stamped with professional seal, and signed by the architect. The architect
				  shall certify that the drawings and specifications were prepared to conform to
				  the Virginia Uniform Statewide Building Code (13VAC5-63) and be consistent with
				  Part 1 and Part 2 of the 2018 Guidelines for Design and Construction of
				  Hospitals of the Facility Guidelines Institute.
Statutory Authority: §§
												32.1-127 and
						32.1-127.001
						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 III - Standards and Design Criteria for New Buildings and Additions, Alterations and Conversion of Existing Buildings › Section 12VAC5-410-655 - Additional building regulations and standards

Current through Register Vol. 40, No. 24, July 15, 2024
A. The use of an incinerator shall require
				  permitting from the nearest regional permitting office for the Department of
				  Environmental Quality.
B. Water
				  shall be obtained from an approved water supply system. Hospitals shall be
				  connected to sewage systems approved by the Department of Health or the
				  Department of Environmental Quality.
C. Each hospital shall establish a monitoring
				  program for the internal enforcement of all applicable fire and safety laws and
				  regulations.
D. All radiological
				  machines shall be registered with the Office of Radiological Health of the
				  Virginia Department of Health. Installation, calibration and testing of
				  machines and storage facilities shall comply with 12VAC5-480.
E. A hospital's food services operation shall
				  comply with 12VAC5-421.
F. Hospital
				  pharmacy services shall comply with Chapter 33 (§ 54.1-3300 et seq.) of
				  Title 54.1 of the Code of Virginia and 18VAC110-20.
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 III - Standards and Design Criteria for New Buildings and Additions, Alterations and Conversion of Existing Buildings › Section 12VAC5-410-660 to 12VAC5-410-710

Current through Register Vol. 40, No. 24, July 15, 2024