Vol. 34 Iss. 11 - January 22, 2018

Chapter 410
Final Regulation

REGISTRAR'S NOTICE: The State Board of Health is claiming an exemption from Article 2 of the Administrative Process Act in accordance with § 2.2-4006 A 4 a of the Code of Virginia, which excludes regulations that are necessary to conform to changes in Virginia statutory law or the appropriation act where no agency discretion is involved. The State Board of Health will receive, consider, and respond to petitions by any interested person at any time with respect to reconsideration or revision.

Title of Regulation: 12VAC5-410. Regulations for the Licensure of Hospitals in Virginia (amending 12VAC5-410-450).

Statutory Authority: §§ 32.1-12, 32.1-123, and 32.1-127 of the Code of Virginia.

Effective Date: February 21, 2018.

Agency Contact: Domica Winstead, Policy Analyst, Office of Licensure and Certification, Virginia Department of Health, 9960 Mayland Drive, Suite 401, Richmond, VA 23233, telephone (804) 367-2157, FAX (804) 527-4502, or email


Pursuant to Chapter 175 of the 2017 Acts of Assembly, the amendments require that hospitals providing psychiatric services establish a written protocol for the refusal to admit medically stable patients referred for psychiatric care that addresses (i) direct verbal communication between the on-call psychiatric physician and the referring physician and (ii) prohibits on-call physicians or other hospital staff from refusing a request for direct verbal communication by a referring physician.

12VAC5-410-450. Psychiatric service.

A. The psychiatric service shall be under the supervision of a physician, licensed by the Board of Medicine, who meets the qualifications of the medical staff bylaws.

B. Psychiatric units shall conform to the applicable licensure requirements pursuant to 12VAC35-105.

C. Every hospital that provides inpatient psychiatric services shall establish written policies for denial of admission of medically stable patients in its psychiatric unit. The policies shall include language that:

1. If a medically stable patient is referred to a hospital's psychiatric unit and denied admission, the referring physician may request direct verbal communication with the on-call physician at the referral hospital; and

2. Prohibits on-call physicians or other hospital staff from refusing a request from the referring physician for direct verbal communication.

VA.R. Doc. No. R18-5385; Filed December 28, 2017, 11:05 a.m.