Part VI. Programs and Services
22VAC40-61-280. Health care supervision.
A. The center shall develop a policy and procedure for monitoring the health status of participants consistent with the particular characteristics and needs of the population served by the center.
B. The center shall provide supervision of participant schedules, care, and activities including attention to specialized needs, such as prevention of falls and wandering.
C. Each participant shall be continually observed and monitored for changes in health status including physical, social, emotional, and mental functioning. Changes shall be discussed with the participant, family, legal representative, physician, or others as appropriate. Documentation of the change and any notifications shall be made in the participant's record.
D. Measures of health status include:
1. Vital signs;
2. Weight;
3. Meal and fluid intake;
4. Elimination;
5. Skin integrity;
6. Behavior;
7. Cognition;
8. Functional ability; and
9. Special needs.
E. When the center identifies a need for a change in health care services, this shall be discussed with the participant, family, legal representative, physician, or others as appropriate and documented in the participant's record. The care plan shall be updated if necessary.
F. If the participant requires skilled or rehabilitative services, the center shall assist the participant and family in securing such services if necessary.
G. If skilled health care and rehabilitative services are provided at the center, the center shall ensure that such providers are licensed, certified, or registered as required by law. These services shall be provided in accordance with the physician or other health care professional's order.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-290. Infection control program.
A. The center shall develop and maintain an infection prevention and occupational health program designed to provide a safe, sanitary, and comfortable environment for participants, staff, and the public.
B. The center shall develop infection prevention policies and procedures appropriate for the services provided by the center and including the physical plant and grounds. These shall be based upon evidence-based guidelines such as those published by the Centers for Disease Control and Prevention or the Virginia Department of Health and updated as recommendations change and shall include:
1. Standard precautions to include:
a. Hand hygiene;
b. Use of personal protective equipment such as gloves and masks;
c. Safe injection and blood glucose monitoring practices;
d. Safe handling of potentially contaminated equipment or surfaces in the center environment; and
e. Respiratory hygiene and cough etiquette.
2. Specific methods and timeframes to monitor infection prevention practices by staff and volunteers.
3. Parameters for ensuring that staff, volunteers, and participants with communicable disease or infections are prohibited from direct contact with others if contact may transmit disease, in accordance with applicable local, state, and federal regulations.
4. Handling, storing, processing, and transporting linens, supplies, and equipment consistent with current infection prevention methods.
5. Handling, storing, and transporting medical waste in accordance with applicable regulations.
6. Maintaining an effective pest control program.
C. The center shall ensure that at least one staff person with training or experience in infection prevention relevant to a congregate care setting is employed by or regularly available (e.g., by contract) to manage the center's infection prevention program.
D. All staff and volunteers shall be trained on requirements of the center's infection prevention program according to their job duties during the orientation period and at least annually. Competencies shall be documented following each training and may include a written test, skills demonstration, or other method as appropriate.
E. The center shall ensure that sufficient and appropriate supplies to maintain standard precautions are available at all times, such as gloves, hand hygiene and cleaning products, and any other supplies needed specific to center services.
F. The director shall be responsible for ensuring that any outbreak of disease as defined by the Virginia Department of Health is immediately reported to the local health department and to the regional licensing office.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-300. Medication management.
A. The center shall have, keep current, and implement a plan for medication management. The center's medication management plan shall address procedures for administering medication and shall include:
1. Standard operating procedures and any general restrictions specific to the center;
2. Methods to ensure an understanding of the responsibilities associated with medication management, including the following:
a. Determining that staff who are responsible for administering medications meet the qualification requirements of subdivisions E 7 a and E 7 b of this section;
b. Ensuring that staff who are responsible for administering medications are trained on requirements of the center's medication management plan; and
c. Ensuring that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration. Supervision shall be provided by (i) an individual employed by the center who is licensed by the Commonwealth of Virginia to administer medications or (ii) the director who has successfully completed a training program as required in subdivisions E 7 a and E 7 b of this section.
3. Methods to ensure that authorizations for the administration of medications are current;
4. Methods to secure and maintain supplies of each participant's prescription medications and any over-the-counter drugs and supplements in a timely manner to avoid missed dosages;
5. Methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs), including within 24 hours of receipt of a new order or a change in an order;
6. Methods for monitoring medication administration and the effective use of the MARs for documentation;
7. Methods to ensure that participants do not receive medications or dietary supplements to which they have known allergies;
8. Methods to ensure accurate accounting for all controlled substances whenever received by center staff, returned to participant, or whenever assigned medication administration staff changes;
9. Procedures for proper disposal of medication; and
10. Procedures for preventing, detecting, and investigating suspected or reported drug diversion.
B. The center shall have readily accessible as reference materials for medication aides at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old.
C. Prescription and nonprescription medications, including sample medications, shall be given to a participant according to the center's medication policies and only with written or verbal authorization from the physician or prescriber or the physician's authorized agent. For the purposes of this section, an "authorized agent" means an employee of the physician who is under the physician's immediate and personal supervision. Verbal orders shall be reviewed and signed by the physician or prescriber within 10 working days.
D. The center shall maintain a list of all medications, including those taken at home and at the center, for each participant. The center shall attempt to verify and update the list of center-administered medications with the prescribing health care professional at least twice a year. Unsuccessful attempts to verify shall be documented.
E. The following standards shall apply when medications are administered to participants at the adult day center:
1. All medication shall be in the original container with the prescription label or direction label attached and legible. Sample medications shall remain in the original packaging, labeled by a physician or other prescriber or pharmacist with the participant's name, the name of the medication, the strength, dosage, and route and frequency of administration, until administered.
2. All medication shall be labeled with the participant's name, the name of the medication, the strength and dosage amount, the route of administration, and the frequency of administration.
3. The medication shall be kept in a locked compartment or area, not accessible to participants. The locked compartment or area shall be free from direct sunlight and high temperatures and free from dampness and shall remain darkened when closed.
4. The area in which the medication is prepared shall have sufficient light so that the labels can be read accurately and the correct dosage can be clearly determined.
5. Medication shall be refrigerated, if required. When medication is stored in a refrigerator used for food, the medications shall be stored together in a locked container in a clearly defined area. If a refrigerator is used for medication only, it is permissible to store dietary supplements and foods and liquids used for medication administration.
6. Unless it is contrary to the center's policy, a participant may take the participant's own medication, provided that:
a. A physician has deemed the participant capable of self-administering medication;
b. The physician has given written authorization for the participant to self-administer the participant's medication; and
c. Medications are kept in a safe manner inaccessible to other participants.
7. When the center staff administers medications to participants, the following standards shall apply:
a. Each staff person who administers medication shall be authorized by § 54.1-3408 of the Code of Virginia. All staff responsible for medication administration shall:
(1) Be licensed by the Commonwealth of Virginia to administer medications;
(2) Be a registered medication aide;
(3) Successfully complete a training program approved by the Board of Nursing and accepted for use in adult day centers; or
(4) Successfully complete a training program approved by the Board of Nursing for the registration of medication aides that consists of 68 hours of student instruction and training.
b. All staff who administer medications, except those licensed by the Commonwealth, shall complete, on an annual basis, four hours of medication management refresher training on topics specific to the administration of medications in the adult day center setting.
c. Medications shall remain in the original or pharmacy issued container until administered to the participant by the qualified medication staff. All medications shall be removed from the pharmacy container and be administered by the same qualified person within one hour of the individual's scheduled dosing time.
d. Documentation shall be maintained on the MAR of all medications, including prescription, nonprescription, and sample medication, administered to a participant while at the center. This documentation shall become part of the participant's permanent record and shall include:
(1) Name of participant;
(2) All known allergies;
(3) Diagnosis, condition, or specific indications for which the medication is prescribed;
(4) Date medication prescribed;
(5) Drug product name;
(6) Dosage and strength of medication;
(7) Route of administration;
(8) Frequency of administration;
(9) Date and time given and initials of staff administering the medication;
(10) Date the medication is discontinued or changed;
(11) Any medication errors or omissions;
(12) Notation of any adverse effects or unusual reactions that occur; and
(13) The name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARs.
F. In the event of an adverse drug reaction or a medication error, the following applies:
1. Action shall be taken as directed by a physician, pharmacist, or a poison control center;
2. The participant's physician and family member or other legal representative shall be notified as soon as possible. If not contrary to immediate medical needs of the participant, the participant shall also be notified of the error; and
3. Medication administration staff shall document actions taken in the participant's record.
G. The use of PRN (as needed) medications is prohibited unless one or more of the following conditions exist:
1. The participant is capable of determining when medication is needed;
2. A licensed health care professional administers the medication;
3. The participant's physician has provided detailed written instructions, including symptoms that might indicate the need for the medication, exact dosage, exact timeframes the medication is to be given in a 24-hour period, and directions for what to do if symptoms persist; or
4. The center staff has telephoned the participant's physician prior to administering the medication and explained the symptoms and received a documented verbal order that includes the information in subdivision 3 of this subsection.
H. Any physician-ordered treatment provided by staff shall be documented and shall be within the staff's scope of practice.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019; amended, Virginia Register Volume 40, Issue 24, eff. August 14, 2024.
22VAC40-61-310. Restraints.
The use of chemical or physical restraints is prohibited.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-320. Assistance with activities of daily living and ambulation.
A. Dignity, privacy, and confidentiality shall be maintained for participants whenever assistance with activities of daily living (ADLs) is provided.
B. When providing assistance with ADLs, staff shall ensure all necessary supplies and equipment are available and organized to aid in assistance and to maximize the participant's safety.
C. Assistance with eating and feeding.
1. Dining areas shall be supervised by staff whenever meals or snacks are served.
2. Adequate staff shall be present in the dining areas to assist participants who cannot eat independently.
3. Self-feeding skills of participants shall be continuously observed and evaluated so that meals and snacks are not missed because of a participant's inability to feed himself.
4. Appropriate adapted utensils, including adapted plates, bowls, and cups with straws and handles, shall be utilized for those participants who need them. Information about effective eating adaptations shall be shared with the participant and his family. Assistance such as, but not limited to, opening containers and cutting food shall be provided to those participants who need it.
5. Low-stimulus dining areas shall be provided for participants with cognitive deficits or other conditions that impair concentration.
6. Changes in food and liquid intake shall be documented in the participant's record, and changes shall be made to the care plan to ensure adequate intake. The participant and his family shall be notified of such changes.
D. Assistance with ambulation and transfer.
1. The ability of the participant to safely transfer and ambulate shall be continually monitored. Any changes shall be documented in the participant's record and noted on the plan of care.
2. There shall be adequate staff to provide individualized assistance to participants to ambulate to activities, meals, and the restroom , and transfer, if such assistance is needed.
3. The center shall have at least one wheelchair available for emergency use, even if all participants are ambulatory or have their own wheelchairs.
4. Staff shall identify unmet ambulation and transfer needs, including equipment needs and repairs, and shall discuss such needs with the participant, family, legal representative, or physician, as appropriate.
5. Participants who use wheelchairs shall be offered other seating options throughout the day if appropriate.
E. Assistance with toileting.
1. Staff shall develop and follow appropriate toileting procedures for each participant who requires assistance according to that individual's abilities and plan of care.
2. Participants who are at risk of falling or who have other safety risks shall not be left alone while toileting.
3. Staff shall arrange for coverage of program responsibilities when they must leave the group to assist with toileting a participant.
F. Assistance with bathing.
1. A shower chair, bench, or other seating; safety equipment such as grab bars; and nonslip surfaces shall be provided.
2. The participant shall not be left unattended in the shower or bath. If the bathing area is not in sight or sound of other occupied parts of the building, there shall be an emergency call system to summon additional assistance.
G. Assistance with dressing.
1. Assistance shall be provided according to that individual's abilities and plan of care.
2. Extra clothing shall be available for participants who need to change during the day. Each participant may keep a change of clothing at the center, or the center may keep a supply to use as needed.
3. Participants' clothing, equipment, and supplies kept at the center shall be properly labeled and stored to prevent loss.
4. Special attention shall be given to footwear of participants who are at risk of falling. Staff shall encourage family members to provide appropriate shoes and shall document those recommendations in the participant's record.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-330. Activities.
A. Activities shall be planned to support the plans of care for the participants and shall be consistent with the program statement and the admission policies.
B. Activities shall:
1. Support the physical, social, mental, and emotional skills and abilities of participants in order to promote or maintain their highest level of independence or functioning;
2. Accommodate individual differences by providing a variety of types of activities and levels of involvement; and
3. Offer participants a varied mix of activities including the following categories: physical; social; cognitive, intellectual, or creative; productive; sensory; reflective or contemplative; outdoor; and nature or the natural world. Community resources as well as center resources may be used to provide activities. Any given activity may fall under more than one category.
C. Participation in activities.
1. Participants shall be encouraged but not forced to participate in activity programs offered by the center and the community.
2. During an activity, each participant shall be encouraged but not coerced to join in the activity at his level of functioning, which may include his observation of the activity.
3. If appropriate to meet the needs of the participant with a short attention span, multiple short activities shall be provided.
4. Any restrictions on participation imposed by a physician shall be followed and documented in the participant's record and the plan of care.
D. There shall be a designated staff person who is routinely present in the center and who shall be responsible for managing or coordinating the structured activities program. This staff person shall maintain personal interaction with the participants and familiarity with their needs and interests and 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 an activities professional by a recognized accrediting body;
3. Be a qualified occupational therapist or an occupational therapy assistant;
4. Have at least an associate's degree in a discipline focusing on the provision of activities for adults; or
5. Have one year full-time work experience within the last five years in an activities program in an adult care setting.
E. The requirements of subsection D shall be met by June 28, 2020.
F. Participants, staff, and family members shall be encouraged to be involved in the planning of the activities.
G. Schedule of activities.
1. There shall be planned activities and programs throughout the day whenever the center is in operation.
2. A written schedule of activities shall be developed on a monthly basis.
3. The schedule shall include:
a. Group activities for all participants or small groups of participants; and
b. The name, type, date, and hour of the activity.
4. If one activity is substituted for another, the change shall be noted on the schedule.
5. The current month's schedule shall be posted in a readily accessible location in the center and also may be made available to participants and their families.
6. The schedule of activities for the preceding two years shall be kept at the center.
7. If a participant requires an individual schedule of activities, that schedule shall be a part of the plan of care.
H. During an activity, when needed to ensure that each of the following is adequately accomplished, there shall be staff persons or volunteers to:
1. Lead the activity;
2. Assist the participants with the activity;
3. Supervise the general area;
4. Redirect any individuals who require different activities; and
5. Protect the health, safety, and welfare of the participants involved in the activity.
I. The staff person or volunteer leading the activity shall have a general understanding of the following:
1. Attention spans and functional levels of each of the participants;
2. Methods to adapt the activity to meet the needs and abilities of the participants;
3. Various methods of engaging and motivating individuals to participate; and
4. The importance of providing appropriate instruction, education, and guidance throughout the activity.
J. Adequate supplies and equipment appropriate for the program activities shall be available in the center.
K. All equipment and supplies used shall be accounted for at the end of the activity so that a safe environment can be maintained.
L. In addition to the required scheduled activities, there shall be unscheduled staff and participant interaction throughout the day that fosters an environment that promotes socialization opportunities for participants.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-340. Food service.
A. Meals and snacks shall be provided by the center. The center shall (i) prepare the food, (ii) have the food catered, or (iii) utilize a contract food service.
B. When any portion of an adult day center is subject to inspection by the Virginia Department of Health, the center shall be in compliance with those regulations, as evidenced by an initial and subsequent annual report from the Virginia Department of Health. The report shall be retained at the center for a period of at least two years.
C. If a catering service or contract food service is used, the service shall be approved by the local health department. The center shall be responsible for monitoring continued compliance by obtaining a copy of the Virginia Department of Health approval.
D. The center shall encourage, but not require, participants to eat the meals and snacks provided by the center. If a participant brings food from home, the food shall be labeled with the participant's name, dated, and stored appropriately until meal or snack time. The fact that the participant brought food does not relieve the center of its responsibility to provide meals and snacks.
E. A minimum of 45 minutes shall be allowed for each participant to complete a meal. If a participant needs additional time to finish the meal due to special needs, such additional time shall be provided.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019; amended, Virginia Register Volume 40, Issue 24, eff. August 14, 2024.
22VAC40-61-350. Serving of meals and snacks.
A. Centers shall serve meals and snacks at appropriate times, depending on the hours of operation. For example, a center open during the hours of 7 a.m. to 1 p.m. must serve a morning snack and a mid-day meal; a center open during the hours of 8 a.m. to 5 p.m. must serve a morning snack, a mid-day meal, and an afternoon snack; a center open during the hours of 2 p.m. to 6 p.m. must serve an afternoon snack; a center open after 6 p.m. must serve an evening meal. Centers open after 9 p.m. shall serve an evening snack. Snacks shall also be available throughout the day.
B. There shall be at least two hours between scheduled snacks and meals.
C. Adequate kitchen facilities and equipment shall be provided for preparation and serving of meals and snacks or for the catering of meals.
D. Sufficient working refrigeration shall be available to store perishable food and medicine.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-360. Menu and nutrition requirements.
A. Food preferences of participants shall be considered when menus are planned.
B. Menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to participants.
1. Any menu substitutions or additions shall be recorded on the posted menu.
2. Menus shall be kept at the center for two years.
C. Minimum daily menu.
1. Unless otherwise ordered in writing by the participant's physician, the daily menu, including snacks, for each participant shall meet the current guidelines of the U.S. Department of Agriculture food guidance system or the dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration the age, sex and activity of the participant.
2. Other foods may be added to enhance the meals or meet individual participant needs.
3. Drinking water shall be available at all times.
D. When a diet is prescribed for a participant by his physician or other prescriber, it shall be prepared and served according to the physician's or other prescriber's orders.
E. A current copy of a diet manual containing acceptable practices and standards for nutrition shall be available to staff responsible for food preparation and meal planning.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-370. Observance of religious dietary practices.
A. The participant's religious dietary practices shall be respected.
B. Religious dietary practices of the director, staff, or licensee shall not be imposed upon participants unless mutually agreed upon in the participant agreement.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-380. Transportation services.
A. Centers that provide participant transportation directly or by contract shall ensure that the following requirements are met:
1. The vehicle shall be accessible and appropriate for the participants being transported. Vehicles shall be equipped with a ramp or hydraulic lift to allow entry and exit if there are participants who remain in their wheelchairs during transport.
2. The vehicle's seats shall be attached to the floor, and wheelchairs shall be secured when the vehicle is in motion.
3. Arrangement of wheelchairs and other equipment in the vehicle shall not impede access to exits.
4. The vehicle shall be insured for at least the minimum limits established by law and regulation.
5. All vehicles shall have working heat and air conditioning systems.
6. The vehicle shall meet the safety standards set by the Department of Motor Vehicles and shall be kept in satisfactory condition to ensure the safety of participants.
B. Centers that provide participant transportation directly or by contract shall ensure that during transportation the following requirements are met:
1. The driver has a valid driver's license to operate the type of vehicle being used.
2. Virginia statutes regarding safety belts are followed.
3. Every person remains seated while the vehicle is in motion.
4. Doors are properly closed and locked while the vehicle is in motion.
5. Supervision and safety needs of participants are maintained at all times.
6. The following information is maintained in vehicles used for transportation:
a. The center's name, address, and phone number;
b. A list of the names of the participants being transported;
c. A list of the names, addresses, and telephone numbers of participants' emergency contact persons; and
d. A first aid kit containing the supplies as listed in 22VAC40-61-550.
7. The driver, another staff person, or a volunteer in the vehicle is current in first aid and CPR training.
8. There shall be a means of communication between the driver and the center.
C. If staff or volunteers supply personal vehicles, the center shall be responsible for ensuring that the requirements of subsections A and B of this section are met.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.
22VAC40-61-390. Field trips.
A. Any center that takes participants on field trips shall develop a policy that addresses the following:
1. A communication plan between staff at the center and staff who are accompanying participants on a field trip;
2. Maintenance of staff-to-participant ratio at both the center and on the field trip as required by 22VAC40-61-200;
3. Provision of adequate food and water for participants during field trips;
4. Safe storage of food to prevent food-borne illnesses; and
5. Medication administration that meets the requirements of 22VAC40-61-300.
B. Before leaving on a field trip, a list of participants taking the trip and a schedule of the trip's events and locations shall be left at the center and shall be accessible to staff.
C. A wheelchair that is available for emergency use shall be taken on field trips.
D. The requirements of 22VAC40-61-380 apply when participants are transported on field trips.
Statutory Authority
§ 63.2-1733 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 3, eff. December 29, 2019.