Commonwealth Senior Living appreciates the chance to take part in this review. We operate 26 assisted living communities across Virginia, and we offer the following comments in a spirit of partnership with the Department, drawn from our experience serving residents and families throughout the Commonwealth.

These Standards matter, and we support keeping them in place; they help ensure residents are safe and well cared for. We also see this review as a good opportunity to refine a number of provisions so they better fit how communities operate today. Our recommendations are offered in that constructive spirit.

We recommend the following amendments and clarifications.

1. 22VAC40-73-10 (Definitions), "Health care provider."

Recommendation: Revise the definition of "health care provider" so that it tracks the definition in the Code of Virginia and includes any individual licensed to provide a specific health care service within their scope of practice, allowing the Standards to keep pace as the Commonwealth adds credentialed professions.

2. 22VAC40-73-120 (Staff orientation and initial training).

Recommendation: Confirm and clarify that a new team member may work under the sight supervision of a trained direct care staff person or the administrator while orientation is being completed, which allows greater flexibility in scheduling orientation and training.

3. 22VAC40-73-140 (Administrator qualifications).

Recommendation: Collaborate with the Virginia Board of Long-Term Care Administrators to reduce barriers to licensure as an administrator.

4. 22VAC40-73-140 (Administrator qualifications), subsection D.2.

Recommendation: Add a qualification pathway (v): "have at least three years of health care experience, to include at least one year in a managerial or supervisory role, in a health care setting within the five years prior to application," to match the requirements to participate in the AIT program under the Board of Long-Term Care Administrators.

5. 22VAC40-73-150 (Administrator provisions and responsibilities), coverage and notification timelines.

The requirement in subsection B to "immediately" employ a new administrator or appoint a qualified acting administrator uses an undefined term that is operationally impossible to satisfy, since recruiting or credentialing a qualified administrator cannot occur instantaneously. The separate notification provisions in B.1 and B.2 are also duplicative.

Recommendation: Replace "immediately" in subsection B with a defined, reasonable period, and consolidate the notification requirements of B.1 and B.2 into a single written notice to the regional licensing office (and, where applicable, the Virginia Board of Long-Term Care Administrators) within 14 days of an administrator change.

6. 22VAC40-73-150 and 22VAC40-73-170, on-site hours requirement.

The requirement that the administrator be on site 40 hours per week does not account for vacation, off-site education, mentoring, or other legitimate responsibilities, and contributes to administrator burnout and turnover in a workforce already under strain. State workforce data indicate that the large majority of assisted living facility administrators already work 40 or more hours per week.

Recommendation: Reduce the minimum on-site requirement from 40 hours to 30 hours per week, a generally recognized full-time threshold, which would allow the administrator to be off site for training and mentoring while remaining on call, with a corresponding adjustment to the required day and night shift coverage hours.

7. 22VAC40-73-150 (Administrator provisions and responsibilities), acting administrator timelines (subsections B.5-6, B.7, and B.9).

The window during which a facility may operate under an acting administrator (150 days, or 90 days if the acting administrator has not applied for licensure) is difficult to meet. The AIT program alone requires 640 hours, which at 40 hours per week is roughly 16 weeks, or about 112 days, before accounting for state processing and examination scheduling. Separately, the restriction in B.9 barring a facility from operating under an acting administrator more than twice in any two-year period significantly hinders an industry with high rates of retirement and turnover.

Recommendation: Extend the acting administrator window, and the single limited extension available under B.7, to reflect the realistic AIT and examination timeline, and eliminate the two-times-in-two-years restriction in B.9 and the corresponding provision in the Code.

8. 22VAC40-73-200 (Direct care staff qualifications and certification).

There is confusion over which certifications are acceptable, and DMAS has not approved personal care aide (PCA) training in over ten years, leaving communities unsure how to evaluate the adequacy of other organizations' direct care training programs.

Recommendation: Clearly specify which certifications satisfy the standard, establish a current approval standard for direct care training, and provide a means to verify the adequacy of third party training programs.

9. 22VAC40-73-260 (First aid and CPR).

Recommendation: Update the standard to match the current first aid and CPR standards effective July 1, 2026, expand the list of acceptable training providers, and tie currency to the certification's listed expiration date, or two years where none is listed.

10. 22VAC40-73-320 (Physical examination and report), hospital admissions.

Completing the required physical examination is often difficult when a prospective resident is in the hospital, as hospital physicians frequently decline to complete the assisted living admission forms and much of the required information already exists in the hospital's electronic medical record. This delays or prevents timely, appropriate discharges to assisted living.

Recommendation: Allow the facility to rely on the hospital's notes, history, and electronic medical record, with electronically signed orders, to satisfy the admission physical when the required information is present, focusing on whether the facility has the information needed to safely admit the resident rather than on the specific form or format.

11. 22VAC40-73-320 (Physical examination and report), serious cognitive impairment screening.

The physician questions on serious cognitive impairment, where the physician circles "yes" or "no," are written unclearly. Because these are the two questions that determine whether a resident requires a secured unit, the lack of clarity causes significant confusion and repeated back and forth at a point that directly affects resident placement and safety.

Recommendation: Reword these questions for clarity so the determination is unambiguous.

12. 22VAC40-73-330 (Mental health screening).

By its terms, this provision applies only where behaviors within the previous six months indicate mental illness or a related condition, yet some inspectors interpret it, through 22VAC40-73-310 B.4, to require a screening for all residents. It also does not specify who is qualified to complete the screening.

Recommendation: Clarify that the screening applies only to residents meeting the behavioral criteria, not to all admissions, and specify who is qualified to complete it.

13. 22VAC40-73-360 (Emergency placement).

Recommendation: Clarify that public and private pay individuals may be equally supported and placed, and that an independent physician (including a physician assistant or nurse practitioner) or an adult protective services worker may document and approve the placement.

14. 22VAC40-73-380 (Resident personal and social information).

Recommendation: Limit required information to that which is vital to the resident's health, safety, and well-being (for example, birthplace is not necessary), and combine overlapping subitems.

15. 22VAC40-73-400 (Monthly statement of charges and payments).

Recommendation: Expressly permit electronic records and electronic delivery of the monthly statement, consistent with the many facilities that maintain records electronically.

16. 22VAC40-73-420.A (Acceptance back in facility).

Subsection A requires a facility to establish procedures ensuring that a resident detained under a temporary detention order is considered for acceptance back into the facility, while A.2 requires the facility to determine whether it can meet the resident's needs. As written, the mandatory acceptance language in A is in tension with the needs determination in A.2.

Recommendation: Revise subsection A so that a resident's return remains subject to the facility's determination under A.2 that it can safely meet the resident's needs, resolving the internal inconsistency.

17. 22VAC40-73-490 (Health care oversight).

The requirement that the licensed health care professional providing oversight have two years of experience in specified settings is not relevant to whether the professional is qualified, and unnecessarily limits the pool of professionals available to provide oversight.

Recommendation: Base eligibility on current, active licensure rather than the two-year experience requirement, and review the section as a whole to align it with current healthcare practice.

18. 22VAC40-73-510 (Mental health services coordination and support).

The provision is unclear and contains redundant language. Portions duplicate the facility's existing obligation under other sections to meet residents' needs, which can confuse assisted living professionals.

Recommendation: Review and reword the section to remove redundancy and improve clarity.

19. 22VAC40-73-520 (Activity and recreational requirements).

Recommendation: Revise the section to remove redundancy with the program of care requirements in 22VAC40-73-30, remove outdated language, and avoid overly specific or non-measurable requirements that create hardship for smaller communities or turn on inspector subjectivity.

20. 22VAC40-73-680 (Administration of medications).

When a PRN medication is documented on the MAR with specific parameters and a signed prescriber order, the additional separate paper order in the chart is redundant and creates duplicative work for both the prescriber and the community.

Recommendation: Eliminate the duplicate documentation requirement where the PRN is already recorded on the MAR with parameters and a signed order.

21. 22VAC40-73-760 (Living room or multipurpose room).

Recommendation: Simplify the section and remove outdated references, such as radio and current newspaper, that no longer reflect how residents access information and entertainment.

22. 22VAC40-73-1130 (Staffing).

The fixed staffing count, one additional direct care staff member for every 10 residents or portion thereof, does not account for the actual acuity or needs of the residents served, and strains facilities' ability to care for residents given the limited direct care workforce.

Recommendation: Replace the fixed count with the standard already used in 22VAC40-73-280, staff "adequate in knowledge, skills, and abilities and sufficient in numbers to provide services," so that staffing is based on the actual needs of the residents rather than a fixed ratio, applied consistently across assisted living and memory care.

We appreciate your consideration of these recommendations, and please reach out if it would help to discuss any of them further. Commonwealth Senior Living cares about getting these Standards right, because clear and workable rules are part of keeping residents safe and well served. We are glad to be a resource to the Department as this review continues.