A. The minimum service volume of a mobile unit shall be prorated on a site-by-site basis reflecting the amount of time that proposed mobile units will be used, and existing mobile units have been used, during the relevant reporting period, at each site using the following formula:

Required full-time minimum service volume

X

Number of days the service will be on site each week

X 0.2 =

Prorated minimum services volume (not to exceed the required full-time minimum service volume) ]

B. [ This section does not prohibit an applicant from seeking to obtain a COPN for a fixed site service provided capacity for the service has been achieved as described in the applicable service section The average annual utilization of existing and approved CT, MRI, PET, lithotripsy, and catheterization services in a health planning district shall be calculated for such services as follows:

(

Total volume of all units of the relevant service in the reporting period

)

X

100

=

% Average Utilization

(

# of existing or approved fixed units

X

Fixed unit minimum service volume

)

+

Y Utilization

Y = the sum of the minimum service volume of each mobile site in the health planning district with the minimum services volume for each such site prorated according to subsection A of this section.

C. This section does not prohibit an applicant from seeking to obtain a COPN for a fixed site service provided capacity for the services has been achieved as described in the applicable service section. ]

D. Applicants shall not use this section to justify a need to establish new services.

12VAC5-230-80. Institutional need When institutional expansion needed.

A. Notwithstanding any other provisions of this chapter, consideration will be given to the commissioner may grant approval for the expansion of services at an existing medical care facilities facility in a [ health ] planning districts district with an excess supply of such services when the proposed expansion can be justified on the basis of facility-specific utilization a facility's need having exceeded its current service capacity to provide such service or on the geographic remoteness of the facility.

B. If a facility with an institutional need to expand is part of a network health system, the underutilized services at other facilities within the network should be relocated health system should be reallocated, when appropriate, to the facility within the planning district with the institutional need when possible to expand before additional services are approved for the applicant. However, underutilized services located at a health system's geographically remote facility may be disregarded when determining institutional need for the proposed project.

C. This section is not applicable to nursing facilities pursuant to § 32.1-102.3:2 of the Code of Virginia.

12VAC5-230-90. Compliance with the terms of a condition.

A. The commissioner may condition the approval of a COPN to provide care to Virginia's indigent population, patients with specialized needs, or the medically underserved.

B. The applicant shall actively seek to provide opportunities to offer the conditioned service directly to indigent or uninsured persons at a reduced rate or free of charge to patients with specialized needs, or by the facilitation of primary care services in designated medically underserved areas.

C. If the direct provision of the conditioned services does not fulfill the terms of the condition, the center may determine the applicant to be in compliance with the terms of the condition when:

1. The applicant is part of a facility or provider network and the facility or provider network has provided reduced rate or uncompensated care at or above the regional standard; or

2. The applicant provides direct financial support for community based health care services at a value equal to or greater than the difference between the terms of the condition and the amount of direct care provided.

Such direct financial support shall be in addition to, and not a substitute for, other charitable giving chosen by the applicant.

D. Acceptable proof for direct financial support is a signed receipt indicating the number or amount of services or other support provided and dollar value of that service or support. Applicants providing direct financial support for community based health care services should render that support through one of the following organizations:

1. The Virginia Association of Free Clinics;

2. The Virginia Health Care Foundation; or

3. The Virginia Primary Care Association.

E. Applicants shall demonstrate compliance with the terms of a condition for the previous 12-month period. The written condition report shall be certified or affirmed by the applicants and filed with the center. Such report shall include, but is not limited to, the:

1. Facility or service name and address;

2. Certificate number;

3. Facility or service gross patient revenues;

4. Dollar value of the charity care provided, excluding bad debts and disallowances from payers; and

5. Number of individuals served by the direct provision of care or a receipt from one of the allowable organizations listed in subsection D of this section.

Part II
Diagnostic Imaging Services

Article 1
Criteria and Standards for Computed Tomography

12VAC5-230-100. Accessibility 12VAC5-230-90. Travel time.

CT services should be within 30 minutes driving time one way, under normal conditions, of 95% of the population of the [ health ] planning district [ using a mapping software as determined by the commissioner ].

12VAC5-230-110 12VAC5-230-100. Need for new fixed site [ or mobile ] service.

A. No CT service should be approved at a location that is within 30 minutes driving time one way of:

1. A service that is not yet operational; or

2. An existing CT unit that has performed fewer than 3,000 scans during the relevant reporting period.

B. A. No new fixed site [ or mobile ] CT service or network shall should be approved unless all existing fixed site CT services or networks in the [ health ] planning district performed an average of 4,500 CT scans per machine during the relevant reporting period. [ 10,000 7,400 ] procedures per existing and approved CT scanner during the relevant reporting period and the proposed new service would not significantly reduce the utilization of existing [ fixed site ] providers in the [ health ] planning district [ below 10,000 procedures ]. The utilization of existing scanners operated by a hospital and serving an area distinct from the proposed new service site may be disregarded in computing the average utilization of CT scanners in such [ health ] planning district.

C. Consideration may be given to new CT services proposed for sites located beyond 30 minutes driving time one way of existing facilities that do not meet the 4,500 scans per machine criterion if the proposed sites are in rural areas B. [ Existing ] CT scanners [ to be ] used solely for simulation with radiation therapy treatment shall be exempt from [ the utilization criteria of ] this article [ when applying for a COPN. In addition, existing CT scanners used solely for simulation with radiation therapy treatment may be disregarded in computing the average utilization of CT scanners in such health planning district ].

12VAC5-230-120 12VAC5-230-110. Expansion of existing fixed site service.

Proposals to increase the number of CT scanners in expand an existing medical care facility's CT service or network may through the addition of a CT scanner should be approved only if when the existing service or network services performed an average of 3,000 CT scans [ 10,000 7,400 ] procedures per scanner for the relevant reporting period. The commissioner may authorize placement of a new unit at the applicant's existing medical care facility or at a separate location within the applicant's primary service area for CT services, provided the proposed expansion is not likely to significantly reduce the utilization of existing providers in the [ health ] planning district [ below 10,000 procedures ].

12VAC5-230-120. Adding or expanding mobile CT services.

A. Proposals for mobile CT scanners shall demonstrate that, for the relevant reporting period, at least 4,800 procedures were performed and that the proposed mobile unit will not significantly reduce the utilization of existing CT providers in the [ health ] planning district [ below 10,000 procedures for fixed site scanners or 4,800 procedures for mobile scanners ].

B. Proposals to convert [ authorized ] mobile CT scanners to fixed site scanners shall demonstrate that, for the relevant reporting period, at least 6,000 procedures were performed [ by the mobile scanner ] and that the proposed conversion will not significantly reduce the utilization of existing CT providers in the [ health ] planning district [ below 10,000 procedures for fixed site scanners or 4,800 procedures for mobile scanners ].

12VAC5-230-130. Staffing.

Providers of CT services should be under the direct supervision of one or more board-certified diagnostic radiologists direction or supervision of one or more qualified physicians.

12VAC5-230-140. Space.

Applicants shall provide documentation that:

1. A suitable environment will be provided for the proposed CT services, including protection against known hazards; and

2. Space will be provided for patient waiting, patient preparation, staff and patient bathrooms, staff activities, storage of records and supplies, and other space necessary to accommodate the needs of handicapped persons.

Article 2
Criteria and Standards for Magnetic Resonance Imaging

12VAC5-230-150. Accessibility. 12VAC5-230-140. Travel time.

MRI services should be within 30 minutes driving time one way, under normal conditions, of 95% of the population of the [ health ] planning district [ using a mapping software as determined by the commissioner ].

Article 2
Criteria and Standards for Magnetic Resonance Imaging

12VAC5-230-160 12VAC5-230-150. Need for new fixed site service.

A. No new fixed site MRI services shall should be approved unless all existing fixed site MRI services in the [ health ] planning district performed an average of 4,000 scans per machine 5,000 procedures per existing and approved fixed site MRI scanner during the relevant reporting period and the proposed new service would not significantly reduce the utilization of existing fixed site MRI providers in the [ health ] planning district [ below 5,000 procedures ]. The utilization of existing scanners operated by a hospital and serving an area distinct from the proposed new service site may be disregarded in computing the average utilization of MRI scanners in such [ health ] planning district.

B. Consideration may be given to new MRI services proposed for sites located beyond 30 minutes driving time one way of existing facilities that do not meet the 4,000 scans per machine criterion of the prospered sites are in rural areas.

12VAC5-230-170 12VAC5-230-160. Expansion of services fixed site service.

Proposals to expand an existing medical care facility's MRI services through the addition of a new scanning unit of an MRI scanner may be approved if when the existing service performed at least 4,000 scans an average of 5,000 MRI procedures per existing unit scanner during the relevant reporting period. The commissioner may authorize placement of the new unit at the applicant's existing medical care facility, or at a separate location within the applicant's primary service area for MRI services, provided the proposed expansion is not likely to significantly reduce the utilization of existing providers in the [ health ] planning district [ below 5,000 procedures ].

12VAC5-230-170. Adding or expanding mobile MRI services.

A. Proposals for mobile MRI scanners shall demonstrate that, for the relevant reporting period, at least 2,400 procedures were performed and that the proposed mobile unit will not significantly reduce the utilization of existing MRI providers in the [ health ] planning district [ below 2,400 procedures for mobile scanners ].

B. Proposals to convert [ authorized ] mobile MRI scanners to fixed site scanners shall demonstrate that, for the relevant reporting period, 3,000 procedures were performed [ by the mobile scanner ] and that the proposed conversion will not significantly reduce the utilization of existing MRI providers in the [ health ] planning district [ below 5,000 procedures for fixed site scanners and 2,400 procedures for mobile scanners ].

12VAC5-230-180. Staffing.

MRI machines services should be under the direct, on-site supervision of one or more board-certified diagnostic radiologists direct supervision of one or more qualified physicians.

12VAC5-230-190. Space.

Applicants should provide documentation that:

1. A suitable environment will be provided for the proposed MRI services, including shielding and protection against known hazards; and

2. Space will be provided for patient waiting, patient preparation, staff and patient bathrooms, staff activities, storage of records and supplies, and other space necessary to accommodate the needs of handicapped persons.

Article 3
Magnetic Source Imaging

12VAC5-230-200 12VAC5-230-190. Policy for the development of MSI services.

Because Magnetic Source Imaging (MSI) scanning systems are still in the clinical research stage of development with no third-party payment available for clinical applications, and because it is uncertain as to how rapidly this technology will reach a point where it is shown to be clinically suitable for widespread use and distribution on a cost-effective basis, it is preferred that the entry and development of this technology in Virginia should initially occur at or in affiliation with, the academic medical centers in the state.

Article 4
Positron Emission Tomography

12VAC5-230-210 12VAC5-230-200. Accessibility Travel time.

The service area for each proposed PET service shall be an entire planning district PET services should be within 60 minutes driving time one way under normal conditions of 95% of the [ health ] planning district [ using a mapping software as determined by the commissioner ].

Article 4
Positron Emission Tomography

12VAC5-230-220 12VAC5-230-210. Need for new fixed site service.

A. Whether the applicant is a consortium of hospitals, a hospital network, or a single general hospital, at least 850 new PET appropriate cases should have been diagnosed in the planning district. If the applicant is a hospital, whether free-standing or within a hospital system, 850 new PET appropriate cases shall have been diagnosed and the hospital shall have provided radiation therapy services with specific ancillary services suitable for the equipment before a new fixed site PET service should be approved for the [ health ] planning district.

B. If the applicant is a general hospital, the facility shall provide radiation therapy services and specific ancillary services suitable for the equipment, and have reported at least 500 new courses of treatment or at least 8,000 treatment visits in the most recent reporting period No new fixed site PET services should be approved unless an average of 6,000 procedures [ preexisting per existing ] and approved fixed site PET scanner were performed in the [ health ] planning district during the relevant reporting period and the proposed new service would not significantly reduce the utilization of existing fixed site PET providers in the [ health ] planning district [ below 6,000 procedures ]. The utilization of existing scanners operated by a hospital and serving an area distinct from the proposed new service site may be disregarded in computing the average utilization of PET units in such [ panning health planning ] district.

Note: For the purposes of tracking volume utilization, an image taken with a PET/CT scanner that takes concurrent PET/CT images shall be counted as one PET procedure. Images made with PET/CT scanners that can take PET or CT images independently shall be counted as individual PET procedures and CT procedures respectively, unless those images are made concurrently.

C. If the applicant is a consortium of general hospitals or a hospital network, at least one of the consortium or network members shall provide radiation therapy services and specific ancillary services suitable for the equipment, and have reported at least 500 new PET appropriate patients.

D. Future applications of PET equipment shall be evaluated based on review of national literature.

12VAC5-230-230. Additional scanners. 12VAC5-230-220. Expansion of fixed site services.

No additional PET scanners shall be added in a planning district unless the applicant can demonstrate that the utilization of the existing PET service was at least 1,200 PET scans for a fixed site unit and that the proposed new or expanded service would not reduce the utilization after for existing services below 850 PET scans for a fixed site unit. The applicant shall also provide documentation that he project complies with 12VAC50-230-240. Proposals to increase the number of PET scanners in an existing PET service should be approved only when the existing scanners performed an average of 6,000 procedures for the relevant reporting period and the proposed expansion would not significantly reduce the utilization of existing fixed site providers in the [ health ] planning district [ below 6,000 procedures ].

12VAC5-230-230. Adding or expanding mobile PET or PET/CT services.

A. Proposals for mobile PET or PET/CT scanners [ shall should ] demonstrate that, for the relevant reporting period, at least 230 [ procedures were performed PET or PET/CT appropriate patients were seen ] and that the proposed mobile unit will not significantly reduce the utilization of existing providers in the [ health ] planning district [ below 6,000 procedures for the fixed site PET providers or 230 procedures for the mobile PET providers ].

B. Proposals to convert [ authorized ] mobile PET or PET/CT scanners to fixed site scanners should demonstrate that, for the relevant reporting period, at least 1,400 procedures were performed [ by the mobile scanner ] and that the proposed conversion will not significantly reduce the utilization of existing providers in the [ health ] planning district [ below 6,000 procedures for the fixed site PET or 230 procedures of the mobile PET providers ].

12VAC5-230-240. Staffing.

PET services should be under the direction of a physician who is a board certified radiologist or supervision of one or more qualified physicians. Such physician physicians shall be a designated [ or ] authorized user [ users of isotopes used for PET ] by the Nuclear Regulatory Commission or licensed by the Office Division of Radiologic Health of the Virginia Department of Health, as applicable.

Article 5
Noncardiac Nuclear Imaging Criteria and Standards

12VAC5-230-250. Accessibility Travel time.

Noncardiac nuclear imaging services should be available within 30 minutes driving time one way, under normal driving conditions, of 95% of the population of the [ health ] planning district [ using a mapping software as determined by the commissioner ].

12VAC5-230-260. Introduction of a service Need for new service.

Any applicant proposing to establish a medical care facility for the provision of noncardiac nuclear imaging, or introducing nuclear imaging as a new service at an existing medical care facility, shall provide documentation that No new noncardiac imaging services should be approved unless the service can achieve a minimum utilization level of:

(i) 650 scans 1. 650 procedures in the first 12 months of operation, ;

(ii) 1,000 scans 2. 1,000 procedures in the second 12 months of services, and (iii) 1,250 scans service in the second 12 months of operation service; and

3. The proposed new service would not significantly reduce the utilization of existing providers in the [ health ] planning district.

Note: The utilization of an existing service operated by a hospital and serving an area distinct from the proposed new service site may be disregarded in computing the average utilization of noncardiac nuclear imaging services in such [ health ] planning district.

12VAC5-230-270. Staffing.

The proposed new or expanded noncardiac nuclear imaging service shall should be under the direction of a board certified physician or supervision of one or more qualified physicians a designated [ or ] authorized user [ users of isotopes licensed ] by the Nuclear Regulatory Commission or the Office Division of Radiologic Health of the Virginia Department of Health, as applicable.

Part III
Radiation Therapy Services

Article 1
Radiation Therapy Services

12VAC5-230-280. Accessibility Travel time.

Radiation therapy services should be available within 60 minutes driving time one way, under normal conditions, for of 95% of the population of the [ health ] planning district [ using a mapping software as determined by the commissioner ].

12VAC5-230-290. Availability Need for new service.

A. No new radiation therapy service [ shall should ] be approved unless:

(i) existing 1. Existing radiation therapy machines located in the [ health ] planning district were used for at least 320 cancer cases and at least performed an average of 8,000 [ treatment visits procedures per existing and approved radiation therapy machine ] for in the relevant reporting period; and

(ii) it can be reasonably projected that the 2. The new service will perform at least 6,000 5,000 procedures by the third second year of operation without significantly reducing the utilization of existing radiation therapy machines within 60 minutes drive time one way, under normal conditions, such that less than 8,000 procedures will be performed by an existing machine providers in the [ health ] planning district.

B. The number of radiation therapy machines needed in a primary service area [ health ] planning district will be determined as follows:

	Population x Cancer Incidence Rate x 60%
	320

where:

1. The population is projected to be at least 75,000 150,000 people three years from the current year as reported in the most current projections of the Virginia Employment Commission a demographic entity as determined by the commissioner;

2. The "cancer incidence rate" is based on as determined by data from the Statewide Cancer Registry;

3. 60% is the estimated number of new cancer cases in a [ health ] planning district that are treatable with radiation therapy; and

4. 320 is 100% utilization of a radiation therapy machine based upon an anticipated average of 25 [ treatment visits procedures ] per case.

C. Consideration will be given to the approval of Proposals for new radiation therapy services located at a general hospital at least less than 60 minutes driving time one way, under normal conditions, from any site that radiation therapy services are available if the applicant can shall demonstrate that the proposed new services will perform at least an average of 4,500 [ treatment ] procedures annually by the second year of operation, without significantly reducing the utilization of existing machines located within 60 minutes driving time one way, under normal conditions, from the proposed new service location [ providers services ] in the [ health ] planning [ region district ].

D. Proposals for the expansion of radiation therapy services should not be approved unless all existing radiation therapy machines operated by the applicant in the planning district have performed at least 8,000 procedures for the relevant reporting period.

12VAC5-230-300. Statewide Cancer Registry Expansion of service.

Facilities with radiation therapy services shall participate in the Statewide Cancer Registry as required by Article 9 (§ 32.1-70 et seq.) of Chapter 2 of Title 32.1 of the Code of Virginia

Proposals to [ increase expand ] radiation therapy services should be approved only when all existing radiation therapy [ machines services ] operated by the applicant in the [ health ] planning district have performed an average of 8,000 procedures for the relevant reporting period and the proposed expansion would not significantly reduce the utilization of existing providers [ below 8,000 procedures ].

12VAC5-230-310. Staffing Statewide Cancer Registry.

Radiation therapy services shall be under the direction of a physician board-certified in radiation oncology Facilities with radiation therapy services shall participate in the Statewide Cancer Registry as required by Article 9 (§ 32.1-70 et seq.) of Chapter 2 of Title 32.1 of the Code of Virginia.

12VAC5-230-320. Equipment, patient care; support services Staffing.

In addition to the radiation therapy machine, the service should have direct access to:

1. Simulation equipment capable of precisely producing the geometric relations of the equipment to be used for treatment of the patient;

2. A computerized treatment planning system;

3. A custom block design and cutting system; and

4. Diagnostic, laboratory oncology services

Radiation therapy services should be under the direction or supervision of one or more qualified physicians [ . Such physicians shall be ] designated [ or ] authorized [ users of isotopes licensed ] by the Nuclear Regulatory Commission or the Division of Radiologic Health of the Virginia Department of Health, as applicable.

Article 2
Criteria and Standards for Stereotactic Radiosurgery

12VAC5-230-330. Availability; need for new service Travel time.

No new services should be approved unless (i) the number of procedures performed with existing units in the planning region average more than 350 per year and (ii) it can be reasonably projected that the proposed new service will perform at least 250 procedures in the second year of operation without reducing patient volumes to existing providers to less than 350 procedures Stereotactic radiosurgery services should be available within 60 minutes driving time one way under normal conditions of 95% of the population of a [ health ] planning [ district region using a mapping software as determined by the commissioner ].

12VAC5-230-340. Statewide Cancer Registry Need for new service.

Facilities shall participate in the Statewide Cancer Registry as required by Article 9 (§ 32.1-70 et seq.) of Chapter 2 of Title 32.1 of the Code of Virginia.

A. No new stereotactic radiosurgery services should be approved unless:

1. The number of procedures performed with existing units in the [ health ] planning region averaged more than 350 per year [ in the relevant reporting period ]; and

2. The proposed new service will perform at least 250 procedures in the second year of operation without significantly reducing the utilization of existing providers in the [ health ] planning region [ below 350 treatments ].

B. [ Consideration Preference ] may be given to a [ project that incorporates ] tereotactic radiosurgery service incorporated within an existing standard radiation therapy service using a linear accelerator when an average of 8,000 [ treatments procedures ] during the relevant reporting period [ were performed and the applicant can demonstrate that the volume and cost of the service is justified and utilization of existing services in the health planning region will not be significantly reduced ].

C. [ Consideration Preference ] may be given to a [ project that incorporates a ] dedicated Gamma Knife® [ incorporated ] within an existing radiation therapy service when:

1. At least 350 Gamma Knife® appropriate cases were referred out of the region in the relevant reporting period; and

2. The applicant can demonstrate that:

a. An average of 250 procedures will be preformed in the second year of operation; [ and ]

b. Utilization of existing services in the [ health ] planning region will not be significantly reduced [ below 350 treatments per year; and. ]

[ c. The cost is justified. ]

D. [ Consideration Preference ] may be given to [ a project that incorporates ] non-Gamma Knife® [ SRS ] technology [ incorporated ] within an existing radiation therapy service when:

1. The unit is not part of a linear accelerator;

2. An average of 8,000 radiation [ treatments procedures ] per year were performed by the existing radiation therapy services;

3. At least 250 procedures will be performed within the second year of operation; and

4. Utilization of existing services in the [ health ] planning region will not be significantly reduced [ below 350 treatments ].

12VAC5-230-350. Staffing Expansion of service.

The proposed new or expanded stereotactic radiosurgery services shall be under the direction of a physician who is board-certified in neurosurgery and a radiation oncologist with training in stereotactic radiosurgery

Proposals to increase the number of stereotactic radiosurgery services should be approved only when all existing stereotactic radiosurgery machines in the [ health ] planning region have performed an average of 350 procedures [ per existing and approved unit ] for the relevant reporting period and the proposed expansion would not significantly reduce the utilization of existing providers in the [ health ] planning region [ below 350 procedures ].

Part IV
Cardiac Services

Article 1
Criteria and Standards for Cardiac Catheterization Services

12VAC5-230-360. Accessibility Statewide Cancer Registry.

Adult cardiac catheterization services should be accessible within 60 minutes driving time one way, under normal conditions, for 95% of the population of the planning district Facilities [ with stereotactic radiosurgery services ] shall participate in the Statewide Cancer Registry as required by Article 9 (§ 32.1-70 et seq.) of Chapter 2 of Title 32.1 of the Code of Virginia.

12VAC5-230-370. Availability Staffing.

A. No new fixed site cardiac catheterization laboratory should be approved unless:

1. All existing fixed site cardiac catheterization laboratories located in the planning district were used for at least 960 diagnostic-equivalent cardiac catheterization procedures for the relevant reporting period; and

2. It can be reasonably projected that the proposed new service will perform at least 200 diagnostic equivalent procedures in the first year of operation, 500 diagnostic equivalent procedures in the second year of operation without reducing the utilization of existing laboratories in the planning district to less than 960 diagnostic equivalent procedures at any of those existing laboratories.

B. Proposals for the use of freestanding or mobile cardiac catheterization laboratories shall be approved only if such laboratories will be provided at a site located on the campus of a general or community hospital. Additionally, applicants for proposed mobile cardiac catheterization laboratories shall be able to project that they will perform 200 diagnostic equivalent procedures in the first year of operation, 350 diagnostic equivalent procedures in the second year of operation without reducing the utilization of existing laboratories in the planning district to less than 960 diagnostic equivalent procedures at any of those existing laboratories.

C. Consideration may be given for the approval of new cardiac catheterization services located at a general hospital located 60 minutes or more driving time one way, under normal conditions, from existing laboratories, if it can be projected that the proposed new laboratory will perform at least 200 diagnostic-equivalent procedures in the first year of operation, 400 diagnostic-equivalent procedures in the second year of operation without reducing the utilization of existing laboratories located within 60 minutes driving time one way, under normal conditions, of the proposed new service location.

D. Proposals for the addition of cardiac catheterization laboratories shall not be approved unless all existing cardiac catheterization laboratories operated in the planning district by the applicant have performed at least 1,200 diagnostic-equivalent procedures for the relevant reporting period, and the applicant can demonstrate that the expanded service will achieve a minimum of 200 diagnostic equivalent procedures per laboratory in the first 12 months of operation, 400 diagnostic equivalent procedures in the second 12 months of operation without reducing the utilization of existing cardiac catheterization laboratories in the planning district below 960 diagnostic equivalent procedures.

E. Emergency cardiac catheterization services shall be available within 30 minutes of admission to the facility.

F. No new or expanded pediatric cardiac catheterization services should be approved unless the proposed service will be provided at a hospital that:

1. Provides open heart surgery services, provides pediatric tertiary care services, has a pediatric intensive care unit and provides neonatal special care or has a cardiac intensive care unit and provides pediatric open heart surgery services; and

2. The applicant can demonstrate that each proposed laboratory will perform at least 100 pediatric cardiac catheterization procedures in the first year of operation and 200 pediatric cardiac catheterization procedures in the second year of operation.

G. Applications for new or expanded cardiac catheterization services that include nonemergent interventional cardiology services should not be approved unless emergency open heart surgery services are available within 15 minutes drive time in the hospital where the proposed cardiac catheterization service will be located.

Stereotactic radiosurgery services should be under the direction or supervision of one or more qualified physicians.

Part IV
Cardiac Services

Article 1
Criteria and Standards for Cardiac Catheterization Services

12VAC5-230-380. Staffing Travel time.

A. Cardiac catheterization services should have a medical director who is board-certified in cardiology and clinical experience in the performing physiologic and angiographic procedures.

In the case of pediatric cardiac catheterization services, the medical director should be board-certified in pediatric cardiology and have clinical experience in performing physiologic and angiographic procedures.

B. All physicians who will be performing cardiac catheterization procedures should be board-certified or board-eligible in cardiology and clinical experience in performing physiologic and angiographic procedures.

In the case of pediatric catheterization services, each physician performing pediatric procedures should be board-certified or board-eligible in pediatric cardiology, and have clinical experience in performing physiologic and angiographic procedures.

C. All anesthesia services should be provided by or supervised by a board-certified anesthesiologist.

In the case of pediatric catheterization services, the anesthesiologist should be experienced and trained in pediatric anesthesiology.

Cardiac catheterization services should be within 60 minutes driving time one way under normal conditions of 95% of the population of the [ health ] planning district [ using mapping software as determined by the commissioner ].

Article 2
Criteria and Standards for Open Heart Surgery

12VAC5-230-390. Accessibility Need for new service.

Open heart surgery services should be available 24 hours per day 7 days per week and accessible within a 60 minutes driving time one way, under normal conditions, for 95% of the population of the planning district.

A. No new fixed site cardiac catheterization [ laboratory service ] should be approved for a [ health ] planning district unless:

1. Existing fixed site cardiac catheterization [ laboratories services ] located in the [ health ] planning district performed an average of 1,200 cardiac catheterization DEPs [ per existing and approved laboratory ] for the relevant reporting period; [ and ]

2. The proposed new service will perform an average of 200 DEPs in the first year of operation and 500 DEPs in the second year of operation; and

3. The utilization of existing services in the [ health ] planning district will not be significantly reduced.

B. Proposals for mobile cardiac catheterization laboratories should be approved only if such laboratories will be provided at a site located on the campus of an inpatient hospital. Additionally, applicants for proposed mobile cardiac catheterization laboratories shall be able to project that they will perform an average of 200 DEPs in the first year of operation and 350 DEPs in the second year of operation without significantly reducing the utilization of existing laboratories in the [ health ] planning district below 1,200 procedures.

C. [ Consideration Preference ] may be given [ for to a project that locates ] new cardiac catheterization services [ located ] at an inpatient hospital that is 60 minutes or more driving time one way under normal conditions from existing [ laboratories services ] if the applicant can demonstrate that the proposed new laboratory will perform an average of 200 DEPs in the first year of operation and 400 DEPs in the second year of operation without significantly reducing the utilization of existing laboratories in the [ health ] planning district.

12VAC5-230-400. Availability Expansion of services.

A. No new open heart services should be approved unless:

1. The service will be made available in a general hospital with established cardiac catheterization services that have been used for at least 960 diagnostic equivalent procedures for the relevant reporting period and have been in operation for at least 30 months;

2. All existing open heart surgery rooms located in the planning district have been used for at least 400 open heart surgical procedures for the relevant reporting period; and

3. It can be reasonably projected that the proposed new service will perform at least 150 procedures per room in the first year of operation and 250 procedures per room in the second year of operation without reducing the utilization of existing open heart surgery programs in the planning district to less than 400 open heart procedures performed at those existing services.

B. Notwithstanding subsection A of this subsection, consideration will be given to the approval of new open heart surgery services located at a general hospital more than 60 minutes driving time one way, under normal conditions, from any site in which open heart surgery services are currently available if it can be projected that the proposed new service will perform at least 150 open heart procedures in the first year of operation; and 200 procedures in the second year of operation without reducing the utilization of existing open heart surgery rooms to less than 400 procedures per room within 2 hours driving time one way, under normal conditions, from the proposed new service location.

Such hospitals should also have provided at least 960 diagnostic-equivalent cardiac catheterization procedures during the relevant reporting period on equipment that has been in operation at least 30 months.

C. Proposals for the expansion of open heart surgery services should not be approved unless all existing open heart surgery rooms operated by the applicant have performed at least:

1. 400 adult-equivalent open heart surgery procedures in the relevant reporting period when the proposed facility is within two hours driving time one way, under normal conditions, of an existing open heart surgery service; or

2. 300 adult-equivalent open heart surgery procedures in the relevant reporting period when the applicant proposes expanding services in excess of two hours driving time, under normal conditions, of an existing open heart surgery service.

D. No new or expanded pediatric open heart surgery services should be approved unless the proposed new or expanded service is provided at a hospital that:

1. Has pediatric cardiac catheterization services that have been in operation for 30 months and have performed at least 200 pediatric cardiac catheterization procedures for the relevant reporting period; and

2. Has pediatric intensive care services and provides neonatal special care.

Proposals to increase cardiac catheterization services should be approved only when:

1. All existing cardiac catheterization laboratories operated by the applicant's facilities where the proposed expansion is to occur have performed an average of 1,200 DEPs [ per existing and approved laboratory ] for the relevant reporting period; and

2. The applicant can demonstrate that the expanded service will achieve an average of 200 DEPs per laboratory in the first 12 months of operation and 400 DEPs in the second 12 months of operation without significantly reducing the utilization of existing cardiac catheterization laboratories in the [ health ] planning district.

12VAC5-230-410. Staffing Pediatric cardiac catheterization.

A. Open heart surgery services should have a medical director certified by the American Board of Thoracic Surgery in cardiovascular surgery with special qualifications and experience in cardiac surgery.

In the case of pediatric open heart surgery, the medical director shall be certified by the American Board of Thoracic Surgery in cardiovascular surgery and experience in pediatric cardiovascular surgery and congenital heart disease.

B. All physicians performing open heart surgery procedures should be board-certified or board-eligible in cardiovascular surgery, with experience in cardiac surgery. In addition to the cardiovascular surgeon who performs the procedure, there should be a suitably trained board-certified or board-eligible cardiovascular surgeon acting as an assistant during the open heart surgical procedure. There should also be present at least one board-certified or board-eligible anesthesiologist with experience in open heart surgery.

In the case of pediatric open heart surgery services, each physician performing and assisting with pediatric procedures should be board-certified or board-eligible in cardiovascular surgery with experience in pediatric cardiovascular surgery. In addition to the cardiovascular surgeon who performs the procedure, there should be a suitably trained board-certified or board-eligible cardiovascular surgeon acting as an assistant during the open heart surgical procedure. All pediatric procedures should include a board-certified anesthesiologist with experience in pediatric anesthesiology and pediatric open heart surgery.

No new or expanded pediatric cardiac catheterization services should be approved unless:

1. The proposed service will be provided at an inpatient hospital with open heart surgery services, pediatric tertiary care services or specialty or subspecialty level neonatal special care;

2. The applicant can demonstrate that the proposed laboratory will perform at least 100 pediatric cardiac catheterization procedures in the first year of operation and 200 pediatric cardiac catheterization procedures in the second year of operation; and

3. The utilization of existing pediatric cardiac catheterization laboratories in the [ health ] planning district will not be reduced below 100 procedures per year.

Part V
General Surgical Services

12VAC5-230-420. Accessibility Nonemergent cardiac catheterization.

Surgical services should be available within 30 minutes driving time one way, under normal conditions, for 95% of the population of the planning district.

Proposals to provide elective interventional cardiac procedures such as PTCA, transseptal puncture, transthoracic left ventricle puncture, myocardial biopsy or any valvuoplasty procedures, diagnostic pericardiocentesis or therapeutic procedures should be approved only when open heart surgery services are available on-site in the same hospital in which the proposed non-emergent cardiac service will be located.

12VAC5-230-430. Availability Staffing.

A. The combined number of inpatient and outpatient general purpose surgical operating rooms needed in a planning district, exclusive of Level I and Level II Trauma Centers dedicated to the needs of the trauma service, dedicated cesarean section rooms, or operating rooms designated exclusively for open heart surgery, will be determined as follows:

FOR= ((ORV/POP) x (PROPOP)) x AHORV

1600

ORV = the sum of total operating room visits (inpatient and outpatient) in the planning district in the most recent five years for which operating room utilization data has been reported by Virginia Health Information; and

POP = the sum of total population in the planning district in the most recent five years for which operating room utilization data has been reported by Virginia Health Information, as found in the most current projections of the Virginia Employment Commission.

PROPOP = the projected population of the planning district five years from the current year as reported in the most current projections of the Virginia Employment Commission.

AHORV = the average hours per general purpose operating room visit in the planning district for the most recent year for which average hours per general purpose operating room visit has been calculated from information collected by Virginia Health Information.

FOR = future general purpose operating rooms needed in the planning district five years from the current year.

1600 = available service hours per operating room per year based on 80% utilization of an operating room that is available 40 hours per week, 50 weeks per year.

B. Projects involving the relocation of existing general purpose operating rooms within a planning district may be authorized when it can be reasonably documented that such relocation will improve the distribution of surgical services within a planning district by making services available within 30 minutes driving time one way, under normal conditions, of 95% of the planning district's population.

A. Cardiac catheterization services should have a medical director who is board certified in cardiology and has clinical experience in performing physiologic and angiographic procedures.

In the case of pediatric cardiac catheterization services, the medical director should be board-certified in pediatric cardiology and have clinical experience in performing physiologic and angiographic procedures.

B. Cardiac catheterization services should be under the direct supervision or one or more qualified physicians. Such physicians should have clinical experience in performing physiologic and angiographic procedures.

Pediatric catheterization services should be under the direct supervision of one or more qualified physicians. Such physicians should have clinical experience in performing pediatric physiologic and angiographic procedures.

Part VI
General Inpatient Services

Article 2
Criteria and Standards for Open Heart Surgery

12VAC5-230-440. Accessibility Travel time.

Acute care inpatient facility beds A. Open heart surgery services should be within 30 60 minutes driving time one way, under normal conditions, of 95% of the population of a the [ health ] planning district [ using mapping software as determined by the commissioner ].

B. Such services shall be available 24 hours a day, seven days a week.

12VAC5-230-450. Availability Need for new service.

A. Subject to the provisions of 12VAC5-230-80, no new inpatient beds should be approved in any planning district unless:

1. The resulting number of beds does not exceed the number of beds projected to be needed, for each inpatient bed category, for that planning district for the fifth planning horizon year;

2. The average annual occupancy, based on the number of beds, is at least 70% (midnight census) for the relevant reporting period; or

3. The intensive care bed capacity has an average annual occupancy of at least 65% for the relevant reporting period, based on the number of beds.

A. No new open heart services should be approved unless:

1. The service will be available in an inpatient hospital with an established cardiac catheterization service that has performed an average of 1,200 DEPs for the relevant reporting period and has been in operation for at least 30 months;

2. Open heart surgery [ programs services ] located in the [ health ] planning district performed an average of 400 open heart and closed heart surgical procedures for the relevant reporting period; and

3. The proposed new service will perform at least 150 procedures per room in the first year of operation and 250 procedures per room in the second year of operation without significantly reducing the utilization of existing open heart surgery [ programs services ] in the [ health ] planning district [ below 400 open and closed heart procedures ].

B. No proposal to replace or relocate inpatient beds to a location not contiguous to the existing site should be approved unless:

1. Off-site replacement is necessary to correct life safety or building code deficiencies;

2. The population currently served by the beds to be moved will have reasonable access to the beds at the new site, or to neighboring inpatient facilities;

3. The beds to be replaced experienced an average annual utilization of 70% (midnight census) for general inpatient beds and 65% for intensive care beds in the relevant reporting period;

4. The number of beds to be moved off site is taken out of service at the existing facility; and

5. The off-site replacement of beds results in: (i) a decrease in the licensed bed capacity; (ii) a substantial cost savings, cost avoidance, or consolidation of underutilized facilities; or (iii) generally improved operating efficiency in the applicant's facility or facilities.

B. [ Consideration Preference ] may be given to [ a project that locates ] new open heart surgery services [ located ] at an inpatient hospital more than 60 minutes driving time one way under normal condition from any site in which open heart surgery services are currently available [ when and ]:

1. The proposed new service will perform an average of 150 open heart procedures in the first year of operation and 200 procedures in the second year of operation without significantly reducing the utilization of existing open heart surgery rooms within two hours driving time one way under normal conditions from the proposed new service location below 400 procedures per room; and

2. The hospital provided an average of 1,200 cardiac catheterization DEPs during the relevant reporting period in a service that has been in operation at least 30 months.

C. For proposals involving a capital expenditure of $5 million or more, and involving the conversion of underutilized beds to medical/surgical, pediatric or intensive care, consideration will be given to a proposal if: (i) there is a projected need in the category of inpatient beds that would result from the conversion; and (ii) it can be demonstrated that the average annual occupancy of the beds to be converted would reach the standard in subdivisions B 1, 2 and 3 for the bed category that would result from the conversion, by the first year of operation.

D. In addition to the terms of 12VAC5-230-80, a need for additional general inpatient beds may be demonstrated if the total number of beds in a given category in the planning district is less than the number of such beds projected as necessary to meet demand in the fifth planning horizon year for which the application is submitted.

E. The number of medical/surgical beds projected to be needed in a planning district shall be computed as follows:

1. Determine the projected total number of medical/surgical and pediatric inpatient days for the fifth planning horizon year as follows:

a. Add the medical/surgical and pediatric inpatient days for the past three years for all acute care inpatient facilities in the planning district as reported in the Annual Survey of Hospitals;

b. Add the projected planning district population for the same three year period as reported by the Virginia Employment Commission;

c. Divide the total of the medical/surgical and pediatric inpatient days by the total of the population and express the resulting rate in days per 1,000 population;

d. Multiply the days per 1,000 population rate by the projected population for the planning district (expressed in thousands) for the fifth planning horizon year.

2. Determine the projected number of medical/surgical and pediatric beds that may be needed in the planning district for the planning horizon year as follows:

a. Divide the result in subdivision E 1 d of this subsection by 365;

b. Divide the quotient obtained by 0.80 in planning districts in which 50% or more of the population resides in nonrural areas or 0.75 in planning districts in which less than 50% of the population resides in nonrural areas.

3. Determine the projected number of medical/surgical and pediatric beds that may be established or relocated within the planning district for the fifth planning horizon year as follows:

a. Determine the number of medical/surgical and pediatric beds as reported in the inventory;

b. Subtract the number of beds identified in subdivision E 1 from the number of beds needed as determined in subdivision E 2 b of this subsection. If the difference indicated is positive, then a need may exist for additional medical/surgical or pediatric beds. If the difference is negative, then no need for additional beds exists.

F. The projected need for intensive care beds shall be computed as follows:

1. Determine the projected total number of intensive care inpatient days for the fifth planning horizon year as follows:

a. Add the intensive care inpatient days for the past three years for all inpatient facilities in the planning district as reported in the annual survey of hospitals;

b. Add the planning district's projected population for the same three-year period as reported by the Virginia Employment Commission;

c. Divide the total of the intensive care days by the total of the population to obtain the rate in days per 1,000 population;

d. Multiply the days per 1,000 population rate by the projected population for the planning district (expressed in thousands) for the fifth planning horizon year to yield the expected intensive care patient days.

2. Determine the projected number of intensive care beds that may be needed in the planning district for the planning horizon year as follows:

a. Divide the number of days projected in subdivision F 1 d of this subsection by 365 to yield the projected average daily census;

b. Calculate the beds needed to assure with 99% probability that an intensive care bed will be available for unscheduled admissions.

3. Determine the projected number of intensive care beds that may be established or relocated within the planning district for the fifth planning horizon year as follows:

a. Determine the number of intensive care beds as reported in the inventory.

b. Subtract the number of beds identified in subdivision F 3 a of this subsection from the number of beds needed as determined in subdivision F 2 b of this subsection. If the difference is positive, then a need may exist for additional intensive care beds. If the difference is negative, then no need for additional beds exists.

G. No hospital should relocate beds to a new location if underutilized beds (less than 85% average annual occupancy for medical/surgical and pediatric beds), when the relocation involves such beds, and less than 65% average annual occupancy for intensive care beds when relocation involves such beds, are available within 30 minutes of the site of the proposed hospital.

Part VII
Nursing Facilities

12VAC5-230-460. Accessibility Expansion of service.

A. Nursing facility beds should be accessible within 60 minutes driving time one way, under normal conditions, to 95% of the population in a planning region.

B. Nursing facilities should be accessible by public transportation when such systems exist in an area.

C. Preference will be given to proposals that improve geographic access and reduce travel time to nursing facilities within a planning district

Proposals to [ increase expand ] open heart surgery services shall demonstrate that existing open heart surgery rooms operated by the applicant have performed an average of:

1. 400 adult equivalent open heart surgery procedures in the relevant reporting period [ of if ] the proposed increase is within one hour driving time one way under normal conditions of an existing open heart surgery service, or

2. 300 adult equivalent open heart surgery procedures in the relevant reporting period if the proposed service is in excess of one hour driving time one way under normal conditions of an existing open heart surgery service in the [ health ] planning district.

12VAC5-230-470. Availability Pediatric open heart surgery services.

A. No planning district shall be considered to have a need for additional nursing facility beds unless (i) the bed need forecast in that planning district (see subsection D of this section) exceeds the current inventory of beds in that planning district and (ii) the estimated average annual occupancy of all existing Medicaid-certified nursing facility beds in the planning district was at least 93% for the most recent two years following the first year of operation of new beds, excluding the bed inventory and utilization of the Virginia Veterans Care Center.

B. No planning district shall be considered to have a need for additional beds if there are unconstructed beds designated as Medicaid-certified.

C. Proposals for expanding existing nursing facilities should not be approved unless the facility has operated for at least two years and the average annual occupancy of the facility's existing beds was at least 93% in the most recent year for which bed utilization has been reported to the department.

Exceptions will be considered for facilities that operated at less than 93% average annual occupancy in the most recent year for which bed utilization has been reported when the facility has a rehabilitative or other specialized care focus that results in a relatively short average length of stay, causing an average annual occupancy lower than 93% for the facility.

D. The bed need forecast will be computed as follows:

PDBN = (UR64 x PP64) + (UR69 x PP69) + (UR74 x PP74) + (UR79 x PP79) + (UR84 x PP84) + (UR85 x PP85) where:

PDBN = Planning district bed need.

UR64 = The nursing home bed use rate of the population aged 0 to 64 in the planning district as determined in the most recent nursing home patient origin study authorized by the department.

PP64 = The population aged 0 to 64 projected for the planning district three years from the current year as most recently published by the Virginia Employment Commission.

UR69 = The nursing home bed use rate of the population aged 65 to 69 in the planning district as determined in the most recent nursing home patient origin study authorized by the department.

PP69 = The population aged 65 to 69 projected for the planning district three years from the current year as most recently published by the Virginia Employment Commission.

UR74 = The nursing home bed use rate of the population aged 70 to 74 in the planning district as determined in the most recent nursing home patient origin study authorized by the department.

PP74 = The population aged 70 to 74 projected for the planning district three years from the current year as most recently published by the Virginia Employment Commission.

UR79 = The nursing home bed use rate of the population aged 75 to 79 in the planning district as determined in the most recent nursing home patient origin study authorized by the department.

PP79 = The population aged 75 to 79 projected for the planning district three years from the current year as most recently published by the Virginia Employment Commission.

UR84 = The nursing home bed use rate of the population aged 80 to 84 in the planning district as determined in the most recent nursing home patient origin study authorized by the department.

PP84 = The population aged 80 to 84 projected for the planning district three years from the current year as most recently published by the Virginia Employment Commission.

UR85+ = The nursing home bed use rate of the population aged 85 and older in the planning district as determined in the most recent nursing home patient origin study authorized by the department.

PP85+ = The population aged 85 and older projected for the planning district three years from the current year as most recently published by the Virginia Employment Commission.

Planning district bed need forecasts will be rounded as follows:

Planning District Bed Need	Rounded Bed Need
1-29	0
30-44	30
45-84	60
85-104	90
105-134	120
135-164	150
165-194	180
195-224	210
225+	240

The above applies, except in the case of a planning district that has two or more nursing facilities, has had an average annual occupancy rate in excess of 93% for the most recent two years for which bed utilization has been reported to the department, and has a forecasted bed need of 15 to 29 beds. In such a case, the bed need for this planning district will be rounded to 30.

E. No new freestanding nursing facilities of less than 90 beds should be authorized. Consideration will be given to new freestanding facilities with fewer than 90 nursing facility beds when such facilities can be justified on the basis of a lack of local demand for a larger facility and a maldistribution of nursing facility beds within a planning district.

F. Proposals for the development of new nursing facilities or the expansion of existing facilities by continuing care retirement communities will be considered when:

1. The total number of new or additional beds plus any existing nursing facility beds operated by the continuing care provider does not exceed 10% of the continuing care provider's total existing or planned independent living and adult care residence;

2. The proposed beds are necessary to meet existing or reasonably anticipated obligations to provide care to present or prospective residents of the continuing care facility;

3. The applicant agrees in writing not to seek certification for the use of such new or additional beds by persons eligible to receive Medicaid;

4. The applicant agrees in writing to obtain the resident's written acknowledgement, prior to admission, that the applicant does not serve Medicaid recipients and that, in the event such resident becomes a Medicaid recipient and is eligible for nursing facility placement, the resident will not be eligible for placement in the CCRC's nursing facility unit;

5. The applicant agrees in writing that only continuing care contract holders who have resided in the CCRC as independent living residents or adult care residents will be admitted to the nursing facility unit after the first three years of operation.

G. The construction cost of proposed nursing facilities should be comparable to the most recent cost for similar facilities in the same health planning region. Consideration should be given to the current capital cost reimbursement methodology utilized by the Department of Medical Assistance Services.

H. Consideration should be given to applicants proposing to replace outdated and functionally obsolete facilities with modern nursing facilities that will result in the more cost efficient delivery of health care services to residents in a more aesthetically pleasing and comfortable environment. Proponents of the replacement and relocation of nursing facility beds should demonstrate that the replacement and relocation are reasonable and could result in savings in other cost centers, such as realized operational economies of scale and lower maintenance costs.

No new [ or expanded ] pediatric open heart surgery service should be approved unless the proposed new [ or expended ] service is provided at an inpatient hospital that:

1. Has pediatric cardiac catheterization services that have been in operation for 30 months and have performed an average of 200 pediatric cardiac catheterization procedures for the relevant reporting period; and

2. Has pediatric intensive care services and provides specialty or subspecialty neonatal special care.

Part VIII
Lithotripsy Services

12VAC5-230-480. Accessibility Staffing.

A. The waiting time for lithotripsy services should be no more than one week Open heart surgery services should have a medical director who is board certified in cardiovascular or cardiothoracic surgery by the appropriate board of the American Board of Medical Specialists.

In the case of pediatric cardiac surgery, the medical director should be board certified in cardiovascular or cardiothoracic surgery, with special qualifications and experience in pediatric cardiac surgery and congenital heart disease, by the appropriate board of the American Board of Medical Specialists.

B. Lithotripsy services should be available within 30 minutes driving time in urban areas and 45 minutes driving time one way, under normal conditions, for 95% of the population of the health planning region Cardiac surgery should be under the direct supervision of one or more qualified physicians.

Pediatric cardiac surgery services should be under the direct supervision of one or more qualified physicians.

Part V
General Surgical Services

12VAC5-230-490. Availability Travel time.

A. Consideration will be given to new lithotripsy services established at a general hospital through contract with, or by lease of equipment from, an existing service provider authorized to operate in Virginia, provided the hospital has referred at least two patients per week, or 100 patients annually, for the relevant reporting period to other facilities for lithotripsy services.

B. A new service may be approved at the site of any general hospital or hospital-based clinic or licensed outpatient surgical hospital provided the service is provided by:

1. A vendor currently providing services in Virginia;

2. A vendor not currently providing services who can demonstrate that the proposed unit can provide at least 750 procedures annually at all sites served; or

3. An applicant who can demonstrate that the proposed unit can provide at least 750 procedures annually at all sites to be served.

C. Proposals for the expansion of services by existing vendors or providers of such services may be approved if it can be demonstrated that each existing unit owned or operated by that vendor or provider has provided a minimum of 750 procedures annually at all sites served by the vendor or provider.

D. A new or expanded lithotripsy service may be approved when the applicant is a consortium of hospitals or a hospital network, when a majority of procedures will be provided at sites or facilities owned or operated by the hospital consortium or by the hospital network.

Surgical services should be available within 30 minutes driving time one way under normal conditions for 95% of the population of the [ health ] planning district [ using mapping software as determined by the commissioner ].

Part IX
Organ Transplant

12VAC5-230-500. Accessibility Need for new service.

A. Organ transplantation services should be accessible within two hours driving time one way, under normal conditions, of 95% of Virginia's population. The combined number of inpatient and outpatient general purpose surgical operating rooms needed in a [ health ] planning district, exclusive of [ procedure rooms, ] dedicated cesarean section rooms, operating rooms designated exclusively for cardiac surgery, procedures rooms or VDH-designated trauma services, shall be determined as follows:

	FOR = ((ORV/POP) x (PROPOP)) x AHORV
	1600

Where:

ORV = the sum of total inpatient and outpatient general purpose operating room visits in the [ health ] planning district in the most recent [ three five ] years for which general purpose operating room utilization data has been reported by VHI; and

POP = the sum of total population in the [ health ] planning district as reported by a demographic entity as determined by the commissioner, for the same [ three year five-year ] period as used in determining ORV.

PROPOP = the projected population of the [ health ] planning district five years from the current year as reported by a demographic program as determined by the commissioner.

AHORV = the average hours per general purpose operating room visit in the [ health ] planning district for the most recent year for which average hours per general purpose operating room visits have been calculated as reported by VHI.

FOR = future general purpose operating rooms needed in the [ health ] planning district five years from the current year.

1600 = available service hours per operating room per year based on 80% utilization of an operating room available 40 hours per week, 50 weeks per year.

B. Providers of organ transplantation services should facilitate access to pre- and post-transplantation services needed by patients residing in rural locations by establishing part-time satellite clinics Projects involving the relocation of existing [ general purpose ] operating rooms within a [ health ] planning district may be authorized when it can be reasonably documented that such relocation will [ : (i) ] improve the distribution of surgical services within a [ health ] planning district by making services available within 30 minutes driving time one way under normal conditions of 95% of the planning district's population; (ii) result in the provision of the same surgical services at a lower cost to surgical patients in the health planning district; or (iii) optimize the number of operations in the health planning district that are performed on an outpatient basis ].

12VAC5-230-510. Availability Staffing.

A. There should be no more than one program for each transplantable organ in a health planning region.

B. Proposals to expand existing transplantation programs shall demonstrate that existing organ transplantation services comply with all applicable Medicare program coverage criteria. Surgical services should be under the direction or supervision of one or more qualified physicians.

Part VI
Inpatient Bed Requirements

12VAC5-230-520. Minimum utilization; minimum survival rate; service proficiency; systems operations Travel time.

A. Proposals to establish or expand organ transplantation services should demonstrate that the minimum number of transplants would be performed annually. The minimum number of transplants required by organ system is:

Kidney	30
Pancreas or kidney/pancreas	12
Heart	17
Heart/Lung	12
Lung	12
Liver	21
Intestine	2

Performance of minimum transplantation volumes does not indicate a need for additional transplantation capacity or programs.

B. Preference will be given to expansion of successful existing services, either by enabling necessary increases in the number of organ systems being transplanted or by adding transplantation capability for additional organ systems, rather than developing additional programs that could reduce average program volume.

C. Facilities should demonstrate that they will achieve and maintain minimum transplant patient survival rates. Minimum one-year survival rates, listed by organ system, are:

Kidney	95%
Pancreas or kidney/pancreas	90%
Heart	85%
Heart/Lung	60%
Lung	77%
Liver	86%
Intestine	77%

D. Proposals to add additional organ transplantation services should demonstrate at least two years successful experience with all existing organ transplantation systems.

E. All physicians that perform transplants should be board-certified by the appropriate professional examining board, and should have a minimum of one year of formal training and two years of experience in transplant surgery and post-operative care.

Inpatient beds should be within 30 minutes driving time one way under normal conditions of 95% of the population of a [ health ] planning district [ using a mapping software as determined by the commissioner ].

Part X
Miscellaneous Capital Expenditures

12VAC5-230-530. Purpose Need for new service.

This part of the SMFP is intended to provide general guidance in the review of projects that require COPN authorization by virtue of their expense but do not involve changes in the bed or service capacity of a medical care facility addressed elsewhere in this chapter. This part may be used in coordination with other parts of the SMFP addressing changes in bed or service capacity used in the COPN review process.

A. No new inpatient beds should be approved in any [ health ] planning district unless:

1. The resulting number of beds for each bed category contained in this article does not exceed the number of beds projected to be needed for that [ health ] planning district for the fifth planning horizon year; and

2. The average annual occupancy based on the number of beds in the [ health ] planning district for the relevant reporting period is:

a. 80% at midnight census for medical/surgical or pediatric beds;

b. 65% at midnight census for intensive care beds.

B. For proposals to convert under-utilized beds that require a capital expenditure of $15 million or more, consideration may be given to such proposal if:

1. There is a projected need in the applicable category of inpatient beds; and

2. The applicant can demonstrate that the average annual occupancy of the converted beds would meet the utilization standard for the applicable bed category by the first year of operation.

For the purposes of this part, "underutilized" means less than 80% average annual occupancy for medical/surgical or pediatric beds, when the relocation involves such beds and less than 65% average annual occupancy for intensive care beds when relocation involves such beds.

12VAC5-230-540. Project need Need for medical/surgical beds.

All applications involving the expenditure of $5 million dollars or more by a medical care facility should include documentation that the expenditure is necessary in order for the facility to meet the identified medical care needs of the public it serves. Such documentation should clearly identify that the expenditure:

1. Represents the most cost-effective approach to meeting the identified need; and

2. The ongoing operational costs will not result in unreasonable increases in the cost of delivering the services provided.

The number of medical/surgical beds projected to be needed in a [ health ] planning district shall be computed as follows:

1. Determine the use rate for the medical/surgical beds for the [ health ] planning district using the formula:

BUR = (IPD/PoP) x 1,000

Where:

BUR = the bed use rate for the [ health ] planning district.

IPD = the sum of total inpatient days in the [ health ] planning district for the most recent [ three five ] years for which inpatient day data has been reported by VHI; and

PoP = the sum of total population [ greater than ] 18 years of age [ and older ] in the [ health ] planning district for the same [ three five ] years used to determine IPD as reported by a demographic program as determined by the commissioner.

2. Determine the total number of medical/surgical beds needed for the [ health ] planning district in five years from the current year using the formula:

ProBed = ((BUR x ProPop)/365)/0.80

Where:

ProBed = The projected number of medical/surgical beds needed in the [ health ] planning district for five years from the current year.

BUR = the bed use rate for the [ health ] planning district determined in subdivision 1 of this section.

ProPop = the projected population [ greater than ] 18 years of age [ and older ] of the [ health ] planning district five years from the current year as reported by a demographic program as determined by the commissioner.

3. Determine the number of medical/surgical beds that are needed in the [ health ] planning district for the five planning horizon years as follows:

NewBed = ProBed – CurrentBed

Where:

NewBed = the number of new medical/surgical beds that can be established in a [ health ] planning district, if the number is positive. If NewBed is a negative number, no additional medical/surgical beds should be authorized for the [ health ] planning district.

ProBed = the projected number of medical/surgical beds needed in the [ health ] planning district for five years from the current year determined in subdivision 2 of this section.

CurrentBed = the current inventory of licensed and authorized medical/surgical beds in the [ health ] planning district.

12VAC5-230-550. Facilities expansion Need for pediatric beds.

Applications for the expansion of medical care facilities should document that the current space provided in the facility for the areas or departments proposed for expansion are inadequate. Such documentation should include:

1. An analysis of the historical volume of work activity or other activity performed in the area or department;

2. The projected volume of work activity or other activity to be performed in the area or department; and

3. Evidence that contemporary design guidelines for space in the relevant areas or departments, based on levels of work activity or other activity, are consistent with the proposal.

The number of pediatric beds projected to be needed in a [ health ] planning district shall be computed as follows:

1. Determine the use rate for pediatric beds for the [ health ] planning district using the formula:

PBUR = (PIPD/PedPop) x 1,000

Where:

PBUR = The pediatric bed use rate for the [ health ] planning district.

PIPD = The sum of total pediatric inpatient days in the [ health ] planning district for the most recent [ three five ] years for which inpatient days data has been reported by VHI; and

PedPop = The sum of population under [ 19 18 ] years of age in the [ health ] planning district for the same [ three five ] years used to determine PIPD as reported by a demographic program as determined by the commissioner.

2. Determine the total number of pediatric beds needed to the [ health ] planning district in five years from the current year using the formula:

ProPedBed = ((PBUR x ProPedPop)/365)/0.80

Where:

ProPedBed = The projected number of pediatric beds needed in the [ health ] planning district for five years from the current year.

PBUR = The pediatric bed use rate for the [ health ] planning district determined in subdivision 1 of this section.

ProPedPop = The projected population under [ 19 18 ] years of age of the [ health ] planning district five years from the current year as reported by a demographic program as determined by the commissioner.

3. Determine the number of pediatric beds needed within the [ health ] planning district for the fifth planning horizon year as follows:

NewPedBed – ProPedBed – CurrentPedBed

Where:

NewPedBed = the number of new pediatric beds that can be established in a [ health ] planning district, if the number is positive. If NewPedBed is a negative number, no additional pediatric beds should be authorized for the [ health ] planning district.

ProPedBed = the projected number of pediatric beds needed in the [ health ] planning district for five years from the current year determined in subdivision 2 of this section.

CurrentPedBed = the current inventory of licensed and authorized pediatric beds in the [ health ] planning district.

12VAC5-230-560. Renovation or modernization Need for intensive care beds.

A. Applications for the renovation or modernization of medical care facilities should provide documentation that:

1. The timing of the renovation or modernization expenditure is appropriate within the life cycle of the affected building or buildings; and

2. The benefits of the proposed renovation or modernization will exceed the costs of the renovation or modernization over the life cycle of the affected building or buildings to be renovated or modernized.

B. Such documentation should include a history of the affected building or buildings, including a chronology of major renovation and modernization expenses.

C. Applications for the general renovation or modernization of medical care facilities should include downsizing of beds or other service capacity when such capacity has not operated at a reasonable level of efficiency as identified in the relevant sections of this chapter during the most recent three-year period.

The projected need for intensive care beds in a [ health ] planning district shall be computed as follows:

1. Determine the use rate for ICU beds for the [ health ] planning district using the formula:

ICUBUR = (ICUPD/Pop) x 1,000

Where:

ICUBUR = The ICU bed use rate for the [ health ] planning district.

ICUPD = The sum of total ICU inpatient days in the [ health ] planning district for the most recent [ three five ] years for which inpatient day data has been reported by VHI; and

Pop = The sum of population [ greater than ] 18 years of age [ or older for adults or under 18 for pediatric patients ] in the [ health ] planning district for the same [ three five ] years used to determine ICUPD as reported by a demographic program as determined by the commissioner.

2. Determine the total number of ICU beds needed for the [ health ] planning district, including bed availability for unscheduled admissions, five years from the current year using the formula:

ProICUBed = ((ICUBUR x ProPop)/365)/0.65

Where:

ProICUBed = The projected number of ICU beds needed in the [ health ] planning district for five years from the current year;

ICUBUR = The ICU bed use rate for the [ health ] planning district as determine in subdivision 1 of this section;

ProPop = The projected population [ greater than ] 18 years of age [ or older for adults or under 18 for pediatric patients ] of the [ health ] planning district five years from the current year as reported by a demographic program as determined by the commissioner.

3. Determine the number of ICU beds that may be established or relocated within the [ health ] planning district for the fifth planning horizon planning year as follows:

NewICUB = ProICUBed – CurrentICUBed

Where:

NewICUBed = The number of new ICU beds that can be established in a [ health ] planning district, if the number is positive. If NewICUBed is a negative number, no additional ICU beds should be authorized for the [ health ] planning district.

ProICUBed = The projected number of ICU beds needed in the [ health ] planning district for five years from the current year as determined in subdivision 2 of this section.

CurrentICUBed = The current inventory of licensed and authorized ICU beds in the [ health ] planning district.

12VAC5-230-570. Equipment Expansion or relocation of services.

Applications for the purchase and installation of equipment by medical care facilities that are not addressed elsewhere in this chapter should document that the equipment is needed. Such documentation should clearly indicate that the (i) proposed equipment is needed to maintain the current level of service provided, or (ii) benefits of the change in service resulting from the new equipment exceed the costs of purchasing or leasing and operating the equipment over its useful life.

A. Proposals to relocate beds to a location not contiguous to the existing site should be approved only when:

1. Off-site replacement is necessary to correct life safety or building code deficiencies;

2. The population currently served by the beds to be moved will have reasonable access to the beds at the new site, or to neighboring inpatient facilities;

3. The number of beds to be moved off-site is taken out of service at the existing facility;

4. The off-site replacement of beds results in:

a. A decrease in the licensed bed capacity;

b. A substantial cost savings, cost avoidance, or consolidation of underutilized facilities; or

c. Generally improved operating efficiency in the applicant's facility or facilities; and

5. The relocation results in improved distribution of existing resources to meet community needs.

B. Proposals to relocate beds within a [ health ] planning district where underutilized beds are within 30 minutes driving time one way under normal conditions of the site of the proposed relocation should be approved only when the applicant can demonstrate that the proposed relocation will not materially harm existing providers.

Part XI
Medical Rehabilitation

12VAC5-230-580. Accessibility Long-term acute care hospitals (LTACHs).

Comprehensive inpatient rehabilitation services should be available within 60 minutes driving time one way, under normal conditions, of 95% of the population of the planning region.

A. LTACHs will not be considered as a separate category for planning or licensing purposes. All LTACH beds remain part of the inventory of inpatient hospital beds.

B. A LTACH shall only be approved if an existing hospital converts existing medical/surgical beds to LTACH beds or if there is an identified need for LTACH beds within a [ health ] planning district. New LTACH beds that would result in an increase in total licensed beds above 165% of the average daily census for the [ health ] planning district will not be approved. Excess inpatient beds within an applicant's existing acute care facilities must be converted to fill any unmet need for additional LTACH beds.

C. If an existing or host hospital converts existing beds for use as LTACH beds, those beds must be delicensed from the bed inventory of the existing hospital. If the LTACH ceases to exist, terminates its services, or does not offer services for a period of 12 months within its first year of operation, the beds delicensed by the host hospital to establish the LTACH shall revert back to that host hospital.

If the LTACH ceases operation in subsequent years of operation, the host hospital may reacquire the LTACH beds by obtaining a COPN, provided the beds are to be used exclusively for their original intended purpose and the application meets all other applicable project delivery requirements. Such an application shall not be subject to the standard batch review cycle and shall be processed as allowed under Part VI (12VAC5-220-280 et seq.) of the Virginia Medical Care Facilities Certificate of Public Need Rules and Regulations.

D. The application shall delineate the service area for the LTACH by documenting the expected areas from which it is expected to draw patients.

E. A LTACH shall be established for 10 or more beds.

F. A LTACH shall become certified by the Centers for Medicare and Medicaid Services (CMS) as a long-term acute care hospital and shall not convert to a hospital for patients needing a length of stay of less than 25 days without obtaining a certificate of public need.

1. If the LTACH fails to meet the CMS requirements as a LTACH within 12 months after beginning operation, it may apply for a six-month extension of its COPN.

2. If the LTACH fails to meet the CMS requirements as a LTACH within the extension period, then the COPN granted pursuant to this section shall expire automatically.

12VAC5-230-590. Availability Staffing.

A. The number of comprehensive and specialized rehabilitation beds needed in a health planning region will be projected as follows:

((UR x PROJ. POP.)/365)/.90

Where UR = the use rate expressed as rehabilitation patient days per population in the health planning region as reported in the most recent "Industry Report for Virginia Hospitals and Nursing Facilities" published by Virginia Health Information; and

PROJ.POP. = the most recent projected population of the health planning region three years from the current year as published by the Virginia Employment Commission.

B. No additional rehabilitation beds should be authorized for a health planning region in which existing rehabilitation beds were utilized at an average annual occupancy of less than 90% in the most recently reported year.

Preference will be given to the development of needed rehabilitation beds through the conversion of underutilized medical/surgical beds.

C. Notwithstanding subsection A of this section, the need for proposed inpatient rehabilitation beds will be given consideration when:

1. The rehabilitation specialty proposed is not currently offered in the health planning region; and

2. A documented basis for recognizing a need for the service or beds is provided by the applicant.

Inpatient services should be under the direction or supervision of one or more qualified physicians.

Part VII
Nursing Facilities

12VAC5-230-600. Staffing Travel time.

Medical rehabilitation facilities should have full-time medical direction by a physiatrist or other physician with a minimum of two years experience in the proposed specialized inpatient medical rehabilitation program.

A. Nursing facility beds should be accessible within 30 minutes driving time one way under normal conditions to 95% of the population in a [ health ] planning district [ using mapping software as determined by the commissioner ].

B. Nursing facilities should be accessible by public transportation when such systems exist in an area.

C. [ Consideration will Preference may ] be given to proposals that improve geographic access and reduce travel time to nursing facilities within a [ health ] planning district.

Part XII
Mental Health Services

Article 1
Psychiatric and Substance Abuse Disorder Treatment Services

12VAC5-230-610. Accessibility Need for new service.

A. Acute psychiatric, acute substance abuse disorder treatment services, and intermediate care substance abuse disorder treatment services should be available within 60 minutes driving time one way, under normal conditions, of 95% of the population.

B. Existing and proposed acute psychiatric, acute substance abuse disorder treatment, and intermediate care substance abuse disorder treatment service providers shall have established plans for the provision of services to indigent patients which include, at a minimum: (i) the minimum number of unreimbursed patient days to be provided to indigent patients who are not Medicaid recipients; (ii) the minimum number of Medicaid-reimbursed patient days to be provided, unless the existing or proposed facility is ineligible for Medicaid participation; (iii) the minimum number of unreimbursed patient days to be provided to local community services boards; and (iv) a description of the methods to be utilized in implementing the indigent patient service plan and assuring the provision of the projected levels of unreimbursed and Medicaid-reimbursed patient days.

C. Proposed acute psychiatric, acute substance abuse disorder treatment, and intermediate care substance abuse disorder treatment service providers shall have formal agreements with their identified community services boards that: (i) specify the number of charity care patient days that will be provided to the community service board; (ii) describe the mechanisms to monitor compliance with charity care provisions; (iii) provide for effective discharge planning for all patients, including return to the patients place of origin or home state if not Virginia; and (iv) consider admission priorities based on relative medical necessity.

D. Providers of acute psychiatric, acute substance abuse disorder treatment, and intermediate care substance abuse disorder treatment services serving large geographic areas should establish satellite outpatient facilities to improve patient access, where appropriate and feasible.

A. A [ health ] planning district should be considered to have a need for additional nursing facility beds when:

1. The bed need forecast exceeds the current inventory of beds for the [ health ] planning district; and

2. The average annual occupancy of all existing and authorized Medicaid-certified nursing facility beds in the [ health ] planning district was at least 93%, excluding the bed inventory and utilization of the Virginia Veterans Care Centers.

Exception: When there are facilities that have been in operation less than three years in the [ health ] planning district, their occupancy can be excluded from the calculation of average occupancy if the facilities [ has had ] an annual occupancy of at least 93% in one of its first three years of operation.

B. No [ health ] planning district should be considered in need of additional beds if there are unconstructed beds designated as Medicaid-certified. This presumption of ‘no need' for additional beds extends for three years [ or the date on the certificate, whichever is longer, for the unconstructed beds from the issuance date of the certificate ].

C. The bed need forecast will be computed as follows:

PDBN = (UR64 x PP64) + (UR69 x PP69) + (UR74 x PP74) + (UR79 x PP79) + (UR84 x PP84) + (UR85 x PP85)

Where:

PDBN = Planning district bed need.

UR64 = The nursing home bed use rate of the population aged 0 to 64 in the [ health ] planning district as determined in the most recent nursing home patient origin study authorized by VHI.

PP64 = The population aged 0 to 64 projected for the [ health ] planning district three years from the current year as most recently published by a demographic program as determined by the commissioner.

UR69 = The nursing home bed use rate of the population aged 65 to 69 in the [ health ] planning district as determined in the most recent nursing home patient origin study authorized by VHI.

PP69 = The population aged 65 to 69 projected for the [ health ] planning district three years from the current year as most recently published by the a demographic program as determined by the commissioner.

UR74 = The nursing home bed use rate of the population aged 70 to 74 in the [ health ] planning district as determined in the most recent nursing home patient origin study authorized by VHI.

PP74 = The population aged 70 to 74 projected for the [ health ] planning district three years from the current year as most recently published by a demographic program as determined by the commissioner.

UR79 = The nursing home bed use rate of the population aged 75 to 79 in the [ health ] planning district as determined in the most recent nursing home patient origin study authorized by VHI.

PP79 = The population aged 75 to 79 projected for the [ health ] planning district three years from the current year as most recently published by a demographic program as determined by the commissioner.

UR84 = The nursing home bed use rate of the population aged 80 to 84 in the [ health ] planning district as determined in the most recent nursing home patient origin study authorized by VHI.

PP84 = The population aged 80 to 84 projected for the [ health ] planning district three years from the current year as most recently published by a demographic program as determined by the commissioner.

UR85+ = The nursing home bed use rate of the population aged 85 and older in the [ health ] planning district as determined in the most recent nursing home patient origin study authorized by VHI.

PP85+ = The population aged 85 and older projected for the [ health ] planning district three years from the current year as most recently published by a demographic program as determined by the commissioner.

[ Planning Health planning ] district bed need forecasts will be rounded as follows:

[ Planning Health Planning ] District Bed Need	Rounded Bed Need
1-29	0
30-44	30
45-84	60
85-104	90
105-134	120
135-164	150
165-194	180
195-224	210
225+	240

Exception: When a [ health ] planning district has:

1. Two or more nursing facilities;

2. Had an average annual occupancy rate in excess of 93% for the most recent two years for which bed utilization has been reported to VHI; and

3. Has a forecasted bed need of 15 to 29 beds, then the bed need for this [ health ] planning district will be rounded to 30.

D. No new freestanding nursing facilities of less than 90 beds should be authorized. However, consideration may be given to a new freestanding facility with fewer than 90 nursing facility beds when the applicant can demonstrate that such a facility is justified based on a locality's preference for such smaller facility and there is a documented poor distribution of nursing facility beds within the [ health ] planning district.

E. When evaluating the [ capital ] cost of a project, consideration may be given to projects that use the current methodology as determined by the Department of Medical Assistance Services.

F. [ Consideration Preference ] may be given to [ proposals to projects that ] replace outdated and functionally obsolete facilities with modern facilities that result in the more cost-efficient resident services in a more aesthetically pleasing and comfortable environment.

12VAC5-230-620. Availability Expansion of services.

A. The combined number of acute psychiatric and acute substance abuse disorder treatment beds needed in a planning district with existing acute psychiatric or acute substance abuse disorder treatment beds or both will be determined as follows:

((UR x PROJ.POP.)/365)/.75

Where UR = the use rate of the planning district expressed as the average acute psychiatric and acute substance abuse disorder treatment patient days per population reported for the most recent five-year period; and

PROJ.POP. = the projected population of the planning district five years from the current year as reported in the most recent published projections of the Virginia Employment Commission.

For purposes of this methodology, no beds shall be included in the inventory of psychiatric or substance abuse disorder beds when these beds (i) are in facilities operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services; (ii) have been converted to other uses; (iii) have been vacant for six months or more; or (iv) are not currently staffed and cannot be staffed for acute psychiatric or substance abuse disorder patient admissions within 24 hours.

B. Subject to the provisions of 12VAC5-230-80, no additional acute psychiatric or acute substance abuse disorder treatment beds should be authorized for a planning district with existing acute psychiatric or acute substance abuse disorder treatment beds or both if the existing inventory of such beds is greater than the need identified using the above methodology.

However, consideration will be given to the addition of acute psychiatric or acute substance abuse disorder beds by existing medical care facilities in planning districts with an excess supply of beds when such additions can be justified on the basis of facility-specific utilization or geographic remoteness, i.e., driving time of 60 minutes or more, one way under normal conditions, to alternate acute care facilities. If the facility with the institutional need for beds is part of a hospital network, underutilized beds at the other facilities within the network should be relocated to the facility with the institutional need if possible.

C. No existing acute psychiatric or acute substance disorder abuse treatment beds should be relocated unless it can be reasonably projected that the relocation will not have a negative impact on the ability of existing acute psychiatric or substance abuse disorder treatment providers or both to continue to provide historic levels of service to Medicaid or other indigent patients.

D. The combined number of acute psychiatric and acute substance abuse disorder treatment beds needed in a planning district without existing acute psychiatric or acute substance abuse disorder treatment beds will be determined as follows:

((UR x PROJ.POP.)/365)/.80

Where UR = the use rate of the health planning region in which the planning district is located expressed as the average acute psychiatric and acute substance abuse disorder treatment patient days per population reported for the most recent five-year period;

PROJ.POP. = the projected population of the planning district five years from the current year as reported in the most recent published projections of the Virginia Employment Commission.

E. Preference will be given to the development of needed acute psychiatric and intermediate substance abuse disorder treatment beds through the conversion of unused general hospital beds. Preference will also be given to proposals for acute psychiatric and substance abuse beds demonstrating a willingness to accept persons under temporary detention orders (TDO) and to have contractual agreements to serve populations served by Community Services Boards, whether through conversion of underutilized general hospital beds or development of new beds.

F. The number of intermediate care substance disorder abuse treatment beds needed in a planning district with existing intermediate care substance abuse disorder treatment beds will be determined as follows:

((UR x PROJ.POP.)/365)/.75

Where UR = the use rate of the planning district expressed as the average intermediate care substance abuse disorder treatment patient days per population reported for the most recent three-year period; and

PROJ.POP. = the projected population of the planning district three years from the current year as reported in the most recent published projections of the Virginia Employment Commission.

G. Subject to the provisions of 12VAC5-230-80, no additional intermediate care substance abuse disorder treatment beds should be authorized for a planning district with existing intermediate care substance abuse disorder treatment beds if the existing inventory of such beds is greater than the need identified. No beds in facilities operated by DMHMRSAS will be included in the inventory of intermediate care substance abuse disorder beds.

However, consideration will be given to the addition of intermediate care substance abuse disorder treatment beds by existing medical care facilities in planning districts with an excess supply of beds when such addition can be justified on the basis of facility-specific utilization or geographic remoteness, i.e., driving time of 60 minutes or more one way under normal conditions, to alternate acute care facilities. If the facility with the institutional need for beds is part of a hospital network, underutilized beds at the other facilities within the network should be relocated to the facility with the institutional need if possible.

H. No existing intermediate care substance abuse disorder treatment beds should be relocated from one site to another unless it can be reasonably projected that the relocation will not have a negative impact on the ability of existing intermediate care substance abuse disorder treatment providers to continue to provide historic levels of service to indigent patients.

I. The number of intermediate care substance abuse disorder treatment beds needed in a planning district without existing intermediate care substance abuse disorder treatment beds will be determined as follows:

((UR x PROJ.POP.)/365)/.75

Where UR = the use rate of the health planning region in which the planning district is located expressed as the average intermediate care substance abuse disorder treatment patient days per population reported for the most recent three-year period;

PROJ.POP. = the projected population of the planning district three years from the current year as reported in the most recent published projections of the Virginia Employment Commission.

J. Preference will be given to the development of needed intermediate care substance abuse disorder treatment beds through the conversion of underutilized general hospital beds.

Proposals to increase existing nursing facility bed capacity should not be approved unless the facility has operated for at least two years and the average annual occupancy of the facility's existing beds was at least 93% in the relevant reporting period as reported to VHI.

Note: Exceptions will be considered for facilities that operated at less than 93% average annual occupancy in the most recent year for which bed utilization has been reported when the facility [ has a rehabilitative or other specialized care program causing a short average length of stay resulting in offers short stay services causing ] an average annual occupancy lower than 93% for the facility.

Article 2
Mental Retardation

12VAC5-230-630. Availability Continuing care retirement communities.

The establishment of new ICF/MR facilities should not be authorized unless the following conditions are met:

1. Alternatives to the proposed service are not available in the area to be served by the new facility;

2. There is a documented source of referrals for the proposed new facility;

3. The manner in which the proposed new facility fits into the continuum of care for the mentally retarded is identified;

4. There are distinct and unique geographic, socioeconomic, cultural, transportation, or other factors affecting access to care that require development of a new ICF/MR;

5. Alternatives to the development of a new ICF/MR consistent with the Medicaid waiver program have been considered and can be reasonably discounted in evaluating the need for the new facility.

6. The proposed new facility is consistent with the current DMHMRSAS Comprehensive Plan and the mental retardation service priorities for the catchment area identified in the plan;

7. Ancillary and supportive services needed for the new facility are available; and

8. Service alternatives for residents of the proposed new facility who are ready for discharge from the ICF/MR setting are available.

Proposals for the development of new nursing facilities or the expansion of existing facilities by continuing care retirement communities (CCRC) will be considered when:

[ 1. The facility is registered with the State Corporation Commission as a continuing care provider pursuant to Chapter 49 (§ 38.2-4900 et seq.) of Title 38.2 of the Code of Virginia; ]

[ 1. 2. ] The [ total ] number of [ new or additional beds plus any existing ] nursing facility beds [ operated by the continuing care provider does not exceed 20% of the continuing care provider's total existing or planned independent living and adult care residence requested in the initial application does not exceed the lesser of 20% of the continuing care retirement community's total number of beds that are not nursing home beds or 60 beds ];

[ 2. 3. ] The [ proposed beds are necessary to meet existing or reasonably anticipated obligations to provide care to present or prospective residents of the continuing care facility number of new nursing facility beds requested in any subsequent application does not cause the continuing care retirement community's total number of nursing home beds to exceed 20% of its total number of beds that are not nursing facility beds ]; and

[ 3. The applicant certifies that :

a. The CCRC has, or will have, a qualified resident assistance fund and that the facility will not rely on federal and state public assistance funds for reimbursement of the proposed beds;

b. The continuing care contract or disclosure statement, as required by § 38.2-4902 of the Code of Virginia, has been filed with the State Corporation Commission and that the commission has deemed the contract or disclosure statement in compliance with applicable law; and

c. Only continuing care contract holders residing in the CCRC as independent living residents or adult care residents or who is a family member of a contract holder residing in a non-nursing facility portion of the CCRC will be admitted to the nursing facility unit after the first three years of operation.

4. The continuing care retirement community has established a qualified resident assistance policy. ]

12VAC5-230-640. Continuity; integration Staffing.

Each facility should have a written transfer agreement with one or more hospitals for the transfer of emergency cases if such hospitalization becomes necessary. Nursing facilities shall be under the direction or supervision of a licensed nursing home administrator and staffed by licensed and certified nursing personnel qualified as required by law.

Part VIII
Lithotripsy Service

12VAC5-230-650. Acceptability Travel time.

Mental retardation facilities should meet all applicable licensure standards as specified in 12VAC35-105, Rules and Regulations of the Licensing of Providers of Mental Health, Mental Retardation and Substance Abuse Services. Lithotripsy services should be available within 30 minutes driving time one way under normal conditions for 95% of the population of the health planning region [ using mapping software as determined by the commissioner ].

Part XIII
Perinatal Services

Article 1
Criteria and Standards for Obstetrical Services

12VAC5-230-660. Accessibility Need for new service.

Obstetrical services should be located within 30 minutes driving time one way, under normal conditions, of 95% of the population in rural areas and within 30 minutes driving time one way, under normal conditions, in urban and suburban areas.

A. [ Consideration Preference ] may be given to [ a project that establishes ] new renal or orthopedic lithotripsy services [ established ] at a new facility through contract with, or by lease of equipment from, an existing service provider authorized to operate in Virginia, [ provided and ] the facility has referred at least two appropriate patients per week, or 100 appropriate patients annually, for the relevant reporting period to other facilities for either renal or orthopedic lithotripsy services.

B. A new renal lithotripsy service may be approved if the applicant can demonstrate that the proposed service can provide at least 750 renal lithotripsy procedures annually.

C. A new orthopedic lithotripsy service may be approved if the applicant can demonstrate that the proposed service can provide at least 500 orthopedic lithotripsy procedures annually.

12VAC5-230-670. Availability Expansion of services.

A. Proposals to establish new obstetrical services in rural areas should demonstrate that obstetrical volumes within the travel times listed in 12VAC5-230-660 will not be negatively affected.

B. Proposals to establish new obstetrical services in urban and suburban areas should demonstrate that a minimum of 2,500 deliveries will be performed annually by the second year of operation and that obstetrical volumes of existing providers located within the travel times listed in 12VAC5-230-660 will not be negatively affected.

C. Applications to improve existing obstetrical services, and to reduce costs through consolidation of two obstetrical services into a larger, more efficient service will be given preference over the addition of new services or the expansion of single service providers.

A. Proposals to [ increase expand ] renal lithotripsy services should demonstrate that each existing unit owned or operated by that vendor or provider has provided at least 750 procedures annually at all sites served by the vendor or provider.

B. Proposals to [ increase expand ] orthopedic lithotripsy services should demonstrate that each existing unit owned or operated by that vendor or provider has provided at least 500 procedures annually at all sites served by the vendor or provider.

12VAC5-230-680. Continuity Adding or expanding mobile lithotripsy services.

A. Perinatal service capacity should be developed and sized to provide routine newborn care to infants delivered in the associated obstetrics service, and shall have the capability to stabilize and prepare for transport those infants requiring the care of a neonatal special care services unit.

B. The application should identify the primary and secondary neonatal special care center nearest the proposed service and provide travel time one way, under normal conditions, to those centers.

A. Proposals for mobile lithotripsy services should demonstrate that, for the relevant reporting period, at least 125 procedures were performed and that the proposed mobile unit will not reduce the utilization of existing machines in the [ health ] planning region.

B. Proposals to convert a mobile lithotripsy service to a fixed site lithotripsy service should demonstrate that, for the relevant reporting period, at least 430 procedures were performed and the proposed conversion will not reduce the utilization of existing providers in the [ health ] planning district.

Article 2
Neonatal Special Care Services

12VAC5-230-690. Accessibility Staffing.

Neonatal special care services should be located within an average of 45 minutes driving time one way, under normal conditions, in urban and suburban areas of hospitals providing general-level newborn services. Lithotripsy services should be under the direction or supervision of one or more qualified physicians.

Part IX
Organ Transplant

12VAC5-230-700. Availability Travel time.

A. Existing neonatal special care units located within the travel times listed in 12VAC5-230-660 should achieve 65% average annual occupancy before new services can be added to the planning region Organ transplantation services should be accessible within two hours driving time one way under normal conditions of 95% of Virginia's population [ using mapping software as determined by the commissioner ].

B. Preference will be given to the expansion of existing services rather than the creation of new services Providers of organ transplantation services should facilitate access to pre and post transplantation services needed by patients residing in rural locations be establishing part-time satellite clinics.

12VAC5-230-710. Neonatal services Need for new service.

The application should identify the service area, levels of service, and capacity of the current general-level newborn service hospitals to be served within the identified area.

A. There should be no more than one program for each transplantable organ in a health planning region.

B. Performance of minimum transplantation volumes as cited in 12VAC5-230-720 does not indicate a need for additional transplantation capacity or programs.

12VAC5-230-720. Transplant volumes; survival rates; service proficiency; systems operations.

A. Proposals to establish organ transplantation services should demonstrate that the minimum number of transplants would be performed annually. The minimum number transplants of required by organ system is:

Kidney	30
Pancreas or kidney/pancreas	12
Heart	17
Heart/Lung	12
Lung	12
Liver	21
Intestine	2

Note: Any proposed pancreas transplant program must be a part of a kidney transplant program that has achieved a minimum volume standard of 30 cases per year for kidney transplants as well as the minimum transplant survival rates stated in subsection B of this section.

B. Applicants shall demonstrate that they will achieve and maintain at least the minimum transplant patient survival rates. Minimum one-year survival rates listed by organ system are:

Kidney	95%
Pancreas or kidney/pancreas	90%
Heart	85%
Heart/Lung	70%
Lung	77%
Liver	86%
Intestine	77%

12VAC5-230-730. Expansion of transplant services.

A. Proposals to [ increase expand ] organ transplantation services shall demonstrate at least two years successful experience with all existing organ transplantation systems at the hospital.

B. [ Consideration will Preference may ] be given to [ expanding successful existing services through increases in a project expanding ] the number of organ systems being transplanted [ at a successful existing service ] rather than developing new programs that could reduce existing program volumes.

12VAC5-230-740. Staffing.

Organ transplant services should be under the direct supervision of one or more qualified physicians.

Part X
Miscellaneous Capital Expenditures

12VAC5-230-750. Purpose.

This part of the SMFP is intended to provide general guidance in the review of projects that require COPN authorization by virtue of their expense but do not involve changes in the bed or service capacity of a medical care facility addressed elsewhere in this chapter. This part may be used in coordination with other service specific parts addressed elsewhere in this chapter.

12VAC5-230-760. Project need.

All applications involving the expenditure of $15 million or more by a medical care facility should include documentation that the expenditure is necessary in order for the facility to meet the identified medical care needs of the public it serves. Such documentation should clearly identify that the expenditure:

1. Represents the most cost-effective approach to meeting the identified need; and

2. The ongoing operational costs will not result in unreasonable increases in the cost of delivering the services provided.

12VAC5-230-770. Facilities expansion.

Applications for the expansion of medical care facilities should document that the current space provided in the facility for the areas or departments proposed for expansion is inadequate. Such documentation should include:

1. An analysis of the historical volume of work activity or other activity performed in the area or department;

2. The projected volume of work activity or other activity to be performed in the area or department; and

3. Evidence that contemporary design guidelines for space in the relevant areas or departments, based on levels of work activity or other activity, are consistent with the proposal.

12VAC5-230-780. Renovation or modernization.

A. Applications for the renovation or modernization of medical care facilities should provide documentation that:

1. The timing of the renovation or modernization expenditure is appropriate within the life cycle of the affected building or buildings; and

2. The benefits of the proposed renovation or modernization will exceed the costs of the renovation or modernization over the life cycle of the affected building or buildings to be renovated or modernized.

B. Such documentation should include a history of the affected building or buildings, including a chronology of major renovation and modernization expenses.

C. Applications for the general renovation or modernization of medical care facilities should include downsizing of beds or other service capacity when such capacity has not operated at a reasonable level of efficiency as identified in the relevant sections of this chapter during the most recent five-year period.

12VAC5-230-790. Equipment.

Applications for the purchase and installation of equipment by medical care facilities that are not addressed elsewhere in this chapter should document that the equipment is needed. Such documentation should clearly indicate that the (i) proposed equipment is needed to maintain the current level of service provided, or (ii) benefits of the change in service resulting from the new equipment exceed the costs of purchasing or leasing and operating the equipment over its useful life.

Part XI
Medical Rehabilitation

12VAC5-230-800. Travel time.

Medical rehabilitation services should be available within 60 minutes driving time one way under normal conditions of 95% of the population of the [ health ] planning district [ using mapping software as determined by the commissioner ].

12VAC5-230-810. Need for new service.

A. The number of comprehensive and specialized rehabilitation beds shall be determined as follows:

((UR x PROPOP)/365)/ [ .85 .80 ]

Where:

UR = the use rate expressed as rehabilitation patient days per population in the [ health ] planning district as reported by VHI; and

PROPOP = the most recent projected population of the [ health ] planning district five years from the current year as published by a demographic entity as determined by the commissioner.

B. Proposals for new medical rehabilitation beds should be considered when the applicant can demonstrate that:

1. The rehabilitation specialty proposed is not currently offered in the [ health ] planning district; and

2. There is a documented need for the service or beds in the [ health ] planning district.

12VAC5-230-820. Expansion of services.

No additional rehabilitation beds should be authorized for a [ health ] planning district in which existing rehabilitation beds were utilized with an average annual occupancy of less than [ 85% 80% ] in the most recently reported year.

[ Exception: Consideration Preference ] may be given to [ expanding a project to expand ] rehabilitation beds [ through the conversion of by converting ] underutilized medical/surgical beds.

12VAC5-230-830. Staffing.

Medical rehabilitation facilities should be under the direction or supervision of one or more qualified physicians.

Part XII
Mental Health Services

Article 1
Acute Psychiatric and Acute Substance Abuse Disorder Treatment Services

12VAC5-230-840. Travel time.

Acute psychiatric and acute substance abuse disorder treatment services should be available within 60 minutes driving time one way under normal conditions of 95% of the population [ using mapping software as determined by the commissioner ].

12VAC5-230-850. Continuity; integration.

A. Existing and proposed acute psychiatric and acute substance abuse disorder treatment providers shall have established plans for the provision of services to indigent patients that include:

1. The minimum number of unreimbursed patient days to be provided to indigent patients who are not Medicaid recipients;

2. The minimum number of Medicaid-reimbursed patient days to be provided, unless the existing or proposed facility is ineligible for Medicaid participation;

3. The minimum number of unreimbursed patient days to be provided to local community services boards; and

4. A description of the methods to be utilized in implementing the indigent patient service plan and assuring the provision of the projected levels of unreimbursed and Medicaid-reimbursed patient days.

B. Proposed acute psychiatric and acute substance abuse disorder treatment providers shall have formal agreements with the appropriate local community services boards or behavioral health authority that:

1. Specify the number of patient days that will be provided to the community service board;

2. Describe the mechanisms to monitor compliance with charity care provisions;

3. Provide for effective discharge planning for all patients, including return to the patient's place of origin or home state if not Virginia; and

4. Consider admission priorities based on relative medical necessity.

C. Providers of acute psychiatric and acute substance abuse disorder treatment serving large geographic areas should establish satellite outpatient facilities to improve patient access where appropriate and feasible.

12VAC5-230-860. Need for new service.

A. The combined number of acute psychiatric and acute substance abuse disorder treatment beds needed in a [ health ] planning district with existing acute psychiatric or acute substance abuse disorder treatment beds or both will be determined as follows:

((UR x PROPOP)/365)/.75

Where:

UR = the use rate of the [ health ] planning district expressed as the average acute psychiatric and acute substance abuse disorder treatment patient days per population reported for the most recent five-year period; and

PROPOP = the projected population of the [ health ] planning district five years from the current year as reported in the most recent published projections by a demographic entity as determined by the Commissioner of the Department of Mental Health, Mental Retardation and Substance Abuse Services.

For purposes of this methodology, no beds shall be included in the inventory of psychiatric or substance abuse disorder beds when these beds (i) are in facilities operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services; (ii) have been converted to other uses; (iii) have been vacant for six months or more; or (iv) are not currently staffed and cannot be staffed for acute psychiatric or substance abuse disorder patient admissions within 24 hours.

B. Subject to the provisions of 12VAC5-230-70, no additional acute psychiatric or acute substance abuse disorder treatment beds should be authorized for a [ health ] planning district with existing acute psychiatric or acute substance abuse disorder treatment beds or both if the existing inventory of such beds is greater than the need identified using the above methodology.

[ Consideration Preference ] may also be given to the addition of acute psychiatric or acute substance abuse beds dedicated for the treatment of geriatric patients in [ health ] planning districts with an excess supply of beds when such additions are justified on the basis of the specialized treatment needs of geriatric patients.

C. No existing acute psychiatric or acute substance disorder abuse treatment beds should be relocated unless it can be reasonably projected that the relocation will not have a negative impact on the ability of existing acute psychiatric or substance abuse disorder treatment providers or both to continue to provide historic levels of service to Medicaid or other indigent patients.

D. The combined number of acute psychiatric and acute substance abuse disorder treatment beds needed in a [ health ] planning district without existing acute psychiatric or acute substance abuse disorder treatment beds will be determined as follows:

((UR x PROPOP)/365)/.75

Where:

UR = the use rate of the health planning region in which the [ health ] planning district is located expressed as the average acute psychiatric and acute substance abuse disorder treatment patient days per population reported for the most recent five-year period;

PROPOP = the projected population of the [ health ] planning district five years from the current year as reported in the most recent published projections by a demographic entity as determined by the Commissioner of the Department of Mental Health, Mental Retardation and Substance Abuse Services.

E. Preference [ will may ] be given to the development of needed acute psychiatric beds through the conversion of unused general hospital beds. Preference will also be given to proposals for acute psychiatric and substance abuse beds demonstrating a willingness to accept persons under temporary detention orders (TDO) and that have contractual agreements to serve populations served by community services boards, whether through conversion of underutilized general hospital beds or development of new beds.

Article 2
Mental Retardation

12VAC5-230-870. Need for new service.

The establishment of new ICF/MR facilities with more than 12 beds shall not be authorized unless the following conditions are met:

1. Alternatives to the proposed service are not available in the area to be served by the new facility;

2. There is a documented source of referrals for the proposed new facility;

3. The manner in which the proposed new facility fits into the continuum of care for the mentally retarded is identified;

4. There are distinct and unique geographic, socioeconomic, cultural, transportation, or other factors affecting access to care that require development of a new ICF/MR;

5. Alternatives to the development of a new ICF/MR consistent with the Medicaid waiver program have been considered and can be reasonably discounted in evaluating the need for the new facility;

6. The proposed new facility will have a maximum of 20 beds and is consistent with any plan of the Department of Mental Health, Mental Retardation and Substance Abuse Sservices and the mental retardation service priorities for the catchment area identified in the plan;

7. Ancillary and supportive services needed for the new facility are available; and

8. Service alternatives for residents of the proposed new facility who are ready for discharge from the ICF/MR setting are available.

12VAC5-230-880. Continuity; integration.

Each facility should have a written transfer agreement with one or more hospitals for the transfer of emergency cases if such hospitalization becomes necessary.

12VAC5-230-890. Compliance with licensure standards.

Mental retardation facilities should meet all applicable licensure standards as specified in 12VAC35-105, Rules and Regulations for the Licensing of Providers of Mental Health, Mental Retardation and Substance Abuse Services.

Part XIII
Perinatal [ and Obstetrical ] Services

Article 1
Criteria and Standards for Obstetrical Services

12VAC5-230-900. Travel time.

Obstetrical services should be located within 30 minutes driving time one way under normal conditions of 95% of the population of the [ health ] planning district [ using mapping software as determined by the commissioner ].

12VAC5-230-910. Need for new service.

[ A. ] No new obstetrical services should be approved unless the applicant can demonstrate that, based on the population and utilization of current services, there is a need for such services in the [ health ] planning district without [ significantly ] reducing the utilization of existing providers in the [ panning health planning ] district.

[ B. Applications to improve existing obstetrical services, and to reduce costs through consolidation of two obstetrical services into a larger, more efficient service should be given preference over establishing new services or expanding single service providers. ]

12VAC5-230-920. Continuity.

A. Perinatal service capacity, including service availability for unscheduled admissions, should be developed to provide routine newborn care to infants delivered in the associated obstetrics service, and shall be able to stabilize and prepare for transport those infants requiring the care of a neonatal special care services unit.

B. The proposal shall identify the primary and secondary neonatal special care center nearest the proposed service shall provide transport one-way to those centers.

12VAC5-230-930. Staffing.

Obstetric services should be under the direction or supervision of one or more qualified physicians.

Article 2
Neonatal Special Care Services

12VAC5-230-940. Travel time.

A. Intermediate level neonatal special care services should be located within 30 minutes driving time one way under normal conditions of hospitals providing general level new born services [ using mapping software as determined by the commissioner ].

B. Specialty and subspecialty neonatal special care services should be located within 90 minutes driving time one way under normal conditions of hospitals providing general or intermediate level newborn services [ using mapping software as determined by the commissioner ].

12VAC5-230-950. Need for new service.

[ A. ] No new level of neonatal service shall be offered by a hospital unless that hospital has first obtained a COPN granting approval to provide each such level of service.

[ B. Preference will be given to the expansion of existing services, rather than to the creation of new services. ]

12VAC5-230-960. Intermediate level newborn services.

A. Existing [ neonatal special care units providing ] intermediate level newborn services as designated in 12VAC5-410-443 [ , located within 30 minutes driving time one way under normal conditions ] should achieve 85% average annual occupancy before new intermediate level newborn services can be added to the [ health ] planning region.

B. [ Neonatal special care units providing intermediate Intermediate ] level newborn services as designated in 12VAC5-410-443 should contain a minimum of six bassinets [ , stations or beds ].

C. No more than four bassinets [ , stations and beds ] for intermediate level newborn services as designated in 12VAC5-410-443 per 1,000 live births should be established in each [ health ] planning region [ , with a bassinet or station counting as the equivalent of one bed ].

12VAC5-230-970. Specialty level newborn services.

A. Existing [ neonatal special care units providing ] specialty level newborn services as designated in 12VAC5-410-443 [ located within 90 minutes driving time one way under normal conditions ] should achieve 85% average annual occupancy before new specialty level newborn services can be added to the [ health ] planning region.

B. [ Neonatal special care units providing specialty Specialty ] level newborn services as designated in 12VAC5-410-443 should contain a minimum of 18 bassinets [ , stations or beds. A station shall equal one bed ].

C. No more than four bassinets [ , stations and beds ] for specialty level newborn services as designated in 12VAC5-410-443 per 1,000 live births should be established in each [ health ] planning region [ , with a bassinet or station counting as the equivalent of one bed ].

D. Proposals to establish specialty level [ neonatal special care ] services as designated in 12VAC5-410-443 shall demonstrate that service volumes of existing specialty level [ neonatal special care newborn service ] providers located within the travel time listed in 12VAC5-230-940 will not be [ significantly ] reduced.

12VAC5-230-980. Subspecialty level newborn services.

A. Existing [ neonatal special care units providing ] subspecialty level newborn services as designated in 12VAC5-410-443 [ located within 90 minutes driving time one way under normal conditions ] should achieve 85% average annual occupancy before new subspecialty level newborn services can be added to the [ health ] planning region.

B. [ Neonatal special care units providing subspecialty Subspecialty ] level newborn services as designated in 12VAC5-410-443 should contain a minimum of 18 bassinets [ , stations or beds. A station shall equal one bed ].

C. No more than four bassinets [ , stations and beds ] for subspecialty level newborn services as designated in 12VAC5-410-443 per 1,000 live births should be established in each [ health ] planning region [ , with a bassinet or station counting as the equivalent of one bed ].

D. Proposals to establish subspecialty level [ neonatal special care newborn ] services as designated in 12VAC5-410-443 shall demonstrate that service volumes of existing subspecialty level [ neonatal special care newborn ] providers located within the travel time listed in 12VAC5-230-940 will not be [ significantly ] reduced.

12VAC5-230-990. Neonatal services.

The application shall identify the service area and the levels of service of all the hospitals to be served by the proposed service.

12VAC5-230-1000. Staffing.

All levels of neonatal special care services should be under the direction or supervision of one or more qualified physicians as described in 12VAC5-410-443.