Virginia Regulatory Town Hall View Chapter

Virginia Department of Health

State Board of Health

Regulations for the Licensure of Hospitals in Virginia [12 VAC 5 ‑ 410]

Chapter Information

Description	The regulations prescribe standards and requirements for the licensing, construction, maintenance and operation of hospitals.
State Authority	32.1-123
Federal Authority	None entered
Text of Regulation	Link to Virginia Administrative Code
Goals of Regulation	Whether the regulations continue to prescribe appropriate and effective standards and requirements for the licensing, construction, maintenance and operation of hospitals.
Meetings	See all meetings (2) relating to this chapter.

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:	regulatorycomment@vdh.virginia.gov
Telephone:	(804)367-2102 FAX: (804)527-4502 TDD: ()-

Action Title	Latest Stage	Status
Current Actions
Amend Regulations after Enactment of Chapters 254 and 265 of the 2025 Acts of Assembly	Emergency/NOIRA	Secretary of Health and Human Resources review in progress.
Amend Regulation after Enactment of Chapters 712 and 772 of the 2022 Acts of Assembly	Fast-Track	Secretary of Health and Human Resources review in progress.

Action Title	Latest Stage	Status
Past Actions
Amend Regulation after Enactment of Chapters 238, 423, 428, 457, 472, 488, 544, 557, and 589 of the 2025 Acts of Assembly	Final	Stage complete. This regulation became effective on 11/19/2025.
Amend Regulation after Enactment of Chapters 207, 249, 441, and 505 of the 2024 Acts of Assembly	Final	Stage complete. This regulation became effective on 09/24/2025.
Repeal and Replace Hospital Regulation following Periodic Review	NOIRA	Stage complete. Comment period ended 06/18/2025.
Adopt regulations setting forth the requirements for emergency room personnel security training	Final	Stage complete. This regulation became effective on 07/17/2024.
Amend Regulation to Conform to Chapters 72 and 220 (2021 Acts of Assembly, Special Session I), to Conform to Chapters 1080, 1081, and 1088 (2020 Acts of Assembly), and to Update Clinical Standards	Fast-Track	Stage complete. This regulation became effective on 06/04/2026.
Amend Regulation to Conform to Chapters 219, 233, and 525 of the 2021 Acts of Assembly, Special Session I	Fast-Track	Stage complete. This regulation became effective on 05/22/2025.
Amend Regulation to Conform to Chapter 56 of the 2020 Acts of Assembly, Special Session I	Final	Stage complete. This regulation became effective on 03/31/2021.
Amend regulations to revise construction standards for inpatient and outpatient hospitals	Final	Stage complete. This regulation became effective on 06/09/2021.
Amend Regulation to Conform to Chapters 714 and 942 of the 2020 Acts of Assembly	Final	Stage complete. This regulation became effective on 08/06/2020.
Amend Regulations to Conform to Ch. 433 of the 2019 Acts of Assembly	Fast-Track	Stage complete. This regulation became effective on 04/15/2021.
Amend Regulations to Conform to Chapters 136, 343, 670 and 671 of 2019 Acts of Assembly	Final	Stage complete. This regulation became effective on 08/23/2019.
Amend Regulations to Conform to Chapters 271 and 682 of the 2018 Acts of Assembly	Final	Stage complete. This regulation became effective on 07/10/2019.
Amend Regulations to Conform to Chapters 454, 565, 571 and 791 of 2018	Final	Stage complete. This regulation became effective on 11/14/2018.
Amend Regulations to Conform to Provisions of HB1777 of 2017 Session	Final	Stage complete. This regulation became effective on 02/21/2018.
Amend regulations to reflect legislative changes concerning patient discharge planning	Final	Stage complete. This regulation became effective on 04/08/2016.
Update the Regulations to reflect a CMS issued final rule enabling hospitals that are part of a hospital system to have a unified integrated medical staff	Fast-Track	Stage complete. This regulation became effective on 04/22/2016.
Update the Regulations to reflect a CMS-issued final rule enabling dietitians in the hospital setting to order therapeutic diets	Fast-Track	Stage complete. This regulation became effective on 01/14/2016.
Regulations for Licensure of Abortion Facilities	Final	Stage complete. This regulation became effective on 06/20/2013.
Hospital Policies Required	Final	Stage complete. This regulation became effective on 11/01/2011.
Required offer to mothers of newborns of a blood sample for future DNA sampling	Final	Stage complete. This regulation became effective on 11/01/2011.
Update of Hospital Building/Construction regulations	Final	Stage complete. This regulation became effective on 07/15/2010.
Repeal of sections in 12 VAC 5-410 with promulgation of a new regulation, 12 VAC 5-411	NOIRA	Stage withdrawn on 09/05/2014 after the comment period had ended.
Hospital visitor policies	Final	Stage complete. This regulation became effective on 02/04/2008.
Adoption of amendments defining	Fast-Track	Stage complete. This regulation became effective on 05/09/2005.
Breast milk amendment; reformatting	Fast-Track	Stage complete. This regulation became effective on 02/14/2005.
Adoption of APA-Article II-exempt, non-discretionary regulatory amendments	Final	Stage complete. This regulation became effective on 11/01/2002.
Amend in accordance with emergency provision of 1999 law.	Final	Stage complete. This regulation became effective on 02/28/2002.
Exempt action to require conformance of organ donor routine contact protocols with federal law.	Final	Stage complete. This regulation became effective on 10/27/2000.

Action Title	Latest Stage	Status
Withdrawn Actions
Amend Regulations to Require Establisment of Policies to Follow when a Stillbirth Occurs	NOIRA	Stage withdrawn on 04/07/2022 after the comment period had ended.
Perioperative Nurse Requirement	Fast-Track	Stage withdrawn on 10/24/2005 after submission to the Registrar.

Last Activity	Status
Periodic Reviews
12/5/2022 Agency Completed	Amend
10/3/2007 Agency Completed	Amend