Article 3. Procedures for Licensure or License Renewal
12VAC5-410-40. General.
Article 3
Procedures for Licensure or License Renewal
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.
Historical Notes
Derived from VR355-33-500 § 1.4, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-50. Classification.
Hospitals to be licensed shall be classified as general hospitals or outpatient surgical hospitals defined by 12VAC5-410-10.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 1.5, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-60. Separate license.
A. A separate license shall be required by hospitals maintained on separate campuses even though the hospitals are operated under the same management. Separate license is not required for separate buildings on the same campus or within the same complex of buildings or for an emergency department of a general hospital.
B. Hospitals that 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.
Historical Notes
Derived from VR355-33-500 § 1.6, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 29, Issue 19, eff. June 20, 2013; Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-70. Request for issuance.
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.
B. The renewal of a hospital license shall be conditioned upon the up-to-date payment of any civil penalties owed as a result of willful refusal, failure, or neglect to honor certain conditions established in their award of a Certificate of Public Need pursuant to § 32.1-102.4 F of the Code of Virginia.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 1.7, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 18, Issue 10, eff. February 28, 2002; Volume 23, Issue 10, eff. March 1, 2007.
12VAC5-410-80. Service charge.
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.
Historical Notes
Derived from VR355-33-500 § 1.8, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 23, Issue 10, eff. March 1, 2007.
12VAC5-410-90. License expiration.
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.
Historical Notes
Derived from VR355-33-500 § 1.9, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-100. Name.
Every hospital shall be designated by a permanent and appropriate name that shall appear on the application for license.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 1.10, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 23, Issue 10, eff. March 1, 2007; Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-110. Bed capacity.
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.
Historical Notes
Derived from VR355-33-500 § 1.11, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 23, Issue 10, eff. March 1, 2007; Volume 35, Issue 24, eff. August 23, 2019.
12VAC5-410-120. Posting of license.
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.
Historical Notes
Derived from VR355-33-500 § 1.12, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-130. Surrender of license; mid-term change of license.
A. Upon revocation or suspension of a license, the hospital shall surrender its license to the OLC.
B. The hospital shall notify the director of the OLC in writing by submitting a mid-term change application no fewer than 30 calendar days in advance of implementing any of the following:
1. Change of location of the hospital, including change of location of any emergency department, not located on the hospital's campus;
2. Change of ownership of the hospital;
3. Change of operator of the hospital;
4. Change of name of the hospital;
5. Change of bed capacity, except as provided in 12VAC5-410-110 C, which shall be accompanied by an approved Certificate of Public Need if the requested change is for an increase in bed capacity;
6. Change of services being provided, including any proposed addition or discontinuation, regardless of whether licensure is required for the service; or
7. Closure of the hospital.
C. The OLC shall:
1. Consider the submission date of a mid-term change application to be the date it is postmarked or the date it is received, whichever is earlier; and
2. Notify the licensee in writing if the commissioner will issue a changed license.
D. The commissioner's issuance of a changed license to the hospital shall satisfy the requirements of subdivision C 2 of this section.
E. Upon receipt of the changed license, the licensee shall return its prior license issued by the commissioner to the OLC and destroy any copies of the prior license.
F. A license may not be transferred or assigned. The commissioner may not issue a changed license in response to a change of operator of the hospital, but shall instead require the hospital to obtain a new license. If the hospital intends to implement a change of operator, it shall:
1. File for a new license in accordance with 12VAC5-410-70 no fewer than 30 calendar days in advance of any change of operator; and
2. Upon receipt of the new license, surrender its prior license issued by the commissioner to the OLC and destroy any copies of the prior license.
G. If the hospital is closing or will otherwise no longer be operational, it shall:
1. Notify patients, legal representatives, and the OLC no fewer than seven calendar days prior to closing or ceasing operations where all clinical records are to be located following closure or cessation of operations; and
2. Surrender its license to the OLC and destroy all copies of its license no more than five calendar days after the hospital closes or ceases operations.
H. The OLC shall determine if any changes listed in subsection B of this section affect the terms of the license or the continuing eligibility for a license. An inspector may inspect the hospital during the process of evaluating a proposed change.
Statutory Authority
§§ 32.1-12, 32.1-127, and 32.1-132 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 1.13, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 23, Issue 10, eff. March 1, 2007; Volume 35, Issue 24, eff. August 23, 2019; Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-140. Inspection procedure.
A. The OLC shall make periodic unannounced on-site inspections of a hospital as necessary but not less frequently than biennially. The OLC may make on-site inspections of applicants for licensure. Compliance with all standards shall be determined by the OLC.
B. The hospital or applicant shall:
1. Make available to the inspector any requested records;
2. Permit an inspector to enter upon and into its property to inspect or investigate as the inspector reasonably deems necessary in order to determine the state of compliance with the provisions of this chapter and all laws administered by the board; and
3. Allow the inspector access to interview the agents, employees, independent contractors, patients, legal representatives, patient family members, and any person under the hospital's or applicant's control, direction, or supervision.
C. After the on-site inspection, the inspector shall:
1. Discuss the findings of the inspection with the chief executive officer or the chief executive officer's designee; and
2. Provide a written inspection report to the chief executive officer or the chief executive officer's designee.
D. If the OLC cites one or more licensing violations in the written inspection report, the chief executive officer or the chief executive officer's designee shall submit a plan of correction in accordance with 12VAC5-410-150.
E. The OLC may presume that a general hospital deemed by a general hospital accrediting organization and certified for participation in Title XVIII of the Social Security Act (42 USC § 301 et seq.) generally meets the requirements of Part II (12VAC5-410-170 et seq.) of this chapter provided the following conditions are met:
1. The general hospital provides to the OLC, upon request, a copy of the most current accreditation survey findings made by the general hospital accrediting organization; and
2. The general hospital notifies the OLC within 10 days after receipt of any notice of revocation or denial of accreditation by the general hospital accrediting organization.
F. The OLC may presume that an outpatient surgical hospital deemed by an outpatient surgical hospital accrediting organization and certified for participation in Title XVIII of the Social Security Act (42 USC § 301 et seq.) generally meets the requirements of Part IV (12VAC5-410-1150 et seq.) of this chapter provided the following conditions are met:
1. The outpatient surgical hospital provides to the OLC, upon request, a copy of the most current accreditation survey findings made by the outpatient surgical hospital accrediting organization; and
2. The outpatient surgical hospital notifies the OLC within 10 days after receipt of any notice of revocation or denial of accreditation by the outpatient surgical hospital accrediting organization.
G. The OLC may presume that a unit or part of a general hospital licensed or certified by another state agency or another section, bureau, or division of the OLC meets the requirements of Part II (12VAC5-410-170 et seq.) of this chapter for that specific unit or part provided the following conditions are met:
1. The general hospital provides the OLC, upon request, a copy of the most current inspection report made by the other state agency; and
2. The general hospital notifies the OLC within 10 days after receipt of any notice of revocation or suspension by the other state agency.
H. The OLC may presume that a unit or part of an outpatient surgical hospital licensed or certified by another state agency or another section, bureau, or division of the OLC meets the requirements of Part IV (12VAC5-410-1150 et seq.) of this chapter for that specific unit or part provided the following conditions are met:
1. The outpatient surgical hospital provides the OLC, upon request, a copy of the most current inspection report made by the other state agency; and
2. The outpatient surgical hospital notifies the OLC within 10 days after receipt of any notice of revocation or suspension by the other state agency.
I. Notwithstanding any other provision of this chapter to the contrary, if the OLC finds, after inspection, violations pertaining to environmental health or life safety, the hospital shall receive a written licensing report of such findings. The hospital shall be required to submit a plan of correction in accordance with provisions of 12VAC5-410-150.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 1.14, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 23, Issue 10, eff. March 1, 2007; Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-150. Plan of correction.
A. Upon receipt of a written inspection report, the chief executive officer or the chief executive officer's designee shall prepare a written plan of correction addressing each licensing violation cited at the time of inspection.
B. The chief executive officer or the chief executive officer's designee shall submit to the OLC a written plan of correction no more than 15 business days after receipt of the inspection report. The plan of correction shall contain, for each licensing violation cited:
1. A description of the corrective action to be taken and the position title of the employees to implement the corrective action. If employees share the same position title, the chief executive officer or the chief executive officer's designee shall assign the employees a unique identifier to distinguish them;
2. The expected correction date, not to exceed 45 business days from the exit date of the inspection; and
3. A description of the measures implemented to prevent a recurrence of each licensing violation.
C. The chief executive officer or the chief executive officer's designee shall ensure that the person responsible for the validity of the plan of correction signs, dates, and indicates their title on the plan of correction.
D. The OLC shall notify the chief executive officer or the chief executive officer's designee, in writing, if the OLC determines any item in the plan of correction is unacceptable.
E. The OLC may conduct an inspection to verify that any portion of a plan of correction has been implemented.
F. The chief executive officer or the chief executive officer's designee shall ensure the plan of correction is implemented and monitored so that compliance is maintained.
G. The commissioner may deny licensure or renewal of licensure if the chief executive officer or the chief executive officer's designee fails to submit an acceptable plan of correction or fails to implement an acceptable plan of correction.
H. The OLC shall consider the submission date of a plan of correction to be the date the plan of correction is postmarked or the date it is received, whichever is earlier.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 1.15, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 23, Issue 10, eff. March 1, 2007; Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-160. Disciplinary action.
A. A hospital may not:
1. Violate the provisions of this chapter or Article 1 (§ 32.1-123 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia;
2. Permit, aid, or abet the commission of any illegal act in the hospital;
3. Engage in a pattern of violations pursuant to § 38.2-3445.01 of the Code of Virginia; or
4. Engage in a pattern of violations of § 38.2-3407.15 B 13 of the Code of Virginia.
B. The commissioner may:
1. For each violation of subsection A of this section:
a. Deny, revoke, or suspend the license to operate a hospital, in accordance with the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia);
b. Refer a hospital for criminal prosecution pursuant to § 32.1-27 A of the Code of Virginia; or
c. Petition an appropriate court for an injunction, mandamus, or other appropriate remedy or imposition of a civil penalty against a hospital pursuant to § 32.1-27 B or C of the Code of Virginia;
2. For each violation of subsection A of this section by or occurring in a long-term care nursing unit of a general hospital if that unit is a certified nursing facility:
a. Restrict or prohibit new admissions to the long-term care nursing unit in accordance with the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia);
b. Petition an appropriate court for imposition of a civil monetary penalty against a hospital pursuant to § 32.1-27.1 A of the Code of Virginia; or
c. Petition an appropriate court for appointment of a receiver for the long-term care nursing unit pursuant to § 32.1-27.1 B of the Code of Virginia; and
3. For each violation of subdivision A 3 of this section, levy a fine upon the hospital in an amount not to exceed $1,000 per violation, in accordance with the Administrative Process Act.
C. Suspension of a license shall in all cases be for an indefinite time.
D. For each violation of subsection A of this section and with the consent of the person who has violated subsection A of this section, the board may provide, in an order issued by the board, for the payment of civil charges for past violations in specific sums, which may not exceed the limits specified in § 32.1-27 of the Code of Virginia or if applicable, the limits specified in § 32.1-27.1 of the Code of Virginia.
E. Upon receipt of a completed application and a nonrefundable service charge, the commissioner may issue a new license to a hospital that has had its license revoked if the commissioner determines that:
1. The conditions upon which revocation was based have been corrected; and
2. The applicant is in compliance with this chapter, Article 1 (§ 32.1-123 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia, and all other applicable state and federal laws and regulations.
F. Upon receipt of a completed application, the commissioner may partially or completely restore a suspended license to a hospital if the commissioner determines that:
1. The conditions upon which suspension was based have been completely or partially corrected; and
2. The interests of the public will not be jeopardized by resumption of operation.
G. The commissioner may not require an additional service charge for restoring a license pursuant to subsection F of this section.
H. The hospital shall submit evidence relevant to subdivisions E 1, E 2, F 1, and F 2 of this section that is satisfactory to the commissioner or the commissioner's designee. The commissioner or the commissioner's designee may conduct an inspection prior to making a determination.
Statutory Authority
§§ 32.1-12, 32.1-27, 32.1-27.1, 32.1-127, 32.1-135, 32.1-137.07, and 38.2-3407.15 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 1.16, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 42, Issue 18, eff. June 4, 2026.