Article 2. Patient Care Services
12VAC5-410-230. Patient care management.
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.
E. Each hospital shall have a reliable method for identification of each patient, including newborn infants.
F. Each hospital shall include in its visitation policy a provision allowing each adult patient to receive visits from any individual from whom the patient desires to receive visits, subject to other restrictions contained in the visitation policy including the patient's medical condition and the number of visitors permitted in the patient's room simultaneously.
G. If the Governor has declared a public health emergency related to the novel coronavirus (COVID-19), each hospital shall allow a person with a disability who requires assistance as a result of such disability to be accompanied by a designated support person at any time during which health care services are provided.
1. In any case in which health care services are provided in an inpatient setting, and the duration of health care services in such inpatient setting is anticipated to last more than 24 hours, the person with a disability may designate more than one designated support person. However, no hospital shall be required to allow more than one designated support person to be present with a person with a disability at any time.
2. A designated support person shall not be subject to any restrictions on visitation adopted by such hospital. However, such designated support person may be required to comply with all reasonable requirements of the hospital adopted to protect the health and safety of patients and staff of the hospital.
3. Every hospital shall establish policies applicable to designated support persons and shall:
a. Make such policies available to the public on a website maintained by the hospital; and
b. Provide such policies, in writing, to the patient at such time as health care services are provided.
H. Each hospital that is equipped to provide life-sustaining treatment shall develop a policy to determine the medical or ethical appropriateness of proposed medical care, which shall include:
1. A process for obtaining a second opinion regarding the medical and ethical appropriateness of proposed medical care in cases in which a physician has determined proposed care to be medically or ethically inappropriate;
2. Provisions for review of the determination that proposed medical care is medically or ethically inappropriate by an interdisciplinary medical review committee and a determination by the interdisciplinary medical review committee regarding the medical and ethical appropriateness of the proposed health care of the patient;
3. Requirements for a written explanation of the decision of the interdisciplinary medical review committee, which shall be included in the patient's medical record; and
4. Provisions to ensure the patient, the patient's agent, or the person authorized to make the patient's medical decisions in accordance with § 54.1-2986 of the Code of Virginia is informed of the patient's right to obtain the patient's medical record and the right to obtain an independent medical opinion and afforded reasonable opportunity to participate in the medical review committee meeting.
The policy shall not prevent the patient, the patient's agent, or the person authorized to make the patient's medical decisions from obtaining legal counsel to represent the patient or from seeking other legal remedies, including court review, provided that the patient, the patient's agent, person authorized to make the patient's medical decisions, or legal counsel provide written notice to the chief executive officer of the hospital within 14 days of the date of the physician's determination that proposed medical treatment is medically or ethically inappropriate as documented in the patient's medical record.
I. Each hospital shall establish a protocol requiring that, before a health care provider arranges for air medical transportation services for a patient who does not have an emergency medical condition as defined in 42 USC § 1395dd(e)(1), the hospital shall provide the patient or the patient's authorized representative with written or electronic notice that the patient (i) may have a choice of transportation by an air medical transportation provider or medically appropriate ground transportation by an emergency medical services provider and (ii) will be responsible for charges incurred for such transportation in the event that the provider is not a contracted network provider of the patient's health insurance carrier or such charges are not otherwise covered in full or in part by the patient's health insurance plan.
J. Each hospital shall provide written information about the patient's ability to request an estimate of the payment amount for which the participant will be responsible pursuant to § 32.1-137.05 of the Code of Virginia. The written information shall be posted conspicuously in public areas of the hospital, including admissions or registration areas, and included on any website maintained by the hospital.
K. Each hospital shall establish protocols to ensure that any patient scheduled to receive an elective surgical procedure for which the patient can reasonably be expected to require outpatient physical therapy as a follow-up treatment after discharge is informed that the patient:
1. Is expected to require outpatient physical therapy as a follow-up treatment; and
2. Will be required to select a physical therapy provider prior to being discharged from the hospital.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.7, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 19, Issue 1, eff. November 1, 2002; Errata, 19:3 VA.R. 549 October 21, 2002; amended, Virginia Register Volume 24, Issue 11, eff. March 5, 2008; Volume 35, Issue 4, eff. November 14, 2018; Volume 35, Issue 21, eff. July 10, 2019; Volume 35, Issue 24, eff. August 23, 2019; Volume 36, Issue 23, eff. August 6, 2020; Volume 37, Issue 14, eff. March 31, 2021.
12VAC5-410-240. Anesthesia service.
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.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.8, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-250. Sterile supply service.
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.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.9, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-260. Dietary service.
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.
G. Pertinent observations and information relative to the special diets and to dietetic treatment shall be recorded in the patient's medical record.
H. A hospital contracting for food service shall require, as part of the contract, that the contractor comply with the provisions of this section.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.10, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 22, Issue 8, eff. January 25, 2006; Volume 32, Issue 7, eff. January 14, 2016.
12VAC5-410-270. Disaster and mass casualty programs.
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.
Historical Notes
Derived from VR355-33-500 § 2.11, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 22, Issue 8, eff. January 25, 2006; Volume 23, Issue 10, eff. March 1, 2007.
12VAC5-410-280. Emergency service.
A. Hospitals with an emergency department or service shall have 24-hour staff coverage and shall have at least one physician on call at all times. Hospitals without emergency service shall have written policies governing the handling of emergencies.
B. No fewer than one registered nurse shall be assigned to the emergency service on each shift. Such assignment need not be exclusive of other duties, but must have priority over all other assignments.
C. Those hospitals that provide ambulance services shall comply with Article 2.1 (§ 32.1-111.1 et seq.) of Chapter 4 of Title 32.1 of the Code of Virginia and 12VAC5-31.
D. The hospital shall provide equipment, drugs, supplies, and ancillary services commensurate with the scope of anticipated needs, including radiology and laboratory services and facilities for handling and administering of blood and blood products. Emergency drugs and equipment shall remain accessible in the emergency department at all times.
E. Current roster of medical staff members on emergency call, including alternates and medical specialists or consultants, shall be posted in the emergency department.
F. Hospitals shall make special training available, as required, for emergency department personnel.
G. Toxicology reference material and poison antidote information shall be available along with telephone numbers of the nearest poison control centers.
H. Each emergency department shall post notice of the existence of a human trafficking hotline to alert possible witnesses or victims of human trafficking to the availability of a means to gain assistance or report crimes. This notice shall be in a place readily visible and accessible to the public, such as the patient admitting area or public or patient restrooms. The notice shall meet the requirements of § 40.1-11.3 C of the Code of Virginia.
I. Every hospital with an emergency department shall establish a security plan for each emergency department that:
1. Is developed using standards established in the Healthcare Security Industry Guidelines, 13th Edition (International Association for Healthcare Security and Safety);
2. Is based on:
a. The results of a security risk assessment of each emergency department location of the hospital; and
b. Risks for the emergency department identified in consultation with the emergency department medical director and nurse director, including:
(1) Trauma level designation;
(2) Overall patient volume;
(3) Volume of psychiatric and forensic patients;
(4) Incidents of violence against staff;
(5) Level of injuries sustained from such violence; and
(6) Prevalence of crime in the community;
3. Includes the presence of one or more off-duty law-enforcement officers or trained security personnel in the emergency department at all times, except as provided in subsection L of this section, and as indicated to be necessary and appropriate by the security risk assessment; and
4. Outlines training requirements for security personnel in:
a. The potential use of and response to weapons;
b. Defensive tactics;
c. De-escalation techniques;
d. Appropriate physical restraint and seclusion techniques;
e. Crisis intervention;
f. Trauma-informed approaches; and
g. Safely addressing situations involving patients, family members, or other persons who pose a risk of harm to themselves or others due to mental illness or substance abuse or who are experiencing a mental health crisis.
J. The hospital may:
1. Accept from its security personnel the satisfactory completion of the Department of Criminal Justice Services minimum training standards for auxiliary police officers as required by § 15.2-1731 of the Code of Virginia in lieu of the training prescribed by subdivision I 4 of this section; and
2. Request to use industry standards other than those specified in subdivision I 1 of this section by submitting a written request for alternative industry standards to the OLC that:
a. Specifies the title, edition if applicable, and author of the alternative industry standards; and
b. Provides an explanation of how the alternative industry standards are substantially similar to those specified in subdivision I 1 of this section.
K. Every hospital with an emergency department shall update its security plan, including its security risk assessment, for each emergency department location of the hospital as often as necessary but not to exceed two years.
L. The commissioner shall provide a waiver from the requirement that at least one off-duty law-enforcement officer or trained security personnel be present at all times in the emergency department if the hospital demonstrates that a different level of security is necessary and appropriate for any of its emergency departments based upon findings in the security risk assessment.
1. A hospital shall submit a written request for a waiver pursuant to this subsection and shall:
a. Specify the location of the emergency department for which the waiver is requested;
b. Provide a dated copy of the security risk assessment performed for the specified emergency department that has been reviewed and approved by the governing body or its designee; and
c. Indicate the requested duration of the waiver.
2. The commissioner shall specify in any waiver granted pursuant to this subsection:
a. The location of the emergency department for which the waiver is granted;
b. The level of security to be provided at the specified emergency department location;
c. The effective date of the waiver; and
d. The duration of the waiver, which may not exceed two years from the date of issuance.
3. A hospital granted a waiver pursuant to this subsection shall:
a. Notify the commissioner in writing no less than 30 calendar days after its security risk assessment changes if such change impacts when or how many off-duty law-enforcement officers or trained security personnel should be present at the emergency department for which a waiver was granted;
b. Provide a dated copy of the changed security risk assessment performed for the specified emergency department that has been reviewed and approved by the governing body or its designee; and
c. Indicate whether the hospital is:
(1) Requesting a modification to its existing waiver; or
(2) Surrendering its existing waiver.
4. The commissioner may request additional information from the hospital in evaluating the requested waiver.
5. The commissioner may modify or rescind a waiver granted pursuant to this subsection if:
a. Additional information becomes known that alters the basis for the original decision, including if the security risk assessment changes regarding how many off-duty law-enforcement officers or trained security personnel should be present at the emergency department for which a waiver was granted; or
b. Results of the waiver jeopardize the health or safety of patients, employees, contractors, or the public.
6. Pursuant to the Virginia Freedom of Information Act (§ 2.2-3700 et seq. of the Code of Virginia), the Virginia Department of Health:
a. May not release to the public information that a hospital discloses pursuant to this subsection, the waiver request, or the response to the waiver to the extent those records are exempt from disclosure; and
b. Shall notify the Secretary of Public Safety and Homeland Security of any request for records specified in subdivision L 6 a of this section, the person making such request, and the Virginia Department of Health's response to the request.
M. Each hospital with an emergency department shall establish a protocol for treatment of individuals experiencing a substance use-related emergency to include the completion of appropriate assessments or screenings to identify medical interventions necessary for the treatment of the individual in the emergency department. The protocol may also include a process for patients who are discharged directly from the emergency department for the recommendation of follow-up care following discharge for any identified substance use disorder, depression, or mental health disorder, as appropriate, that may include:
1. Instructions for distribution of naloxone;
2. Referrals to peer recovery specialists and community-based providers of behavioral health services; or
3. Referrals for pharmacotherapy for treatment of drug or alcohol dependence or mental health diagnoses.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.12, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 22, Issue 8, eff. January 25, 2006; Volume 35, Issue 4, eff. November 14, 2018; Volume 36, Issue 23, eff. August 6, 2020; Volume 40, Issue 22, eff. July 17, 2024.
12VAC5-410-290. Laboratory service; general.
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.
Historical Notes
Derived from VR355-33-500 § 2.13, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 22, Issue 8, eff. January 25, 2006.
12VAC5-410-300. Clinical laboratory services.
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.
Historical Notes
Derived from VR355-33-500 § 2.14, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-310. Tissue pathology.
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.
Historical Notes
Derived from VR355-33-500 § 2.15, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-320. Quality control.
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.
Historical Notes
Derived from VR355-33-500 § 2.16, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-330. Autopsy service.
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.
Historical Notes
Derived from VR355-33-500 § 2.17, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995.
12VAC5-410-340. Blood banks and transfusion services.
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.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.18, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 22, Issue 8, eff. January 25, 2006.
12VAC5-410-350. Isolation of special microorganisms.
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.
Historical Notes
Derived from VR355-33-500 § 2.19, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 22, Issue 8, eff. January 25, 2006.
12VAC5-410-360. Nuclear medicine.
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.
Historical Notes
Derived from VR355-33-500 § 2.20, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 22, Issue 8, eff. January 25, 2006.
12VAC5-410-370. Medical records.
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 HIPAA (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.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.21, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 22, Issue 8, eff. January 25, 2006.
12VAC5-410-380. Nursing service.
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.
Historical Notes
Derived from VR355-33-500 § 2.22, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 22, Issue 8, eff. January 25, 2006.
12VAC5-410-390. Pharmaceutical service.
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.
Historical Notes
Derived from VR355-33-500 § 2.23, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 19, Issue 1, eff. November 1, 2002; Volume 22, Issue 8, eff. January 25, 2006.
12VAC5-410-400. Radiology service.
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.
Historical Notes
Derived from VR355-33-500 § 2.24, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-410. Social service.
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.
Historical Notes
Derived from VR355-33-500 § 2.25, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-420. Surgical service.
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.
D. A roster of current surgical privileges of every surgical staff member shall be maintained on file in the operating suite.
E. An operating room register shall be maintained which shall include as a minimum:
1. Patient's name and hospital number;
2. Pre- and post-operative diagnosis;
3. Complications, if any;
4. Name of surgeon, first assistant, anesthesiologist or anesthetist, scrub nurse and circulating nurse;
5. Operation performed; and
6. Type of anesthesia.
F. Policies and procedures governing infection control and reporting techniques shall be established in accordance with 12VAC5-410-490.
G. The patient's medical chart shall be available in the surgical suite at time of surgery and shall contain no less than the following information:
1. A medical history and physical examination;
2. Evidence of appropriate informed consent; and
3. A pre-operative diagnosis.
H. An accurate and complete description of operative procedure shall be recorded by the operating surgeon within 48 hours following completion of surgery and made part of the patient's clinical record.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 2.26, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995.