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Department of Health Professions
Guidance Document Change: Updated version on guidance for mandated reports from health care institutions
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10/13/20  3:04 pm
Commenter: R. Brent Rawlings on behalf of Virginia Hospital & Healthcare Association

VHHA Support for Revised Guidance Document 76-34



October 13, 2020


Elaine J. Yeatts      

Agency Regulatory Coordinator

Virginia Department of Health Professions

Perimeter Center

9960 Mayland Drive, Suite 300

Richmond, Virginia 23233


Re: Reporting by Hospitals and Other Health Care Institutions; Revised Guidance Document 76-34


Dear Ms. Yeatts,


Virginia Hospital & Healthcare Association (“VHHA”) appreciates the opportunity to submit comments to the Department of Health Professions in response to the revised Guidance Document, Reporting by Hospitals and Other Health Care Institutions 76-34.


During the 2020 General Assembly, VHHA supported HB471 (Collins) and SB540 (Vogel) making various clarifications to Va. Code § 54.1-2400.6 as applied to health care providers obligated to report disciplinary actions and unprofessional conduct.  VHHA likewise supports the revised Guidance Document 76-34 as it helps to further support and implement these recent changes to law and will be very useful for reporters going forward.


We do, however, have some comments and suggestions on the document that we are respectfully submitting for your consideration:


  • Item III.F.2 provides that reports shall include “A full description of the circumstances surrounding the facts required to be reported.”  (Emphasis added.)  We are concerned that the phrase “full description” may imply that an investigation is required, which is inconsistent with the language of the statute.  We are also concerned that the use of the word “facts” may imply that the reporter is adopting any accusation of misconduct as “fact,” which could unintentionally expose a reporter to defamation claims.  One suggestion would be to revise this sentence to read “A description of the information available to the reporter regarding disciplinary actions against, allegations of misconduct by, or impairment of certain health care professionals.”  Further, we suggest that an additional question be included in III.F - “Are reporters required to complete an investigation prior to reporting?”  The purpose of the question and response would be to further clarify that an investigation is not required in all instances.


  • Under Item III.E.1, “What Must Be Reported,” we suggest including the following for purposes of clarification: “In addition, reporting is required when a health professional has been involuntarily admitted, either at his institution or any other health care institution, for treatment of substance abuse or a psychiatric illness.”



On behalf of VHHA, thank you for your work to assist health care providers in complying with this important law and the opportunity to submit public comment on the Revised Guidance Document.  




                                                                        R. Brent Rawlings

                                                                        Senior Vice President & General Counsel

CommentID: 87359