Article 2. Policies and Procedures
12VAC5-410-1160. General statement.
Article 2
Policies and Procedures
Policies and procedures may vary depending on scope and type of service, personnel, equipment and location of the facility. It is recognized that no two facilities will be identical because of variations in the scope and objective of the outpatient service. Even though each facility may be different, certain standards and procedures shall be applicable to all in assuring the delivery of a high quality of care.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 4.2, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995.
12VAC5-410-1170. Policy and procedures manual.
A. Each outpatient surgical hospital shall develop a policy and procedures manual that shall include provisions covering the following items:
1. The types of emergency and elective procedures that may be performed in the facility.
2. Types of anesthesia that may be used.
3. Admissions and discharges, including:
a. Criteria for evaluating the patient before admission and before discharge; and
b. 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.
4. Written informed consent of patient prior to the initiation of any procedures.
5. Procedures for housekeeping and infection control and prevention.
6. Disaster preparedness.
7. Facility security.
B. Every outpatient surgical hospital where surgical procedures are performed shall adopt a policy requiring the use of a smoke evacuation system for all planned surgical procedures that are likely to generate surgical smoke.
C. An outpatient surgical hospital shall provide a copy of approved policies and procedures and any subsequent revisions to the OLC upon request.
D. Each outpatient surgical hospital shall establish a protocol relating to the rights and responsibilities of patients based on 42 CFR 416.50. The protocol shall include a process reasonably designed to inform patients of patient rights and responsibilities. Patients shall be given a copy of patient rights and responsibilities upon admission.
E. Each outpatient surgical 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 within the outpatient surgical hospital pharmacy.
F. During a declared public health emergency related to a communicable disease of public health threat, each hospital shall establish a protocol to allow patients to receive visits from a rabbi, priest, minister, or clergy member of a religious denomination or sect. Such protocol shall be consistent with guidance from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services and subject to compliance with an executive order, order of public health, department guidance, or other applicable federal or state guidance having the effect of limiting visitation.
1. The protocol may restrict the frequency and duration of visits and may require visits to be conducted virtually using interactive audio or video technology.
2. The protocol may require the person visiting a patient pursuant to this subsection to comply with all reasonable requirements of the hospital adopted to protect the health and safety of the person, patients, and staff of the hospital.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from VR355-33-500 § 4.3, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 19, Issue 1, eff. November 1, 2002; Volume 23, Issue 10, eff. March 1, 2007; Volume 28, Issue 2, eff. November 1, 2011; Volume 36, Issue 23, eff. August 6, 2020; Volume 37, Issue 14, eff. March 31, 2021; Volume 42, Issue 1, eff. September 24, 2025; Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-1171. Persons with a disability; designated support person in outpatient surgical hospitals.
A. For the purposes of this section, "admission" means accepting a person for observation.
B. An outpatient surgical hospital shall allow a person with a disability who requires support and assistance necessary due to the specifics of the person's disability to be accompanied by a DSP who will provide support and assistance necessary due to the specifics of the person's disability to the person with a disability during an admission.
1. In any case in which the duration of the admission lasts more than 24 hours, the person with a disability may designate more than one DSP.
2. No outpatient surgical hospital shall be required to allow more than one DSP to be present with a person with a disability at any time.
C. An outpatient surgical hospital may:
1. Not subject a DSP to any restrictions on visitation;
2. Require a DSP to comply with all reasonable requirements of the outpatient surgical hospital adopted to protect the health and safety of the person with a disability, the DSP, the staff and other patients of or visitors to the outpatient surgical hospital, and the public; and
3. Restrict a DSP's access to specified areas of and movement on the premises of the outpatient surgical hospital when such restrictions are determined by the outpatient surgical hospital to be reasonably necessary to protect the health and safety of the person with a disability, the DSP, the staff and other patients of or visitors to an outpatient surgical hospital, and the public.
D. An outpatient surgical hospital may request that a person with a disability provide documentation indicating status as a person with a disability.
1. If the person with a disability fails, refuses, or is unable to provide documentation requested pursuant to this subsection, an outpatient surgical hospital may perform an objective assessment of the person to determine qualification as a person with a disability.
2. If an outpatient surgical hospital fails to perform an objective assessment pursuant to subdivision 1 of this subsection, an outpatient surgical hospital may not prohibit a DSP from accompanying a person with a disability for the purpose of providing support and assistance necessary due to the specifics of the person's disability.
E. An outpatient surgical hospital shall:
1. Establish protocols to inform patients, at the time of admission, of the right of a person with a disability who requires support and assistance necessary due to the specifics of the person's disability to be accompanied by a DSP for the purpose of providing support and assistance necessary due to the specifics of the person's disability;
2. Develop and make available to a patient or the patient's guardian, authorized representative, or care provider, upon request, written information regarding the right of a person with a disability who requires support and assistance necessary due to the specifics of the person's disability to be accompanied by a DSP and any policies related to that right; and
3. Make the written information described in subdivision 2 of this subsection available to the public on the hospital's website.
F. This section may not:
1. Alter the obligation of an outpatient surgical hospital to provide patients with effective communication support or other required services, regardless of the presence of a DSP or other reasonable accommodation, consistent with applicable federal or state law or regulations; or
2. Be interpreted to:
a. Prevent an outpatient surgical hospital from complying, interfere with the ability of the outpatient surgical hospital to comply with, or cause an outpatient surgical hospital to violate any federal or state law or regulation;
b. Deem a DSP to be acting under the direction or control of an outpatient surgical hospital or as an agent of an outpatient surgical hospital; or
c. Require an outpatient surgical hospital to allow a DSP to perform any action or provide any support or assistance necessary due to the specifics of the person's disability when the outpatient surgical hospital reasonably determines that the performance of the action or provision would be:
(1) Medically or therapeutically contraindicated; or
(2) A threat to the health and safety of the person with a disability, the DSP, or the staff or other patients of or visitors to the outpatient surgical hospital.
Statutory Authority
§§ 32.1-12, 32.1-127, and 32.1-173.08 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-1175. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 32, Issue 14, eff. April 8, 2016; repealed, Virginia Register Volume 42, Issue 18, eff. June 4, 2026.
12VAC5-410-1176. Outpatient surgical hospitals; reports of threats or acts of violence against health care providers.
A. For the purposes of this section:
"Employee of the hospital" or "employee" means an employee of the outpatient hospital or a health care provider credentialed by the outpatient hospital or engaged by the hospital to perform health care services on the premises of the outpatient hospital.
"Workplace violence" means any act of violence or threat of violence, without regard to the intent of the perpetrator, that occurs against an employee of the hospital while on the premises of such hospital and engaged in the performance of his duties. "Workplace violence" includes (i) the threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether physical injury is sustained, and (ii) any incident involving the threat of using dangerous weapons or using common objects as weapons or to cause physical harm, regardless of whether physical injury is sustained.
B. An outpatient hospital shall:
1. Establish a workplace violence incident reporting system, through which the outpatient hospital shall document, track, and analyze any incident of workplace violence reported.
2. Use the results of the analysis to make improvements in preventing workplace violence, including improvements achieved through continuing education in targeted areas, including (i) de-escalation training, (ii) risk identification, and (iii) violence prevention planning.
3. Clearly communicate the reporting system to all employees, including to any new employees at the employee orientation. The reporting system shall include guidelines on when and how to report incidents of workplace violence to the employer, security agencies, and appropriate law-enforcement authorities;
4. Record all reported incidents of workplace violence as voluntarily reported by an employee; and
5. Adopt a policy that prohibits any person from discriminating or retaliating against any employee of the outpatient hospital for reporting to, or seeking assistance or intervention from, the employer, security agencies, law-enforcement authorities, local emergency services organizations, government agencies, or others participating in any incident investigation. The policy shall comply with the provisions of § 40.1-27.3 of the Code of Virginia.
C. An outpatient hospital shall maintain the record of reported incidents of workplace violence made pursuant to subsection B of this section for at least two years and shall include in the record, at a minimum:
1. The date and time of the incident;
2. A description of the incident, including the job title of the affected employee;
3. Whether the perpetrator was a patient, visitor, employee, or other person;
4. A description of where the incident occurred;
5. Information relating the type of incident, including whether the incident involved (i) a physical attack without a weapon; (ii) an attack with a weapon or object; (iii) a threat of physical force or use of a weapon or other object with the intent to cause bodily harm; (iv) sexual assault or the threat of sexual assault; or (v) anything else not listed in subdivisions (i) through (iv);
6. The response to and any consequences of the incident, including (i) whether security or law enforcement was contacted and, if so, their response and (ii) whether the incident resulted in any change to outpatient hospital policy; and
7. Information about the individual who completed the report, including the individual's name, job title, and the date of completion.
D. The outpatient hospital shall:
1. Report the data collected and reported pursuant to subsection C of this section to the chief medical officer and the chief nursing officer of the outpatient hospital on, at a minimum, a quarterly basis; and
2. Send a report to the Virginia Department of Health on an annual basis that includes, at a minimum, the number of incidents of workplace violence voluntarily reported by an employee pursuant to subsection B of this section. A report made to the Virginia Department of Health pursuant to this subsection shall be aggregated to remove any personally identifiable information.
Statutory Authority
§§ 32.1-12 and 32.1-127 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 42, Issue 5, eff. November 19, 2025.
12VAC5-410-1178. Financial assistance in outpatient surgical hospitals.
A. As used in this section, "patient" and "uninsured patient" have the same meanings as ascribed to these terms in § 32.1-137.010 A of the Code of Virginia.
B. An outpatient surgical hospital shall make reasonable efforts to screen every uninsured patient to determine whether the individual is eligible for medical assistance pursuant to the state plan for medical assistance or for financial assistance under the outpatient surgical hospital's financial assistance policy.
C. An outpatient surgical hospital shall inform every uninsured patient who receives services at the outpatient surgical hospital and who is determined to be eligible for assistance under the outpatient surgical hospital's financial assistance policy of the option to enter into a payment plan with the outpatient surgical hospital.
1. A payment plan entered into pursuant to this subsection shall be provided to the patient in writing or electronically and shall provide for repayment of the cumulative amount owed to the outpatient surgical hospital.
2. The amount of monthly payments and the term of the payment plan shall be determined based upon the patient's ability to pay.
3. Any interest on amounts owed pursuant to the payment plan shall not exceed the maximum judgment rate of interest pursuant to § 6.2-302 of the Code of Virginia.
4. The outpatient surgical hospital may not charge any fees related to the payment plan.
5. The payment plan shall allow prepayment of amounts owed without penalty.
D. An outpatient surgical hospital shall develop a process by which either an uninsured patient who agrees to a payment plan pursuant to subsection C of this section or the outpatient surgical hospital may request and shall be granted the opportunity to renegotiate the payment plan.
1. Renegotiation shall include opportunity for a new screening in accordance with subsection B of this section.
2. An outpatient surgical hospital may not charge any fees for renegotiation of a payment plan pursuant to this subsection.
E. An outpatient surgical hospital shall provide written information about:
1. The outpatient surgical hospital's charity care policies, including:
a. Policies related to free and discounted care;
b. Specific eligibility criteria for charity care; and
c. Procedures for applying for charity care;
2. The availability of a payment plan for the payment of debt owed to the outpatient surgical hospital pursuant to subsection C of this section; and
3. The renegotiation process described in subsection D of this section.
F. To provide the information required by subsection F of this section, an outpatient hospital shall:
1. Post the information conspicuously in public areas of the outpatient surgical hospital, including admissions or registration areas and associated waiting rooms;
2. Make the information available to:
a. A patient at the time of admission or discharge or at the time services are provided; and
b. Persons with limited English proficiency in accordance with the U.S. Department of Health and Human Services Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (August 8, 2003, 68 FR 47311), if the outpatient surgical hospital is subject to the requirements of Title VI of the Civil Rights Act of 1964 (Pub. L. No. 88-352), as amended; and
3. Include the information:
a. With any billing statements sent to uninsured patients; and
b. On any website maintained by the outpatient surgical hospital.
G. Notwithstanding any other provision of law, an outpatient surgical hospital may not engage in any action described in § 501(r)(6) of the Internal Revenue Code, as it was in effect on January 1, 2020, to recover a debt for medical services against any patient unless the outpatient surgical hospital has made all reasonable efforts to determine whether the patient:
1. Qualifies for medical assistance pursuant to the state plan for medical assistance; or
2. Is eligible for financial assistance under the outpatient surgical hospital's financial assistance policy.
H. Nothing in this section shall be construed to:
1. Prohibit an outpatient surgical hospital, as part of its financial assistance policy, from requiring a patient to:
a. Provide necessary information needed to determine eligibility for financial assistance under the outpatient surgical hospital's financial assistance policy, medical assistance pursuant to Title XVIII or XIX of the Social Security Act (42 USC § 301 et seq.) or 10 USC § 1071 et seq., or other programs of insurance; or
b. Undertake good faith efforts to apply for and enroll in the programs of insurance for which the patient may be eligible as a condition of awarding financial assistance;
2. Require an outpatient surgical hospital to grant or continue to grant any financial assistance or payment plan pursuant to this section when:
a. A patient has provided false, inaccurate, or incomplete information required for determining eligibility for the outpatient surgical hospital's financial assistance policy; or
b. A patient has not undertaken good faith efforts to comply with any payment plan pursuant to this section; or
3. Prohibit the coordination of benefits as required by state or federal law.
Statutory Authority
§§ 32.1-12, 32.1-127, 32.1-137.01, and 32.1-137.010 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 42, Issue 18, eff. June 4, 2026.