Administrative Code

Virginia Administrative Code
1/22/2022

Part III. Resident Services

12VAC5-371-200. Director of nursing.

A. Each nursing facility shall employ a full-time director of nursing to supervise the delivery of nursing services. The individual hired shall be a registered nurse licensed by the Virginia Board of Nursing.

B. The duties and responsibilities of the director of nursing shall include, but are not limited to:

1. Developing and maintaining (i) nursing service objectives, (ii) standards of practice, (iii) policy and procedure manuals, and (iv) job descriptions for each level of nursing personnel;

2. Recommending to the administrator the resources needed to carry out nursing service, including but not limited to, equipment and supplies and the number and level of nursing personnel to be employed;

3. Participating in the employment of nursing personnel, including (i) recruitment, (ii) selection, (iii) position assignment, (iv) orientation, (v) in-service education, (vi) supervision, (vii) evaluation, and (viii) termination;

4. Participating with the medical director in developing and implementing policies for resident care;

5. Assuring that the comprehensive plan of care is maintained in conjunction with other disciplines;

6. Coordinating nursing services with other services such as medical, rehabilitative, and social services and the resident activity program;

7. Participating in quality assurance committee meetings to identify issues and to develop and implement appropriate plans of action to correct identified problems;

8. Making daily rounds on resident floors, unless this duty has been delegated to another licensed nurse; and

9. Recommending and coordinating the training needs of nursing staff with the individual responsible for in-service training.

C. A registered nurse, designated in writing by the administrator, shall serve in the temporary absence of the director of nursing so there is the equivalent of a full-time director of nursing on duty for a minimum of five days a week.

D. The director of nursing shall not function as a nursing supervisor in facilities with 60 or more beds.

E. The nursing facility shall notify the OLC, in writing, within five days of a vacancy in the director of nursing position. The written notice shall give the name and Virginia license number of the individual appointed to serve as director of nursing, and whether the appointment is permanent or temporary.

F. The director of nursing position shall not be held by a temporary designate for more than 90 days. Temporary agency personnel shall not be utilized to fill the director of nursing position.

G. Written notification, giving the name and license number of the individual, shall be sent to the OLC when a permanent appointment is made.

H. A license for a new nursing facility or an increase in bed size in an existing nursing facility shall not be issued if the director of nursing position is vacant.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 23, Issue 10, eff. March 1, 2007.

12VAC5-371-210. Nurse staffing.

A. A nursing supervisor, designated by the director of nursing, shall be responsible for all nursing activities in the nursing facility, or in the section to which assigned, including:

1. Making daily visits to determine resident physical, mental, and emotional status and implementing any required nursing intervention;

2. Reviewing medication records for completeness, accuracy in the transcription of physician orders, and adherence to stop-order policies;

3. Reviewing resident plans of care for appropriate goals and approaches, and making revisions based on individual needs;

4. Assigning to the nursing staff responsibility for nursing care;

5. Supervising and evaluating performance of all nursing personnel on the unit; and

6. Keeping the director of nursing services, or director of nursing designee, informed of the status of residents and other related matters.

B. The nursing facility shall provide qualified nurses and certified nurse aides on all shifts, seven days per week, in sufficient number to meet the assessed nursing care needs of all residents.

C. Nursing personnel, including registered nurses, licensed practical nurses, and certified nurse aides shall be assigned duties consistent with their education, training and experience.

D. Weekly time schedules shall be maintained and shall indicate the number and classification of nursing personnel who worked on each unit for each shift. Schedules shall be retained for one year.

E. 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 Part IV (18VAC19-20-240 et seq.) of the Regulations Governing the Practice of Nursing and with a plan developed and implemented by the nursing facility.

F. Before allowing a nurse aide to perform resident care duties, the nursing facility shall verify that the individual is:

1. A certified nurse aide in good standing;

2. Enrolled full-time in a nurse aide education program approved by the Virginia Board of Nursing; or

3. Has completed a nurse aide education program or competency testing, but has not yet been placed on the nurse aide registry.

G. Any person employed to perform the duties of a nurse aide on a permanent full-time, part-time, hourly, or contractual basis must be registered as a certified nurse aide within 120 days of employment.

H. Nurse aides employed or provided by a temporary personnel agency shall be certified to deliver nurse aide services.

I. The services provided or arranged with a temporary personnel agency shall meet professional standards of practice and be provided by qualified staff according to each resident's comprehensive plan of care.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 22, Issue 7, eff. January 11, 2006; Volume 37, Issue 17, eff. May 27, 2021.

12VAC5-371-220. Nursing services.

A. Each nursing facility shall implement written resident care policies and procedures which support an active program of nursing care directed toward assisting all residents to achieve outcomes consistent with their highest level of self-care and independence.

B. All medications and treatments will be administered as prescribed in the resident's medical plan of care.

C. Services shall be provided to prevent clinically avoidable complications, including, but not limited to:

1. Pressure ulcer development;

2. Contracture;

3. Loss of continence;

4. Dehydration; and

5. Malnutrition.

D. Each resident shall be given proper daily personal attention and care, including skin, nail, hair and oral hygiene, in addition to any specific care ordered by the attending physician. Provision of daily personal care shall be documented in the clinical record.

E. Each resident shall be dressed in clean clothing and be free of odors. Each resident shall be encouraged to wear day clothing when out of bed.

F. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly. Residents whose medical conditions prohibit tub or shower baths shall have a sponge bath daily.

G. Residents who are incontinent shall have a partial bath, clean clothing and linens each time their clothing or bed linen is soiled.

H. The attending physician, nurse practitioner or physician assistant and the resident's family or responsible party shall be notified of any changes in a resident's condition which indicate a need to alter medical treatment.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997.

12VAC5-371-230. Medical direction.

A. Each nursing facility shall have a written agreement with one or more physicians licensed by the Virginia Board of Medicine to serve as medical director.

B. The duties of the medical director shall include, but are not limited to:

1. Advising the administrator and the director of nursing on medical issues, including the criteria for residents to be admitted, transferred or discharged from the nursing facility;

2. Advising on the development and execution of policies and procedures that have a direct effect upon the quality of medical and nursing care delivered to residents;

3. Acting as liaison and consulting with the administrator and the attending physician on matters regarding medical and nursing care policies and procedures of the nursing facility;

4. Advising and providing consultation to the nursing facility staff regarding communicable diseases, infection control and isolation procedures, and serving as liaison with local health officials;

5. Providing temporary physician services when the admitting physician is not the attending physician, in order to assure that the resident has temporary medical orders;

6. Providing physician services in case of emergency in the event that the resident's attending physician cannot be reached; and

7. Advising on the development and execution of an employee health program, which shall include provisions for determining that employees are free of communicable diseases according to current acceptable standards of practice.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997.

12VAC5-371-240. Physician services.

A. Each resident shall be under the care of a physician licensed by the Virginia Board of Medicine. Nurse practitioners and physician assistants licensed to practice in Virginia may provide care as assigned by the supervising physician and within the parameters of professional licensing.

B. Prior to, or at the time of admission, each resident, his designated representative, or the entity responsible for his care shall designate an attending physician.

C. A complete medical plan of care must be provided at the time of admission, or within 48 hours after admission. The plan shall include:

1. Primary diagnosis;

2. Identification of resident problems;

3. Medical history and physical exam;

4. Orders for medications;

5. Treatments;

6. Restorative services;

7. Activity levels;

8. Diet;

9. Special procedures recommended for health and safety of the resident; and

10. Advance directives, if known.

D. The admission medical plan of care shall be prescribed and signed by the attending physician. Subsequent medical plans of care for the same resident may be prescribed and signed by a nurse practitioner or physician assistant according to their practice agreements.

E. The physician, nurse practitioner or physician assistant shall review the resident's medical plan of care at each visit and write a progress note.

F. Each resident shall be seen by his attending physician and the resident's total program of care shall be reviewed and appropriately revised as necessary.

G. All verbal orders shall be immediately recorded and signed by the individual receiving them, and shall be countersigned by the prescribing person.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 22, Issue 7, eff. January 11, 2006.

12VAC5-371-250. Resident assessment and care planning.

A. The nursing facility shall conduct an initial and periodic assessment of each resident's needs. The assessment shall accurately describe the resident's capability to perform daily life functions and significant impairments in functional capacity. This comprehensive assessment shall include, but is not limited to:

1. Medically defined conditions and prior medical history;

2. Medical status;

3. Physical and mental functional status;

4. Sensory and physical impairments;

5. Nutritional status and requirements;

6. Special treatments or procedures;

7. Psychosocial status;

8. Discharge potential;

9. Dental condition;

10. Activities potential;

11. Rehabilitative potential;

12. Cognitive status;

13. Drug therapy; and

14. Any known advance directives.

B. The nursing facility shall conduct a complete assessment:

1. No later than 14 days after the date of admission;

2. Promptly after a significant change in the resident's physical or mental condition; and

3. In all cases, at least once every 12 months.

C. The nursing facility shall review each resident's assessment at least once every three months and shall update the plan of care as indicated.

D. Each assessment shall be coordinated by a registered nurse who signs, dates and certifies completion of the assessment.

E. Each assessment shall be conducted or coordinated with the participation of health professionals. Each person completing a portion of the assessment shall sign and date that portion of the assessment.

F. The nursing facility shall use the results of the assessment to develop, review, and revise the resident's comprehensive plan of care.

G. A comprehensive plan of care shall be developed for each resident. The plan shall include measurable objectives and timetables to meet the resident's medical, nursing, nutritional, and psychosocial needs identified in the comprehensive assessment. The plan shall also describe the services that are to be furnished to maintain or improve the resident's physical, mental, and psychosocial status.

H. The comprehensive plan of care shall be developed within seven days of completion of the comprehensive assessment.

I. The comprehensive plan of care shall be prepared by a multidisciplinary team. The multidisciplinary team shall include a registered nurse, the attending physician, to the extent practicable, and other staff in disciplines as determined by the resident's needs. The resident, the resident's family or legal representative shall also be provided a meaningful opportunity to participate in the care planning.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997.

12VAC5-371-260. Staff development and inservice training.

A. All full-time, part-time, and temporary personnel shall receive orientation to the nursing facility commensurate with their function or job-specific responsibilities.

B. All resident care staff shall receive annual inservice training commensurate with their function or job-specific responsibilities in at least the following:

1. Special needs of residents as determined by the nursing facility staff;

2. Prevention and control of infections;

3. Fire prevention or control and emergency preparedness;

4. Safety and accident prevention;

5. Restraint use, including alternatives to physical and chemical restraints;

6. Confidentiality of resident information;

7. Understanding the needs of the aged and disabled;

8. Resident rights, including personal rights, property rights and the protection of privacy, and procedures for handling complaints;

9. Care of the cognitively impaired;

10. Basic principles of cardiopulmonary resuscitation for licensed nursing staff and the Heimlich maneuver for nurse aides; and

11. Prevention and treatment of pressure sores.

C. The nursing facility shall have an ongoing training program that is planned and conducted for the development and improvement of skills of all personnel.

D. The nursing facility shall maintain written records indicating the content of and attendance at each orientation and inservice training program.

E. The nursing facility shall provide inservice programs, based on the outcome of annual performance evaluations, for nurse aides.

F. Nurse aide inservice training shall consist of at least 12 hours per anniversary year.

G. The nursing facility shall provide training on the requirements for reporting adult abuse, neglect, or exploitation and the consequences for failing to make such a required report to all its employees who are licensed to practice medicine or any of the healing arts, serving as a hospital resident or intern, engaged in the nursing profession, working as a social worker, mental health professional or law-enforcement officer and any other individual working with residents of the nursing facility.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 17, Issue 1, eff. October 27, 2000; Volume 37, Issue 17, eff. May 27, 2021.

12VAC5-371-270. Social services.

A. The nursing facility shall provide a comprehensive social services program to meet the psychosocial and medically related needs of each resident.

B. There shall be at least one designated staff member responsible for coordinating resident social services.

C. This individual shall have one of the following qualifications:

1. A bachelor's degree in social work or human services appropriate to resident needs; or

2. One year, within the last five years, supervised direct social work experience.

D. This individual shall be:

1. Trained in recognizing and assessing the emotional and social needs of residents; and

2. Knowledgeable of community agencies and resources available to meet those needs.

E. The social services coordinator shall assess each resident and participate in the development and implementation of the comprehensive plan of care.

F. Documentation of social services shall be included in the resident's clinical record.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997.

12VAC5-371-280. Resident activities.

A. The nursing facility shall provide activities, on a regularly scheduled basis, specifically suited to the needs and interests of each resident based on the resident's comprehensive plan of care.

B. There shall be at least one staff member responsible for coordinating resident activities. The individual shall meet at least one of the following qualifications:

1. Be a qualified therapeutic recreation specialist or an activities professional;

2. Be eligible for certification as a therapeutic recreation specialist or activities professional by a recognized accrediting body;

3. Have one year full-time experience, within the last five years, in a patient activities program in a health care setting;

4. Be a qualified occupational therapist or occupational therapy assistant; or

5. Have completed 40 hours training in group activities and recognizing and assessing the activity needs of residents.

C. The activities coordinator shall assess each resident and participate in the development and implementation of the comprehensive plan of care.

D. The activities program shall make the fullest possible use of community social and recreational opportunities, including the involvement of volunteers and community groups.

E. Documentation of activities shall be included in the resident's clinical record.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 25, eff. September 1, 1997.

12VAC5-371-290. Special rehabilitative services.

A. The nursing facility shall provide, or arrange for under written agreement, specialized rehabilitative services, such as physical therapy, speech-language pathology services and occupational therapy.

B. Specialized rehabilitative services shall be provided in accordance with accepted standards of practice by qualified therapists, or by trained assistants under the supervision of a licensed or certified therapist.

C. Rehabilitative services shall be authorized by the attending physician and a written plan of care developed in consultation with the appropriate therapist.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997.

12VAC5-371-300. Pharmaceutical services.

A. Provision shall be made for the procurement, storage, dispensing, and accounting of drugs and other pharmacy products in compliance with 18VAC110-20. This may be by arrangement with an off-site pharmacy, but must include provisions for 24-hour emergency service.

B. Each nursing facility shall develop and implement policies and procedures for the handling of drugs and biologicals, including procurement, storage, administration, self-administration, and disposal of drugs.

C. Each nursing facility shall have a written agreement with a qualified pharmacist to provide consultation on all aspects of the provision of pharmacy services in the nursing facility.

D. The consultant pharmacist shall make regularly scheduled visits, at least monthly, to the nursing facility for a sufficient number of hours to carry out the function of the agreement.

E. Excluding cannabidiol oil and THC-A oil, no drug or medication shall be administered to any resident without a valid verbal order or a written, dated and signed order from a physician, dentist, podiatrist, nurse practitioner, or physician assistant, licensed in Virginia.

F. Nursing facility employees who are authorized to possess, distribute, or administer medications to residents may store, dispense, or administer cannabidiol oil or THC-A oil to a resident who has:

1. Been issued a valid written certification for the use of cannabidiol oil or THC-A oil in accordance with subsection B of § 54.1-3408.3 of the Code of Virginia; and

2. Registered with the Board of Pharmacy.

G. Verbal orders for drugs or medications shall only be given to a licensed nurse, pharmacist, or physician.

H. Drugs and medications not limited as to time or number of doses when ordered shall be automatically stopped, according to the written policies of the nursing facility, and the attending physician shall be notified.

I. Each resident's medication regimen shall be reviewed by a pharmacist licensed by the Virginia Board of Pharmacy. Any irregularities identified by the pharmacist shall be reported to the physician and the director of nursing, and their response documented.

J. Medication orders shall be reviewed at least every 60 days by the attending physician, nurse practitioner, or physician's assistant.

K. Prescription and nonprescription drugs and medications may be brought into the nursing facility by a resident's family, friend, or other person provided:

1. The individual delivering the drugs and medications assures timely delivery, in accordance with the nursing facility's written policies, so that the resident's prescribed treatment plan is not disrupted;

2. Each drug or medication is in an individual container; and

3. Delivery is not allowed directly to an individual resident.

In addition, prescription medications shall be obtained and labeled as required by law.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 22, Issue 7, eff. January 11, 2006; Volume 36, Issue 23, eff. August 6, 2020; Volume 37, Issue 17, eff. May 27, 2021.

12VAC5-371-310. Diagnostic services.

A. The nursing facility shall provide, or arrange for under written agreement, laboratory, x-ray and other diagnostic services, as ordered by a physician.

B. The nursing facility shall notify the attending physician of the results of diagnostic services.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997.

12VAC5-371-320. Dental services.

A. Provisions shall be made to assist residents to obtain routine and emergency dental care.

B. Each nursing facility shall make arrangements with a qualified dental professional to provide consultation and recommend oral hygiene policies and practices for the care of residents.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 22, Issue 7, eff. January 11, 2006.

12VAC5-371-330. Restraint usage.

A. A resident shall be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

B. Restraints shall only be used:

1. In accordance with the comprehensive assessment and plan of care, which includes a schedule or plan of rehabilitation training enabling the progressive removal or the progressive use of less restrictive restraints when appropriate; and

2. As a last resort, after completing, implementing, and evaluating the resident's comprehensive assessment and plan of care, when the nursing facility has determined that less restrictive means have failed.

C. If a restraint is used in a nonemergency, the nursing facility shall:

1. Explain the use of the restraint, including potential negative outcomes of restraint use, to the resident or his legal representative, as appropriate;

2. Explain the resident's right to refuse the restraint;

3. Obtain written consent of the resident. If the resident has been legally declared incompetent, obtain written consent from the legal representative; and

4. Include the use of restraint in the plan of care.

D. Restraints shall not be ordered on a standing or PRN basis.

E. Restraints shall be applied only by staff trained in their use.

F. At a minimum, for a resident placed in a restraint, the nursing facility shall:

1. Check the resident at least every 30 minutes;

2. Provide an opportunity for motion, exercise and elimination for not less than 10 minutes each hour in which a restraint is administered; and

3. Document restraint usage, including outcomes, in accordance with nursing facility policy.

G. Emergency orders for restraints shall not be in effect for longer than 24 hours and must be confirmed by a physician within one hour of administration. Each application of emergency restraint shall be considered a single event and shall require a separate physician's order.

H. Temporary restraints may be used for a brief period to allow a medical or surgical procedure, but shall not be used to impose a medical or surgical procedure which the resident has previously refused.

I. The nursing facility shall notify a resident's legal representative, if any, or designated family member as soon as practicable, but no later than 12 hours after administration of a restraint.

J. Chemical restraint shall only be ordered in an emergency situation when necessary to ensure the physical safety of the resident or other individuals.

K. Orders for chemical restraint shall be in writing, signed by a physician, specifying the dose, frequency, duration and circumstances under which the chemical restraint is to be used. Verbal orders for chemical restraints shall be implemented when an emergency necessitates parenteral administration of psychopharmacologic drugs, but only until a written order can reasonably be obtained.

L. Emergency orders for chemical restraints shall:

1. Not be in effect for more than 24 hours; and

2. Be administered only if the resident is monitored continually for the first 15 minutes after each parenteral administration (or 30 minutes for nonparenteral administration) and every 15 minutes thereafter, for the first hour, and hourly for the next eight hours to ensure that any adverse side effects will be noticed and appropriate action taken as soon as possible.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 37, Issue 17, eff. May 27, 2021.

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