Virginia Regulatory Town Hall
Agency
Virginia Department of Health
Board
State Board of Health
 
chapter
Regulations for the Licensure of Hospitals in Virginia [12 VAC 5 ‑ 410]
Guidance Documents
Chapter Information
Description The regulations prescribe standards and requirements for the licensing, construction, maintenance and operation of hospitals.
State Authority 32.1-123
Federal Authority None entered
Exempt from APA No, changes to this chapter are subject to the Administrative Process Act.
Text of Regulation Link to Virginia Administrative Code
Goals of Regulation Whether the regulations continue to prescribe appropriate and effective standards and requirements for the licensing, construction, maintenance and operation of hospitals.
Meetings

Contact Information
Name / Title: Rebekah E. Allen  / Sr. Policy Analyst
Address: Virginia Department of Health
9960 Mayland Drive, Ste. 401
Richmond, VA 23233
Email Address: regulatorycomment@vdh.virginia.gov
Telephone: (804)367-2102    FAX: (804)527-4502    TDD: ()-
Current Actions
Action Title Latest Stage Status
Adopt regulations setting forth the requirements for emergency room personnel security training
Action is Exempt from Article 2 of the Administrative Process Act
Final Governor's office review in progress.
Amend Regulation to Conform to Chapters 72 and 220 (2021 Acts of Assembly, Special Session I), to Conform to Chapters 1080, 1081, and 1088 (2020 Acts of Assembly), and to Update Clinical Standards Fast-Track Secretary of Health and Human Resources review in progress.
Amend Regulation after Enactment of Chapters 712 and 772 of the 2022 Acts of Assembly Fast-Track Secretary of Health and Human Resources review in progress.
Amend Regulation to Conform to Chapters 219, 233, and 525 of the 2021 Acts of Assembly, Special Session I Fast-Track Secretary of Health and Human Resources review in progress.

Past Actions
Action Title Latest Stage Status
Amend Regulation to Conform to Chapter 56 of the 2020 Acts of Assembly, Special Session I
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 03/31/2021.
Amend regulations to revise construction standards for inpatient and outpatient hospitals Final Stage complete. This regulation became effective on 06/09/2021.
Amend Regulation to Conform to Chapters 714 and 942 of the 2020 Acts of Assembly
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 08/06/2020.
Amend Regulations to Conform to Ch. 433 of the 2019 Acts of Assembly Fast-Track Stage complete. This regulation became effective on 04/15/2021.
Amend Regulations to Conform to Chapters 136, 343, 670 and 671 of 2019 Acts of Assembly
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 08/23/2019.
Amend Regulations to Conform to Chapters 271 and 682 of the 2018 Acts of Assembly
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 07/10/2019.
Amend Regulations to Conform to Chapters 454, 565, 571 and 791 of 2018
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 11/14/2018.
Amend Regulations to Conform to Provisions of HB1777 of 2017 Session
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 02/21/2018.
Amend regulations to reflect legislative changes concerning patient discharge planning
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 04/08/2016.
Update the Regulations to reflect a CMS issued final rule enabling hospitals that are part of a hospital system to have a unified integrated medical staff Fast-Track Stage complete. This regulation became effective on 04/22/2016.
Update the Regulations to reflect a CMS-issued final rule enabling dietitians in the hospital setting to order therapeutic diets Fast-Track Stage complete. This regulation became effective on 01/14/2016.
Regulations for Licensure of Abortion Facilities Final Stage complete. This regulation became effective on 06/20/2013.
Hospital Policies Required
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 11/01/2011.
Required offer to mothers of newborns of a blood sample for future DNA sampling
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 11/01/2011.
Update of Hospital Building/Construction regulations
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 07/15/2010.
Repeal of sections in 12 VAC 5-410 with promulgation of a new regulation, 12 VAC 5-411 NOIRA Stage withdrawn on 09/05/2014 after the comment period had ended.
Hospital visitor policies
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 02/04/2008.
Adoption of amendments defining Fast-Track Stage complete. This regulation became effective on 05/09/2005.
Breast milk amendment; reformatting Fast-Track Stage complete. This regulation became effective on 02/14/2005.
Adoption of APA-Article II-exempt, non-discretionary regulatory amendments
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 11/01/2002.
Amend in accordance with emergency provision of 1999 law. Final Stage complete. This regulation became effective on 02/28/2002.
Exempt action to require conformance of organ donor routine contact protocols with federal law.
Action is Exempt from Article 2 of the Administrative Process Act
Final Stage complete. This regulation became effective on 10/27/2000.

Withdrawn Actions
Action Title Latest Stage Status
Amend Regulations to Require Establisment of Policies to Follow when a Stillbirth Occurs NOIRA Stage withdrawn on 04/07/2022 after the comment period had ended.
Perioperative Nurse Requirement Fast-Track Stage withdrawn on 10/24/2005 after submission to the Registrar.

Periodic Reviews
Last Activity Status
12/5/2022 Agency Completed Amend
10/3/2007 Agency Completed Amend