Virginia Regulatory Town Hall
Virginia Department of Health
State Board of Health
Regulations for the Licensure of Hospitals in Virginia [12 VAC 5 ‑ 410]
Action is Exempt from Article 2 of the Administrative Process Act
Amend Regulations to Conform to Chapters 454, 565, 571 and 791 of 2018
Action 5123
General Information
Action Summary House Bill 226, enacted by the 2018 General Assembly and approved by the Governor on March 19, 2018 (identical to Senate Bill 222, approved by the Governor on March 30, 2018), amends and reenacts Va. Code §§ 32.1-127 and 54.1-2990, relating to medically or ethically inappropriate care not required. The two bills require that the Board of Health include in the Regulations for the Licensure of Hospitals that hospitals equipped to provide life-sustaining care establish a policy regarding the withholding of that care when it has been determined by the physician to be medically or ethically inappropriate for the patient. The policies must include a process for obtaining a second opinion regarding determination, as well as provisions for review and documentation by an interdisciplinary team of the determination that the care is inappropriate. Additionally, provisions must be in place that the patient, his agent, or the person authorized to make the patient’s medical decisions in accordance with § 54.1-2986 are informed of the patient’s right to obtain his medical record, containing a written explanation of interdisciplinary team’s decision, and the right to obtain an independent medical opinion and afforded reasonable opportunity to participate in the medical review. The rights of the patient, the patient’s agent or the person authorized to make medical decisions for the patient to seek legal counsel and other legal remedies regarding the decision are preserved by the policy, as long as written notice is provided within 14 days of the determination that the proposed care is either medically or ethically inappropriate. House Bill 886 (2018) requires the Board of Health to include in its regulations governing hospitals that every hospital which provides inpatient psychiatric services to establish a protocol that requires, for every refusal to admit a patient for whom there is a question of medical stability or medical appropriateness for admission due to a situation involving results of a toxicology screening, the on-call physician in the psychiatric unit to which the patient is sought to be transferred to participate in direct verbal communication, either in person or via telephone, with a clinical toxicologist or other person who is a Certified Specialist in Poison Information employed by a poison control center that is accredited by the American Association of Poison Control Centers to review the results of the toxicology screen and determine whether a medical reason for refusing admission to the psychiatric unit related to the results of the toxicology screen exists, if requested to do so by the referring physician. House Bill 1088 (2018) and Senate Bill 725 (2018) both update the Emergency Services section of the hospital regulations. SB 725 requires hospitals to post notice of the existence of the human trafficking hotline to alert possible witnesses or victims of human trafficking to the availability of a means to report crimes or gain assistance in each emergency department and that it be readily visible to the public. HB 1088 requires that any licensed hospitals with an emergency department establish protocols to ensure that security personnel of the emergency department, if any, receive training appropriate to the populations served by the emergency department. The protocol may include training based on a trauma-informed approach in identifying and safely addressing situations involving patients and others 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. Currently, 12VAC5-410-280 regulates emergency services and requires hospitals to make special training available for “emergency department personnel,” but not for “security personnel” in an emergency department.
Chapters Affected Only affects this chapter.
Executive Branch Review This Action is exempt from Article 2 of the Administrative Process Act. The normal executive branch review process is not required. As such, it can be submitted directly for publication and is effective upon publication.
Exempt Citation: Section 2.2-4006(A)(4)(a) of the Code of Virginia
RIS Project Yes  [005661]
Associated Mandates
New Periodic Review This action will not be used to conduct a new periodic review.
Stages associated with this regulatory action.
Stage ID Stage Type Status
8386 Final Stage complete. This regulation became effective on 11/14/2018.
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:
Phone: (804)367-2102    FAX: (804)527-4502    TDD: ()-

This person is the primary contact for this chapter.