                                 CODE OF VIRGINIA

(EFFECTIVE JANUARY 1, 2026) REGULATIONS (§ 32.1-127)

A. The regulations promulgated by the Board to carry out the provisions of this
article shall be in substantial conformity to the standards of health, hygiene,
sanitation, construction and safety as established and recognized by medical and
health care professionals and by specialists in matters of public health and
safety, including health and safety standards established under provisions of
Title XVIII and Title XIX of the Social Security Act, and to the provisions of
Article 2 (&#xA7; 32.1-138 et seq.).

B. Such regulations:

   1. Shall include minimum standards for (i) the construction and maintenance of
   hospitals, nursing homes and certified nursing facilities to ensure the
   environmental protection and the life safety of its patients, employees, and
   the public; (ii) the operation, staffing and equipping of hospitals, nursing
   homes and certified nursing facilities; (iii) qualifications and training of
   staff of hospitals, nursing homes and certified nursing facilities, except
   those professionals licensed or certified by the Department of Health
   Professions; (iv) conditions under which a hospital or nursing home may
   provide medical and nursing services to patients in their places of residence;
   and (v) policies related to infection prevention, disaster preparedness, and
   facility security of hospitals, nursing homes, and certified nursing
   facilities;

   2. Shall provide that at least one physician who is licensed to practice
   medicine in the Commonwealth and is primarily responsible for the emergency
   department shall be on duty and physically present at all times at each
   hospital that operates or holds itself out as operating an emergency service;

   3. May classify hospitals and nursing homes by type of specialty or service
   and may provide for licensing hospitals and nursing homes by bed capacity and
   by type of specialty or service;

   4. Shall also require that each hospital establish a protocol for organ
   donation, in compliance with federal law and the regulations of the Centers
   for Medicare and Medicaid Services (CMS), particularly 42 C.F.R. &#xA7;
   482.45. Each hospital shall have an agreement with an organ procurement
   organization designated in CMS regulations for routine contact, whereby the
   provider&#8217;s designated organ procurement organization certified by CMS
   (i) is notified in a timely manner of all deaths or imminent deaths of
   patients in the hospital and (ii) is authorized to determine the suitability
   of the decedent or patient for organ donation and, in the absence of a similar
   arrangement with any eye bank or tissue bank in Virginia certified by the Eye
   Bank Association of America or the American Association of Tissue Banks, the
   suitability for tissue and eye donation. The hospital shall also have an
   agreement with at least one tissue bank and at least one eye bank to cooperate
   in the retrieval, processing, preservation, storage, and distribution of
   tissues and eyes to ensure that all usable tissues and eyes are obtained from
   potential donors and to avoid interference with organ procurement. The
   protocol shall ensure that the hospital collaborates with the designated organ
   procurement organization to inform the family of each potential donor of the
   option to donate organs, tissues, or eyes or to decline to donate. The
   individual making contact with the family shall have completed a course in the
   methodology for approaching potential donor families and requesting organ or
   tissue donation that (a) is offered or approved by the organ procurement
   organization and designed in conjunction with the tissue and eye bank
   community and (b) encourages discretion and sensitivity according to the
   specific circumstances, views, and beliefs of the relevant family. In
   addition, the hospital shall work cooperatively with the designated organ
   procurement organization in educating the staff responsible for contacting the
   organ procurement organization&#8217;s personnel on donation issues, the
   proper review of death records to improve identification of potential donors,
   and the proper procedures for maintaining potential donors while necessary
   testing and placement of potential donated organs, tissues, and eyes takes
   place. This process shall be followed, without exception, unless the family of
   the relevant decedent or patient has expressed opposition to organ donation,
   the chief administrative officer of the hospital or his designee knows of such
   opposition, and no donor card or other relevant document, such as an advance
   directive, can be found;

   5. Shall require that each hospital that provides obstetrical services
   establish a protocol for admission or transfer of any pregnant woman who
   presents herself while in labor;

   6. Shall also require that each licensed hospital develop and implement a
   protocol requiring written discharge plans for identified, substance-abusing,
   postpartum women and their infants. The protocol shall require that the
   discharge plan be discussed with the patient and that appropriate referrals
   for the mother and the infant be made and documented. Appropriate referrals
   may include, but need not be limited to, treatment services, comprehensive
   early intervention services for infants and toddlers with disabilities and
   their families pursuant to Part H of the Individuals with Disabilities
   Education Act, 20 U.S.C. &#xA7; 1471 et seq., and family-oriented prevention
   services. The discharge planning process shall involve, to the extent
   possible, the other parent of the infant and any members of the
   patient&#8217;s extended family who may participate in the follow-up care for
   the mother and the infant. Immediately upon identification, pursuant to &#xA7;
   54.1-2403.1, of any substance-abusing, postpartum woman, the hospital shall
   notify, subject to federal law restrictions, the community services board of
   the jurisdiction in which the woman resides to appoint a discharge plan
   manager. The community services board shall implement and manage the discharge
   plan;

   7. Shall require that each nursing home and certified nursing facility fully
   disclose to the applicant for admission the home&#8217;s or facility&#8217;s
   admissions policies, including any preferences given;

   8. Shall require that each licensed hospital establish a protocol relating to
   the rights and responsibilities of patients which shall include a process
   reasonably designed to inform patients of such rights and responsibilities.
   Such rights and responsibilities of patients, a copy of which shall be given
   to patients on admission, shall be consistent with applicable federal law and
   regulations of the Centers for Medicare and Medicaid Services;

   9. Shall establish standards and maintain a process for designation of levels
   or categories of care in neonatal services according to an applicable national
   or state-developed evaluation system. Such standards may be differentiated for
   various levels or categories of care and may include, but need not be limited
   to, requirements for staffing credentials, staff/patient ratios, equipment,
   and medical protocols;

   10. Shall require that each nursing home and certified nursing facility train
   all employees who are mandated to report adult abuse, neglect, or exploitation
   pursuant to &#xA7; 63.2-1606 on such reporting procedures and the consequences
   for failing to make a required report;

   11. Shall permit hospital personnel, as designated in medical staff bylaws,
   rules and regulations, or hospital policies and procedures, to accept
   emergency telephone and other verbal orders for medication or treatment for
   hospital patients from physicians, and other persons lawfully authorized by
   state statute to give patient orders, subject to a requirement that such
   verbal order be signed, within a reasonable period of time not to exceed 72
   hours as specified in the hospital&#8217;s medical staff bylaws, rules and
   regulations or hospital policies and procedures, by the person giving the
   order, or, when such person is not available within the period of time
   specified, co-signed by another physician or other person authorized to give
   the order;

   12. Shall require, unless the vaccination is medically contraindicated or the
   resident declines the offer of the vaccination, that each certified nursing
   facility and nursing home provide or arrange for the administration to its
   residents of (i) an annual vaccination against influenza and (ii) a
   pneumococcal vaccination, in accordance with the most recent recommendations
   of the Advisory Committee on Immunization Practices of the Centers for Disease
   Control and Prevention;

   13. Shall require that each nursing home and certified nursing facility
   register with the Department of State Police to receive notice of the
   registration, reregistration, or verification of registration information of
   any person required to register with the Sex Offender and Crimes Against
   Minors Registry pursuant to Chapter 9 (&#xA7; 9.1-900 et seq.) of Title 9.1
   within the same or a contiguous zip code area in which the home or facility is
   located, pursuant to &#xA7; 9.1-914;

   14. Shall require that each nursing home and certified nursing facility
   ascertain, prior to admission, whether a potential patient is required to
   register with the Sex Offender and Crimes Against Minors Registry pursuant to
   Chapter 9 (&#xA7; 9.1-900 et seq.) of Title 9.1, if the home or facility
   anticipates the potential patient will have a length of stay greater than
   three days or in fact stays longer than three days;

   15. Shall require that each licensed hospital include in its visitation policy
   a provision allowing each adult patient to receive visits from any individual
   from whom the patient desires to receive visits, subject to other restrictions
   contained in the visitation policy including, but not limited to, those
   related to the patient&#8217;s medical condition and the number of visitors
   permitted in the patient&#8217;s room simultaneously;

   16. Shall require that each nursing home and certified nursing facility shall,
   upon the request of the facility&#8217;s family council, send notices and
   information about the family council mutually developed by the family council
   and the administration of the nursing home or certified nursing facility, and
   provided to the facility for such purpose, to the listed responsible party or
   a contact person of the resident&#8217;s choice up to six times per year. Such
   notices may be included together with a monthly billing statement or other
   regular communication. Notices and information shall also be posted in a
   designated location within the nursing home or certified nursing facility. No
   family member of a resident or other resident representative shall be
   restricted from participating in meetings in the facility with the families or
   resident representatives of other residents in the facility;

   17. Shall require that each nursing home and certified nursing facility
   maintain, per facility, non-eroding general liability insurance coverage in a
   minimum amount of $1 million per occurrence, and professional liability
   coverage in an amount at least equal to the recovery limit set forth in &#xA7;
   8.01-581.15 per patient occurrence, to compensate patients or individuals for
   injuries and losses resulting from the negligent acts of the facility. Failure
   to maintain such minimum insurance limits under this section shall result in
   revocation of the facility&#8217;s license. Each nursing home and certified
   nursing facility shall provide at licensure renewal or have available to the
   Board proof of the insurance coverages as required by this section;

   18. Shall require each hospital that provides obstetrical services to
   establish policies to follow when a stillbirth, as defined in &#xA7;
   32.1-69.1, occurs that meet the guidelines pertaining to counseling patients
   and their families and other aspects of managing stillbirths as may be
   specified by the Board in its regulations;

   19. Shall require each nursing home to provide a full refund of any unexpended
   patient funds on deposit with the facility following the discharge or death of
   a patient, other than entrance-related fees paid to a continuing care provider
   as defined in &#xA7; 38.2-4900, within 30 days of a written request for such
   funds by the discharged patient or, in the case of the death of a patient, the
   person administering the person&#8217;s estate in accordance with the Virginia
   Small Estates Act (&#xA7; 64.2-600 et seq.);

   20. Shall require that each hospital that provides inpatient psychiatric
   services establish a protocol that requires, for any refusal to admit (i) a
   medically stable patient referred to its psychiatric unit, direct verbal
   communication between the on-call physician in the psychiatric unit and the
   referring physician, if requested by such referring physician, and prohibits
   on-call physicians or other hospital staff from refusing a request for such
   direct verbal communication by a referring physician and (ii) a patient for
   whom there is a question regarding the medical stability or medical
   appropriateness of admission for inpatient psychiatric services 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 by the referring physician;

   21. Shall require that each hospital that is equipped to provide
   life-sustaining treatment shall develop a policy governing determination of
   the medical and ethical appropriateness of proposed medical care, which shall
   include (i) a process for obtaining a second opinion regarding the medical and
   ethical appropriateness of proposed medical care in cases in which a physician
   has determined proposed care to be medically or ethically inappropriate; (ii)
   provisions for review of the determination that proposed medical care is
   medically or ethically inappropriate by an interdisciplinary medical review
   committee and a determination by the interdisciplinary medical review
   committee regarding the medical and ethical appropriateness of the proposed
   health care; and (iii) requirements for a written explanation of the decision
   reached by the interdisciplinary medical review committee, which shall be
   included in the patient&#8217;s medical record. Such policy shall ensure that
   the patient, his agent, or the person authorized to make medical decisions
   pursuant to &#xA7; 54.1-2986 (a) are informed of the patient&#8217;s right to
   obtain his medical record and to obtain an independent medical opinion and (b)
   afforded reasonable opportunity to participate in the medical review committee
   meeting. Nothing in such policy shall prevent the patient, his agent, or the
   person authorized to make medical decisions pursuant to &#xA7; 54.1-2986 from
   obtaining legal counsel to represent the patient or from seeking other
   remedies available at law, including seeking court review, provided that the
   patient, his agent, or the person authorized to make medical decisions
   pursuant to &#xA7; 54.1-2986, or legal counsel provides written notice to the
   chief executive officer of the hospital within 14 days of the date on which
   the physician&#8217;s determination that proposed medical treatment is
   medically or ethically inappropriate is documented in the patient&#8217;s
   medical record;

   22. Shall require every hospital with an emergency department to establish a
   security plan. Such security plan shall be developed using standards
   established by the International Association for Healthcare Security and
   Safety or other industry standard and shall be based on the results of a
   security risk assessment of each emergency department location of the hospital
   and shall include the presence of at least one off-duty law-enforcement
   officer or trained security personnel who is present in the emergency
   department at all times as indicated to be necessary and appropriate by the
   security risk assessment. Such security plan shall be based on identified
   risks for the emergency department, including trauma level designation,
   overall volume, volume of psychiatric and forensic patients, incidents of
   violence against staff, and level of injuries sustained from such violence,
   and prevalence of crime in the community, in consultation with the emergency
   department medical director and nurse director. The security plan shall also
   outline training requirements for security personnel in the potential use of
   and response to weapons, defensive tactics, de-escalation techniques,
   appropriate physical restraint and seclusion techniques, crisis intervention,
   and trauma-informed approaches. Such training shall also include instruction
   on safely addressing situations involving patients, family members, or other
   persons 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. Such
   training requirements may be satisfied through completion of the Department of
   Criminal Justice Services minimum training standards for auxiliary police
   officers as required by &#xA7; 15.2-1731. The Commissioner shall provide a
   waiver from the requirement that at least one off-duty law-enforcement officer
   or trained security personnel be present at all times in the emergency
   department if the hospital demonstrates that a different level of security is
   necessary and appropriate for any of its emergency departments based upon
   findings in the security risk assessment;

   23. Shall require that each hospital establish a protocol requiring that,
   before a health care provider arranges for air medical transportation services
   for a patient who does not have an emergency medical condition as defined in
   42 U.S.C. &#xA7; 1395dd(e)(1), the hospital shall provide the patient or his
   authorized representative with written or electronic notice that the patient
   (i) may have a choice of transportation by an air medical transportation
   provider or medically appropriate ground transportation by an emergency
   medical services provider and (ii) will be responsible for charges incurred
   for such transportation in the event that the provider is not a contracted
   network provider of the patient&#8217;s health insurance carrier or such
   charges are not otherwise covered in full or in part by the patient&#8217;s
   health insurance plan;

   24. Shall establish an exemption from the requirement to obtain a license to
   add temporary beds in an existing hospital or nursing home, including beds
   located in a temporary structure or satellite location operated by the
   hospital or nursing home, provided that the ability remains to safely staff
   services across the existing hospital or nursing home, (i) for a period of no
   more than the duration of the Commissioner&#8217;s determination plus 30 days
   when the Commissioner has determined that a natural or man-made disaster has
   caused the evacuation of a hospital or nursing home and that a public health
   emergency exists due to a shortage of hospital or nursing home beds or (ii)
   for a period of no more than the duration of the emergency order entered
   pursuant to &#xA7; 32.1-13 or 32.1-20 plus 30 days when the Board, pursuant to
   &#xA7; 32.1-13, or the Commissioner, pursuant to &#xA7; 32.1-20, has entered
   an emergency order for the purpose of suppressing a nuisance dangerous to
   public health or a communicable, contagious, or infectious disease or other
   danger to the public life and health;

   25. Shall establish protocols to ensure that any patient scheduled to receive
   an elective surgical procedure for which the patient can reasonably be
   expected to require outpatient physical therapy as a follow-up treatment after
   discharge is informed that he (i) is expected to require outpatient physical
   therapy as a follow-up treatment and (ii) will be required to select a
   physical therapy provider prior to being discharged from the hospital;

   26. Shall permit nursing home staff members who are authorized to possess,
   distribute, or administer medications to residents to store, dispense, or
   administer cannabis oil to a resident who has been issued a valid written
   certification for the use of cannabis oil in accordance with &#xA7; 4.1-1601;

   27. Shall require each hospital with an emergency department to establish a
   protocol for the treatment and discharge of individuals experiencing a
   substance use-related emergency, which shall include provisions for (i)
   appropriate screening and assessment of individuals experiencing substance
   use-related emergencies to identify medical interventions necessary for the
   treatment of the individual in the emergency department and (ii)
   recommendations for follow-up care following discharge for any patient
   identified as having a substance use disorder, depression, or mental health
   disorder, as appropriate, which may include, for patients who have been
   treated for substance use-related emergencies, including opioid overdose, or
   other high-risk patients, (a) the dispensing of naloxone or other opioid
   antagonist used for overdose reversal pursuant to subsection Y of &#xA7;
   54.1-3408 at discharge or (b) issuance of a prescription for and information
   about accessing naloxone or other opioid antagonist used for overdose
   reversal, including information about accessing naloxone or other opioid
   antagonist used for overdose reversal at a community pharmacy, including any
   outpatient pharmacy operated by the hospital, or through a community
   organization or pharmacy that may dispense naloxone or other opioid antagonist
   used for overdose reversal without a prescription pursuant to a statewide
   standing order. Such protocols may also provide for referrals of individuals
   experiencing a substance use-related emergency to peer recovery specialists
   and community-based providers of behavioral health services, or to providers
   of pharmacotherapy for the treatment of drug or alcohol dependence or mental
   health diagnoses;

   28. During a public health emergency related to COVID-19, shall require each
   nursing home and certified nursing facility to establish a protocol to allow
   each patient to receive visits, consistent with guidance from the Centers for
   Disease Control and Prevention and as directed by the Centers for Medicare and
   Medicaid Services and the Board. Such protocol shall include provisions
   describing (i) the conditions, including conditions related to the presence of
   COVID-19 in the nursing home, certified nursing facility, and community, under
   which in-person visits will be allowed and under which in-person visits will
   not be allowed and visits will be required to be virtual; (ii) the
   requirements with which in-person visitors will be required to comply to
   protect the health and safety of the patients and staff of the nursing home or
   certified nursing facility; (iii) the types of technology, including
   interactive audio or video technology, and the staff support necessary to
   ensure visits are provided as required by this subdivision; and (iv) the steps
   the nursing home or certified nursing facility will take in the event of a
   technology failure, service interruption, or documented emergency that
   prevents visits from occurring as required by this subdivision. Such protocol
   shall also include (a) a statement of the frequency with which visits,
   including virtual and in-person, where appropriate, will be allowed, which
   shall be at least once every 10 calendar days for each patient; (b) a
   provision authorizing a patient or the patient&#8217;s personal representative
   to waive or limit visitation, provided that such waiver or limitation is
   included in the patient&#8217;s health record; and (c) a requirement that each
   nursing home and certified nursing facility publish on its website or
   communicate to each patient or the patient&#8217;s authorized representative,
   in writing or via electronic means, the nursing home&#8217;s or certified
   nursing facility&#8217;s plan for providing visits to patients as required by
   this subdivision;

   29. Shall require each hospital, nursing home, and certified nursing facility
   to establish and implement policies to ensure the permissible access to and
   use of an intelligent personal assistant provided by a patient, in accordance
   with such regulations, while receiving inpatient services. Such policies shall
   ensure protection of health information in accordance with the requirements of
   the federal Health Insurance Portability and Accountability Act of 1996, 42
   U.S.C. &#xA7; 1320d et seq., as amended. For the purposes of this subdivision,
   &#8220;intelligent personal assistant&#8221; means a combination of an
   electronic device and a specialized software application designed to assist
   users with basic tasks using a combination of natural language processing and
   artificial intelligence, including such combinations known as &#8220;digital
   assistants&#8221; or &#8220;virtual assistants&#8221;;

   30. During a declared public health emergency related to a communicable
   disease of public health threat, shall require each hospital, nursing home,
   and certified nursing facility to establish a protocol to allow patients to
   receive visits from a rabbi, priest, minister, or clergy of any religious
   denomination or sect consistent with guidance from the Centers for Disease
   Control and Prevention and the Centers for Medicare and Medicaid Services and
   subject to compliance with any executive order, order of public health,
   Department guidance, or any other applicable federal or state guidance having
   the effect of limiting visitation. Such protocol may restrict the frequency
   and duration of visits and may require visits to be conducted virtually using
   interactive audio or video technology. Any such protocol may require the
   person visiting a patient pursuant to this subdivision to comply with all
   reasonable requirements of the hospital, nursing home, or certified nursing
   facility adopted to protect the health and safety of the person, patients, and
   staff of the hospital, nursing home, or certified nursing facility;

   31. Shall require that every hospital that makes health records, as defined in
   &#xA7; 32.1-127.1:03, of patients who are minors available to such patients
   through a secure website shall make such health records available to such
   patient&#8217;s parent or guardian through such secure website, unless the
   hospital cannot make such health record available in a manner that prevents
   disclosure of information, the disclosure of which has been denied pursuant to
   subsection F of &#xA7; 32.1-127.1:03 or for which consent required in
   accordance with subsection E of &#xA7; 54.1-2969 has not been provided;

   32. Shall require that every hospital where surgical procedures are performed
   adopt a policy requiring the use of a smoke evacuation system for all planned
   surgical procedures that are likely to generate surgical smoke. For the
   purposes of this subdivision, &#8220;smoke evacuation system&#8221; means
   smoke evacuation equipment and technologies designed to capture, filter, and
   remove surgical smoke at the site of origin and to prevent surgical smoke from
   making ocular contact or contact with a person&#8217;s respiratory tract;

   33. Shall require every hospital with an emergency department, when conducting
   a urine drug screening to assist in diagnosing a patient&#8217;s condition, to
   include testing for fentanyl in such urine drug screening; and

   34. Shall establish fees for the issuance, change, or renewal of a hospital or
   nursing home license to cover the costs of operating the hospital and nursing
   home licensure and inspection program in a manner that ensures timely
   completion of inspections as set forth in &#xA7; 32.1-126. In establishing
   such fees, the Board shall distribute the costs of operating the hospital and
   nursing home licensure and inspection program in an equitable manner across
   all hospitals or nursing homes and ensure that the amount of such fees shall
   change no more frequently than annually. Fee changes under this section shall
   only be initiated if the expenses allocated to the Hospital and Nursing Home
   Licensure and Inspection Program Fund established under &#xA7; 32.1-130, plus
   any state or other funding sources appropriated for the hospital and nursing
   home licensure and inspection program, are shown to be more than 10 percent
   greater or less than the annual costs of operating the hospital and nursing
   home licensure and inspection program in a manner that ensures timely
   completion of inspections. This analysis shall be conducted separately for
   hospital fees and nursing home fees, and resulting fee changes shall be
   established such that fees are sufficient to cover unfunded expenses but not
   excessive.

C. Upon obtaining the appropriate license, if applicable, licensed hospitals,
nursing homes, and certified nursing facilities may operate adult day centers.

D. All facilities licensed by the Board pursuant to this article which provide
treatment or care for hemophiliacs and, in the course of such treatment, stock
clotting factors, shall maintain records of all lot numbers or other unique
identifiers for such clotting factors in order that, in the event the lot is
found to be contaminated with an infectious agent, those hemophiliacs who have
received units of this contaminated clotting factor may be apprised of this
contamination. Facilities which have identified a lot that is known to be
contaminated shall notify the recipient&#8217;s attending physician and request
that he notify the recipient of the contamination. If the physician is
unavailable, the facility shall notify by mail, return receipt requested, each
recipient who received treatment from a known contaminated lot at the
individual&#8217;s last known address.

E. Hospitals in the Commonwealth may enter into agreements with the Department
of Health for the provision to uninsured patients of naloxone or other opioid
antagonists used for overdose reversal.

F. Hospitals in the Commonwealth shall:

   1. Establish a workplace violence incident reporting system, through which
   each hospital shall document, track, and analyze any incident of workplace
   violence reported. The results of such analysis shall be used to make
   improvements in preventing workplace violence, including improvements achieved
   through continuing education in targeted areas, including de-escalation
   training, risk identification, and violence prevention planning. Such
   reporting system shall (i) be clearly communicated to all employees, including
   to any new employees at the employee orientation, and (ii) include guidelines
   on when and how to report incidents of workplace violence to the employer,
   security agencies, and appropriate law-enforcement authorities;

   2. Record all reported incidents of workplace violence as voluntarily reported
   by an employee; and

   3. Adopt a policy that prohibits any person from discriminating or retaliating
   against any employee of the hospital for reporting to, or seeking assistance
   or intervention from, the employer, security agencies, law-enforcement
   authorities, local emergency services organizations, government agencies, or
   others participating in any incident investigation. Such policy shall comply
   with the provisions of &#xA7; 40.1-27.3.

G. Each hospital in the Commonwealth shall maintain the record of reported
incidents of workplace violence made pursuant to subsection F for at least two
years and shall include in such record, at a minimum:

   1. The date and time of the incident;

   2. A description of the incident, including the job titles of the affected
   employee;

   3. Whether the perpetrator was a patient, visitor, employee, or other person;

   4. A description of where the incident occurred;

   5. Information relating the type of incident, including whether the incident
   involved (i) a physical attack without a weapon; (ii) an attack with a weapon
   or object; (iii) a threat of physical force or use of a weapon or other object
   with the intent to cause bodily harm; (iv) sexual assault or the threat of
   sexual assault; or (v) anything else not listed in subdivisions (i) through
   (iv);

   6. The response to and any consequences of the incident, including (i) whether
   security or law enforcement was contacted and, if so, their response and (ii)
   whether the incident resulted in any change to hospital policy; and

   7. Information about the individual who completed the report, including such
   individual&#8217;s name, job title, and the date of completion.

H. Each hospital shall:

   1. Report the data collected and reported pursuant to subsection G to the
   chief medical officer and the chief nursing officer of such hospital on, at a
   minimum, a quarterly basis; and

   2. Send a report to the Department on an annual basis that includes, at a
   minimum, the number of incidents of workplace violence voluntarily reported by
   an employee pursuant to subsection F. Any report made to the Department
   pursuant to this subdivision shall be aggregated to remove any personally
   identifiable information.

I. As used in this section:
			&#8220;Employee of the hospital&#8221; or &#8220;employee&#8221; means an
employee of the hospital or any health care provider credentialed by the
hospital or engaged by the hospital to perform health care services on the
premises of the hospital.
			&#8220;Workplace violence&#8221; means any act of violence or threat of
violence, without regard to the intent of the perpetrator, that occurs against
an employee of the hospital while on the premises of such hospital and engaged
in the performance of his duties. &#8220;Workplace violence&#8221; includes (i)
the threat or use of physical force against an employee that results in, or has
a high likelihood of resulting in, injury, psychological trauma, or stress,
regardless of whether physical injury is sustained, and (ii) any incident
involving the threat of using dangerous weapons or using common objects as
weapons or to cause physical harm, regardless of whether physical injury is
sustained.

HISTORY: Code 1950, § 32-301; 1972, c. 36; 1979, c. 711; 1985, c. 335; 1986, c.
135; 1987, c. 224; 1988, cc. 325, 418; 1989, cc. 434, 618, 699; 1992, cc. 334,
428; 1993, c. 335; 1996, cc. 361, 411; 1997, c. 454; 1998, c. 450; 2000, cc.
176, 810; 2001, c. 463; 2004, c. 762; 2007, cc. 119, 164, 516; 2011, cc. 406,
412, 670; 2013, c. 320; 2014, c. 320; 2015, c. 661; 2016, c. 85; 2017, cc. 175,
462; 2018, cc. 271, 368, 454, 565, 682, 791; 2019, cc. 136, 343; 2020, cc. 714,
829, 846, 898, 899, 900, 942; 2020, Sp. Sess. I, cc. 10, 11; 2021, Sp. Sess. I,
cc. 219, 233, 525; 2022, cc. 218, 712, 772; 2023, cc. 417, 482, 483, 740, 773;
2024, cc. 37, 150, 207, 249, 441, 505; 2025, cc. 238, 254, 265, 277, 330, 457,
472.