                                 CODE OF VIRGINIA

HOSPITALS, OTHER HEALTH CARE INSTITUTIONS, HOME HEALTH AND HOSPICE
ORGANIZATIONS, AND ASSISTED LIVING FACILITIES REQUIRED TO REPORT DISCIPLINARY
ACTIONS AGAINST AND CERTAIN DISORDERS OF HEALTH PROFESSIONALS; IMMUNITY FROM
LIABILITY; FAILURE TO REPORT (§ 54.1-2400.6)

A. The chief executive officer and the chief of staff of every hospital or other
health care institution in the Commonwealth, the director of every licensed home
health or hospice organization, the director of every accredited home health
organization exempt from licensure, the administrator of every licensed assisted
living facility, and the administrator of every provider licensed by the
Department of Behavioral Health and Developmental Services in the Commonwealth
shall report within 30 days, except as provided in subdivisions 1 and 2, to the
Director of the Department of Health Professions, or in the case of a director
of a home health or hospice organization, to the Office of Licensure and
Certification at the Department of Health (the Office), the following
information regarding any person (i) licensed, certified, or registered by a
health regulatory board or (ii) holding a multistate licensure privilege to
practice nursing or an applicant for licensure, certification or registration
unless exempted under subsection E:

   1. Any information of which he may become aware in his official capacity
   indicating a reasonable belief that such a health professional has been
   involuntarily admitted as a patient, either in his own institution or any
   other health care institution, for treatment of substance abuse or a
   psychiatric illness. The report required by this subdivision shall be made
   within five days of the date on which the chief executive officer, chief of
   staff, director, or administrator learns of the health care
   professional&#8217;s involuntary admission.

   2. Any information of which he may become aware in his official capacity
   indicating a reasonable belief that such a health professional has been
   voluntarily admitted as a patient, either at his institution or any other
   health care institution, for treatment of a substance abuse or psychiatric
   illness and such substance abuse or psychiatric illness may continue for more
   than 30 days after admission. A report required by this subdivision shall be
   made within five days after the 30-day period concludes unless the physician,
   physician assistant, or nurse practitioner treating the health professional
   for substance abuse or psychiatric illness provides written confirmation to
   the entity required to make such report that the health professional no longer
   is believed to be a danger to himself, the public, or his patients.

   3. Any information of which he may become aware in his official capacity
   indicating a reasonable belief, after review and, if necessary, an
   investigation or consultation with the appropriate internal boards or
   committees authorized to impose disciplinary action on a health professional,
   that a health professional may have engaged in unethical, fraudulent or
   unprofessional conduct as defined by the pertinent licensing statutes and
   regulations. The report required under this subdivision shall be submitted
   within 30 days of the date that the chief executive officer, chief of staff,
   director, or administrator determines that such reasonable belief exists.

   4. Any disciplinary proceeding begun by the institution, organization,
   facility, or provider as a result of conduct involving (i) intentional or
   negligent conduct that causes or is likely to cause injury to a patient or
   patients, (ii) professional ethics, (iii) professional incompetence, (iv)
   moral turpitude, or (v) substance abuse. The report required under this
   subdivision shall be submitted within 30 days of the date of written
   communication to the health professional notifying him of the initiation of a
   disciplinary proceeding.

   5. Any disciplinary action taken during or at the conclusion of disciplinary
   proceedings or while under investigation, including but not limited to denial
   or termination of employment, denial or termination of privileges or
   restriction of privileges that results from conduct involving (i) intentional
   or negligent conduct that causes or is likely to cause injury to a patient or
   patients, (ii) professional ethics, (iii) professional incompetence, (iv)
   moral turpitude, or (v) substance abuse. The report required under this
   subdivision shall be submitted within 30 days of the date of written
   communication to the health professional notifying him of any disciplinary
   action.

   6. The voluntary resignation from the staff of the health care institution,
   home health or hospice organization, assisted living facility, or provider, or
   voluntary restriction or expiration of privileges at the institution,
   organization, facility, or provider, of any health professional while such
   health professional is under investigation or is the subject of disciplinary
   proceedings taken or begun by the institution, organization, facility, or
   provider or a committee thereof for any reason related to possible intentional
   or negligent conduct that causes or is likely to cause injury to a patient or
   patients, medical incompetence, unprofessional conduct, moral turpitude,
   mental or physical impairment, or substance abuse.
   				Any report required by this section shall be in writing directed to the
   Director of the Department of Health Professions or to the Director of the
   Office of Licensure and Certification at the Department of Health, shall give
   the name, address, and date of birth of the person who is the subject of the
   report and shall fully describe the circumstances surrounding the facts
   required to be reported. The report shall include the names and contact
   information of individuals with knowledge about the facts required to be
   reported and the names and contact information of individuals from whom the
   hospital or health care institution, organization, facility, or provider
   sought information to substantiate the facts required to be reported. All
   relevant medical records shall be attached to the report if patient care or
   the health professional&#8217;s health status is at issue. The reporting
   hospital, health care institution, home health or hospice organization,
   assisted living facility, or provider shall also provide notice to the
   Department or the Office that it has submitted a report to the National
   Practitioner Data Bank under the Health Care Quality Improvement Act (42
   U.S.C. &#xA7; 11101 et seq.). The reporting hospital, health care institution,
   home health or hospice organization, assisted living facility, or provider
   shall give the health professional who is the subject of the report an
   opportunity to review the report. The health professional may submit a
   separate report if he disagrees with the substance of the report.
   				This section shall not be construed to require the hospital, health care
   institution, home health or hospice organization, assisted living facility, or
   provider to submit any proceedings, minutes, records, or reports that are
   privileged under &#xA7; 8.01-581.17, except that the provisions of &#xA7;
   8.01-581.17 shall not bar (i) any report required by this section or (ii) any
   requested medical records that are necessary to investigate unprofessional
   conduct reported pursuant to this subtitle or unprofessional conduct that
   should have been reported pursuant to this subtitle. Under no circumstances
   shall compliance with this section be construed to waive or limit the
   privilege provided in &#xA7; 8.01-581.17. No person or entity shall be
   obligated to report any matter to the Department or the Office if the person
   or entity has actual notice that the same matter has already been reported to
   the Department or the Office. No person or entity shall be obligated to report
   a health care provider who is participating in a professional program as
   described in subsection B of &#xA7; 8.01-581.16 unless there is a reasonable
   belief that the participant is not competent to continue to practice or is a
   danger to himself or to the health and welfare of his patients or the public.

B. The State Health Commissioner, Commissioner of Social Services, and
Commissioner of Behavioral Health and Developmental Services shall report to the
Department any information of which their agencies may become aware in the
course of their duties that a health professional may be guilty of fraudulent,
unethical, or unprofessional conduct as defined by the pertinent licensing
statutes and regulations. However, the State Health Commissioner shall not be
required to report information reported to the Director of the Office of
Licensure and Certification pursuant to this section to the Department of Health
Professions.

C. Any person making a report by this section, providing information pursuant to
an investigation or testifying in a judicial or administrative proceeding as a
result of such report shall be immune from any civil liability alleged to have
resulted therefrom unless such person acted in bad faith or with malicious
intent.

D. Medical records or information learned or maintained in connection with an
alcohol or drug prevention function that is conducted, regulated, or directly or
indirectly assisted by any department or agency of the United States shall be
exempt from the reporting requirements of this section to the extent that such
reporting is in violation of 42 U.S.C. &#xA7; 290dd-2 or regulations adopted
thereunder.

E. Any person who fails to make a report to the Department as required by this
section shall be subject to a civil penalty not to exceed $25,000 assessed by
the Director. The Director shall report the assessment of such civil penalty to
the Commissioner of Health, Commissioner of Social Services, or Commissioner of
Behavioral Health and Developmental Services, as appropriate. Any person
assessed a civil penalty pursuant to this section shall not receive a license or
certification or renewal of such unless such penalty has been paid pursuant to
&#xA7; 32.1-125.01. The Medical College of Virginia Hospitals and the University
of Virginia Hospitals shall not receive certification pursuant to &#xA7;
32.1-137 or Article 1.1 (&#xA7; 32.1-102.1 et seq.) of Chapter 4 of Title 32.1
unless such penalty has been paid.

HISTORY: Code 1950, § 32-137.1; 1977, c. 639; 1978, c. 541, § 54-325.1; 1979,
cc. 720, 727; 1986, cc. 303, 434; 1988, c. 765, § 54.1-2906; 1994, c. 234;
2000, c. 77; 2003, cc. 456, 753, 762; 2004, cc. 49, 64; 2011, c. 463; 2015, c.
119; 2017, cc. 418, 426; 2020, cc. 45, 230; 2021, Sp. Sess. I, cc. 5, 243; 2024,
cc. 96, 126.