Part X. Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments
Article 1
Subjectivity
22VAC40-73-1000. Subjectivity.
Part X
Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments
Article 1
Subjectivity
All facilities that care for residents with serious cognitive impairments due to a primary psychiatric diagnosis of dementia who cannot recognize danger or protect their own safety and welfare shall be subject to either Article 2 (22VAC40-73-1010 et seq.) or Article 3 (22VAC40-73-1080 et seq.) of this part. All facilities that care for residents with serious cognitive impairments due to any other diagnosis who cannot recognize danger or protect their own safety and welfare shall be subject to Article 2 of this part.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
Article 2
Mixed Population
22VAC40-73-1010. Applicability.
Article 2
Mixed Population
The requirements in this article apply when there is a mixed population consisting of any combination of (i) residents who have serious cognitive impairments due to a primary psychiatric diagnosis of dementia who are unable to recognize danger or protect their own safety and welfare and who are not in a special care unit as provided for in Article 3 (22VAC40-73-1080 et seq.) of this part; (ii) residents who have serious cognitive impairments due to any other diagnosis who cannot recognize danger or protect their own safety and welfare; and (iii) other residents. The requirements in this article also apply when all the residents have serious cognitive impairments due to any diagnosis other than a primary psychiatric diagnosis of dementia and cannot recognize danger or protect their own safety and welfare. Except for special care units covered by Article 3 of this part, these requirements apply to the entire facility unless specified otherwise.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1020. Staffing.
A. When residents are present, there shall be at least two direct care staff members awake and on duty at all times in each building who shall be responsible for the care and supervision of the residents.
B. The requirements of subsection A of this section do not apply to assisted living facilities that are licensed for 10 or fewer residents if not more than three of the residents have serious cognitive impairments. The staffing provisions of 22VAC40-73-280 D apply.
C. During trips away from the facility, there shall be sufficient direct care staff to provide sight and sound supervision to all residents who cannot recognize danger or protect their own safety and welfare.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018; amended, Virginia Register Volume 34, Issue 24, eff. August 23, 2018.
22VAC40-73-1030. Staff training.
A. Within three months of the starting date of employment, the administrator shall attend 12 hours of training in working with individuals who have a cognitive impairment, and the training shall meet the requirements of subsection C of this section.
1. Training in cognitive impairment that meets the requirements of subsection C of this section and was completed in the year prior to employment is transferable and counts toward the required 12 hours if there is documentation of the training.
2. Whether the training counts toward continuing education for administrator licensure and for what period of time depends upon the licensure requirements of the Virginia Board of Long-Term Care Administrators.
B. Within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment, and the training shall meet the requirements of subsection C of this section.
1. The six-hour training received within the first four months of employment is counted toward the annual training requirement for the first year.
2. Training in cognitive impairment that meets the requirements of subsection C of this section and was completed in the year prior to employment is transferable if there is documentation of the training.
3. The documented previous cognitive impairment training referenced in subdivision 2 of this subsection is counted toward the required six hours but not toward the annual training requirement.
C. Curriculum for the training in cognitive impairment for direct care staff and administrators shall be developed by a qualified health professional or by a licensed social worker, shall be relevant to the population in care, shall maximize the level of a resident's functional ability, and shall include:
1. Information about cognitive impairment, including areas such as cause, progression, behaviors, and management of the condition;
2. Communicating with the resident;
3. Resident care techniques for residents with physical, cognitive, behavioral, and social disabilities;
4. Managing dysfunctional behavior;
5. Creating a therapeutic environment;
6. Planning and facilitating activities appropriate for each resident; and
7. Identifying and alleviating safety risks to residents with cognitive impairment.
D. Within the first month of employment, staff, other than the administrator and direct care staff, shall complete two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1040. Doors and windows.
A. Doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Residents with serious cognitive impairments may be limited but not prohibited from exiting the facility or any part thereof. Before limiting any resident from freely leaving the facility, the resident's record shall reflect the behavioral observations or other bases for determining that the resident has a serious cognitive impairment and cannot recognize danger or protect his own safety and welfare.
B. There shall be protective devices on the bedroom and the bathroom windows of residents with serious cognitive impairments and on windows in common areas accessible to these residents to prevent the windows from being opened wide enough for a resident to crawl through. The protective devices on the windows shall be in conformance with the Virginia Uniform Statewide Building Code (13VAC5-63).
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1050. Outdoor access.
A. The facility shall have a secured outdoor area for the residents' use or provide direct care staff supervision while residents with serious cognitive impairments are outside.
B. Weather permitting, residents with serious cognitive impairments shall be reminded of the opportunity to be outdoors on a daily basis.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1060. Indoor walking area.
The facility shall provide to residents free access to an indoor walking corridor or other indoor area that may be used for walking.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1070. Environmental precautions.
A. Special environmental precautions shall be taken by the facility to eliminate hazards to the safety and well-being of residents with serious cognitive impairments. Examples of environmental precautions include signs, carpet patterns and arrows that point the way, and reduction of background noise.
B. When there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
Article 3
Safe, Secure Environment
22VAC40-73-1080. Applicability.
Article 3
Safe, Secure Environment
A. In order to be admitted or retained in a safe, secure environment as defined in 22VAC40-73-10, except as provided in subsection B of this section, a resident must have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safety and welfare. The requirements in this article apply when such residents reside in a safe, secure environment. These requirements apply only to the safe, secure environment.
B. A resident's spouse, parent, adult sibling, or adult child who otherwise would not meet the criteria to reside in a safe, secure environment may reside in the special care unit if the spouse, parent, sibling, or child so requests in writing, the facility agrees in writing, and the resident, if capable of making the decision, agrees in writing. The written request and agreements must be maintained in the resident's file. The spouse, parent, sibling, or child is considered a resident of the facility and as such this chapter applies. The requirements of this article do not apply for the spouse, parent, adult sibling, or adult child because the individual does not have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1090. Assessment.
A. Prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry). The assessment shall be in writing and shall include the following areas:
1. Cognitive functions (e.g., orientation, comprehension, problem-solving, attention and concentration, memory, intelligence, abstract reasoning, judgment, and insight);
2. Thought and perception (e.g., process and content);
3. Mood/affect;
4. Behavior/psychomotor;
5. Speech/language; and
6. Appearance.
B. The assessment required in subsection A of this section shall be maintained in the resident's record.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1100. Approval.
A. Prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority:
1. The resident, if capable of making an informed decision;
2. A guardian or other legal representative for the resident if one has been appointed;
3. A relative who is willing and able to take responsibility to act as the resident's representative, in the following specified order: (i) spouse, (ii) adult child, (iii) parent, (iv) adult sibling, (v) adult grandchild, (vi) adult niece or nephew, (vii) aunt or uncle; or
4. If the resident is not capable of making an informed decision and a guardian, legal representative, or relative is unavailable, an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia.
B. The obtained written approval shall be retained in the resident's file.
C. The facility shall document that the order of priority specified in subsection A of this section was followed, and the documentation shall be retained in the resident's file.
D. As soon as one of the persons in the order as prioritized in subsection A of this section disapproves of placement or retention in the safe, secure environment, then the assisted living facility shall not place or retain the resident or prospective resident in the special care unit.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1110. Appropriateness of placement and continued residence.
A. Prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file.
B. Six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.
C. Whenever warranted by a change in a resident's condition, the licensee, administrator, or designee shall also perform a review of the appropriateness of continued residence in the unit.
D. The reviews specified in subsections B and C of this section shall be performed in consultation with the following persons, as appropriate:
1. The resident;
2. A responsible family member;
3. A guardian or other legal representative;
4. A designated contact person;
5. Direct care staff who provide care and supervision to the resident;
6. The resident's mental health provider;
7. The licensed health care professional required in 22VAC40-73-490;
8. The resident's physician; and
9. Any other professional involved with the resident.
E. The licensee, administrator, or designee shall make a determination as to whether continued residence in the special care unit is appropriate at the time of each review required by subsections B and C of this section. The determination and justification for the decision shall be in writing and shall be retained in the resident's file.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1120. Activities.
A. In addition to the requirements of this section, all the requirements of 22VAC40-73-520 apply to safe, secure environments, except for 22VAC40-73-520 C and E.
B. There shall be at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day.
C. If appropriate to meet the needs of the resident with a short attention span, there shall be multiple short activities.
D. Staff shall regularly encourage residents to participate in activities and provide guidance and assistance, as needed.
E. As appropriate, residents shall be encouraged to participate in supervised activities or programs outside the special care unit.
F. There shall be a designated staff person responsible for managing or coordinating the structured activities program. This staff person shall be on site in the special care unit at least 20 hours a week, shall maintain personal interaction with the residents 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. Have one year full-time work experience within the last five years in an activities program in an adult care setting;
4. Be a qualified occupational therapist or an occupational therapy assistant; or
5. Prior to or within six months of employment, have successfully completed 40 hours of department-approved training in adult group activities and in recognizing and assessing the activity needs of residents.
The required 20 hours on site does not have to be devoted solely to managing or coordinating activities; neither is it required that the person responsible for managing or coordinating the activities program conduct the activities.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1130. Staffing.
A. Except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit.
B. Except during night hours, only one direct care staff member has to be awake and on duty in the unit if sufficient to meet the needs of the residents, if (i) there are no more than five residents present in the unit and (ii) there are at least two other direct care staff members in the building, one of whom is readily available to assist with emergencies in the special care unit, provided that supervision necessary to ensure the health, safety, and welfare of residents throughout the building is not compromised.
C. During night hours, the following number of direct care staff members shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents:
1. When 22 or fewer residents are present, at least two direct care staff members;
2. When 23 to 32 residents are present, at least three direct care staff members;
3. When 33 to 40 residents are present, at least four direct care staff members; and
4. When more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents, or portion thereof.
The requirements in subsections A, B, and C of this section are independent of 22VAC40-73-280 D and 22VAC40-73-1020 A and B.
D. During trips away from the facility, there shall be sufficient direct care staff to provide sight and sound supervision to residents.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018; amended, Virginia Register Volume 34, Issue 24, eff. August 23, 2018; Volume 36, Issue 2, eff. October 17, 2019.
22VAC40-73-1140. Staff training.
A. Within three months of the starting date of employment, the administrator shall attend at least 12 hours of training in cognitive impairment that meets the requirements of subsection C of this section.
1. Training in cognitive impairment that meets the requirements of subsection C of this section and was completed in the year prior to employment is transferable and counts toward the required 12 hours if there is documentation of the training.
2. Whether the training counts toward continuing education for administrator licensure and for what period of time depends upon the licensure requirements of the Virginia Board of Long-Term Care Administrators.
B. Within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section.
1. The training is counted toward the annual training requirement for the first year.
2. Training in cognitive impairment that meets the requirements of subsection C of this section and was completed in the year prior to employment is transferable if there is documentation of the training.
3. The documented previous cognitive impairment training referenced in subdivision 2 of this subsection is counted toward the required 10 hours but not toward the annual training requirement.
C. The training in cognitive impairment required by subsections A and B of this section shall be relevant to the population in care, shall maximize the level of a resident's functional ability, and shall include the following topics:
1. Information about cognitive impairment, including areas such as cause, progression, behaviors, and management of the condition;
2. Communicating with the resident;
3. Resident care techniques for persons with physical, cognitive, behavioral, and social disabilities;
4. Managing dysfunctional behavior;
5.Creating a therapeutic environment;
6. Planning and facilitating activities appropriate for each resident; and
7. Identifying and alleviating safety risks to residents with cognitive impairment.
D. The training specified in subsection C of this section shall be developed and provided by:
1. A licensed health care professional practicing within the scope of his profession who has at least 12 hours of training in the care of individuals with cognitive impairments due to dementia; or
2. A person who has been approved by the department to develop or provide the training.
E. Within the first month of employment, staff, other than the administrator and direct care staff, who will have contact with residents in the special care unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1150. Doors and windows.
A. Doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates. Residents who reside in safe, secure environments may be prohibited from exiting the facility or the special care unit if applicable building and fire codes are met.
B. There shall be protective devices on the bedroom and bathroom windows of residents and on windows in common areas accessible to residents to prevent the windows from being opened wide enough for a resident to crawl through. The protective devices on the windows shall be in conformance with the Virginia Uniform Statewide Building Code (13VAC5-63).
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1160. Outdoor access.
A. The facility shall have a secured outdoor area for the residents' use or provide direct care staff supervision while residents are outside.
B. Residents shall be given the opportunity to be outdoors on a daily basis, weather permitting.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1170. Indoor walking area.
The facility shall provide to residents free access to an indoor walking corridor or other indoor area that may be used for walking.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.
22VAC40-73-1180. Environmental precautions.
A. Special environmental precautions shall be taken by the facility to eliminate hazards to the safety and well-being of residents. Examples of environmental precautions include signs, carpet patterns and arrows that point the way, high visual contrast between floors and walls, and reduction of background noise.
B. When there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
C. Special environmental enhancements, tailored to the population in care, shall be provided by the facility to enable residents to maximize their independence and to promote their dignity in comfortable surroundings. Examples of environmental enhancements include memory boxes, activity centers, rocking chairs, and visual contrast between plates and eating utensils and the table.
Statutory Authority
§§ 63.2-217, 63.2-1732, 63.2-1802, 63.2-1805, and 63.2-1808 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 34, Issue 6, eff. February 1, 2018.