Title of Regulation: 18VAC85-140. Regulations Governing the Practice of Polysomnographic Technologists (adding 18VAC85-140-10 through 18VAC85-140-190).

Statutory Authority: §§ 54.1-2400 and 54.1-2957.15 of the Code of Virginia.

Public Hearing Information:

October 11, 2013 - 1 p.m. - 9960 Mayland Drive, Perimeter Center, 2nd Floor Conference Center, Richmond, VA

Public Comment Deadline: October 25, 2013.

Agency Contact: William L. Harp, M.D., Executive Director, Board of Medicine, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4558, FAX (804) 527-4429, or email william.harp@dhp.virginia.gov.

Basis: Regulations are promulgated under the general authority of § 54.1-2400 of the Code of Virginia, which provides the Board of Medicine the authority to promulgate regulations to administer the regulatory system and § 54.1-2957.14 of the Code of Virginia, which authorizes the board, along with the Advisory Board on Polysomnographic Technology, to regulate the profession of polysomnographic technologists.

Purpose: The goal of this action is to comply with the provisions of Chapter 838 of the 2010 Acts of Assembly for licensure of polysomnographers. The Board of Health Professions undertook a review of the need to regulate the profession resulting in a report recommending licensure. Applying established criteria for studying the need to regulate a profession, the Board of Health Professions concluded the following in its 2010 report:

1. The field of sleep medicine is a rapidly emerging discipline within medicine. In the past two decades, sleep medicine has grown from an obscure, multidisciplinary field pursued by neurologists, otolaryngologists, chest physicians, cardiothoracic physicians, psychiatrists, and other specialists to a recognized subspecialty. The American Medical Association recognized sleep medicine as a self-designated practice specialty in 1995, and in 2006 the American Board of Medical Specialties began certifying Sleep Medicine subspecialists in Family Medicine, Internal Medicine, Pediatrics, Otolaryngology, Psychiatry, and Neurology. The field of polysomnography (sleep medicine technology) has grown alongside sleep medicine. The Registered Polysomnographic Technologist (RPSGT) certification provides a nationally recognized credential for persons performing polysomnography. This credential is considered the gold-standard of credentials for sleep technicians by the American Academy of Sleep Medicine. The Board of Registered Polysomnographic Technologists (BRPT) registered eight polysomnographers in 1979. Today, there are over 13,000 registered polysomnographers.

2. Several professions perform polysomnography. In keeping with the history of sleep medicine, personnel with diverse backgrounds developed expertise in sleep medicine technology (polysomnography) including electroneurodiagnosticians, pulmonary function technologists, respiratory therapists, registered nurses, and polysomnographic technologists. Due to the variety of practitioners performing polysomnograms, it is difficult to estimate the number of persons performing polysomnography. Allowing for a great degree of uncertainty, staff roughly estimates that there may be up to 1,000 persons performing polysomnograms in Virginia. As of July 6, 2009, the BRPT website listed 293 RPSGTs with Virginia addresses.

3. Polysomnography is performed in diverse settings. As sleep medicine has developed, its practice has expanded from research facilities into hospitals and recently into independent diagnostic testing facilities. These facilities may be accredited by the American Academy of Sleep Medicine or the Joint Commission. Many advertised sleep clinics are not accredited. While performing a brief Internet search, staff identified 132 advertised sleep centers with independent addresses. Only 58 of these were accredited or associated with accredited facilities. Polysomnograms are usually performed at night. The delegating physician is usually only available by telephone contact.

4. Polysomnography shares only a few modalities with respiratory therapy; however, respiratory-related conditions account for the greater majority of diagnoses and treatment. Polysomnograms measure a minimum of 11 parameters, but often include many more. Only a few of these may be related to respiration, including oximetry, airflow, or capnography. Other measurements include eye movement, muscle movement, and brainwave measurements. Over 80 sleep disorders have been identified. Only a few of these are related to respiration, including sleep-related apneas. Other disorders include narcolepsy, restless leg syndrome, REM sleep behavior disorder, and insomnia. One study, supported by anecdotal evidence, suggests that up to 95% of conditions diagnosed at sleep centers are respiratory sleep disorders, predominately sleep apnea. Polysomnographers treat these disorders using respiratory care-related modalities, specifically positive airway pressure or low flow supplemental oxygen. Polysomnographers often implement these interventions following preliminary diagnoses made by the polysomnographer in prescribed split-night studies.

5. The unlicensed practice of polysomnography poses a risk of harm to patients. Several factors contribute to the risk of harm: (i) the Commonwealth of Virginia has previously determined that the unlicensed practice of respiratory care poses a risk of harm to consumers; (ii) patients are often alone with polysomnographers, and, as these patients are often asleep, are vulnerable to incompetence, negligence, or malfeasance on the part of polysomnographers; (iii) physicians rely on proper diagnostic tests performed by polysomnographers to diagnose sleep disorders, and improper testing may lead to improper diagnoses, diminishing the health and well-being of patients and possibly leading to further injury or death due to fatigue-related accidents that may also pose a risk to others; and (iv) in the form of prescribed split-night studies, physicians delegate the task of preliminary diagnoses and preliminary treatment of sleep apnea in high probability cases to polysomnographers.

In order to address the risk of harm to patients, regulations prescribe qualifications for minimal competency and standards for appropriate oversight of professional practice to protect the health and safety of patients being treated by polysomnographers.

Substance: Regulations specify (i) qualifications for licensure, including completion of an educational program and certification examination, (ii) criteria for license renewal and continued competency, (iii) requirements for supervision and professional practice, and (iv) fees for obtaining and maintaining licensure.

Issues: The primary advantage to the public is an expansion of physician extenders through the licensure and practice of polysomnographic technologists. Licensure will offer assurance of consistent education, training and minimum competency, and oversight by the Board of Medicine. There is no restriction on the current scope of practice of respiratory care practitioners, but there is an opportunity for a new profession with appropriate education and training. There are no disadvantages to the public. There are no advantages or disadvantages to the agency or the Commonwealth. The number of licensees is expected to be relatively small, and the disciplinary caseload expected to be minimal. Since these licensees will be regulated under the Board of Medicine and the Advisory Board on Polysomnographic Technology and will be licensed and disciplined with existing staff, there are few additional administrative costs for licensure.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. As mandated by Chapter 838 of the 2010 Acts of the Assembly, the Board of Medicine (Board) proposes to promulgate new regulations that will govern the licensure of individuals who, under the direction of a licensed physician, monitor, test and treat those suffering from sleep disorders. Physicians and respiratory care professionals who are already licensed by the Board and whose scope of practice already includes the field of sleep medicine will not have to be separately licensed as polysomnographic technologists.

Result of Analysis. There is insufficient information to ascertain whether benefits will outweigh costs for these proposed regulations.

Estimated Economic Impact. Prior to General Assembly action in 2010, there was no requirement that individuals who worked as technicians in sleep disorder clinics be licensed. Pursuant to this legislative mandate, the Board now proposes to promulgate new regulations that will govern the licensure of polysomnographic technologists. Individuals seeking licensure will have to complete a licensure application, pay the $130 application fee and submit both verification of completion of a Board acceptable credential and documentation of current certification in Basic Cardiac Life Support. The Board currently proposes to accept as acceptable credentials, 1) current certification as a Registered Polysomnographic Technologist from the Board of Registered Polysomnographic Technologists, 2) documentation of the Sleep Disorders Specialist credential from the National Board of Respiratory Care or 3) any other Board approved professional certification from an organization or entity which is a member of the National Organization of Competency Assurance.

After initial licensure, polysomnographic technologists will have to renew their active licenses every two years ($135 fee) at which time they will have to attest to having current certification in Basic Cardiac Life Support and to completing 20 hours of acceptable continuing education. Licensees who are late renewing their licenses but who renew within one additional renewal cycle (two years) will have to pay an additional $50 late renewal fee. Licensees who are more than two years late for renewal will have to pay a $180 reinstatement fee, which must be submitted with an application for reinstatement. Individuals who seek to reinstate a license after revocation will have to pay a fee of $2,000. Licensees who do not plan on practicing for a period of time will have the option of converting their license to inactive status and would have to pay only $70 biennially for renewal.

In addition to the fees listed above, individuals who seek to be licensed by the Board in this field will incur costs for required credentials. Currently the Board of Registered Polysomnographic Technologists has four paths to certification which range from completing 18 months of on-the-job training, completing an online 15 module self study course (this costs approximately $500) and passage of the RPSGT exam ($350 fee for exam and review of credentials) to graduation from a Commission on Accreditation of Allied Health Education Programs (CAAHEP) approved course of study (costs for this path would likely be at least several thousand dollars) and passage of the RPSGT exam. Although the Board will allow documentation of the Sleep Disorders Specialist credential from the National Board of Respiratory Care to count as a verification of competency for licensure, only individuals who already have a degree and licensure in respiratory care would be able to get this credential. Individuals who are already licensed as respiratory care professionals in the Commonwealth will not also be required to be licensed as polysomnographic technologists. Licensees will also incur costs for completing continuing education (fees for courses or seminars, possible travel expenses and the value of time spent completing the continuing education hours). There is insufficient information to ascertain whether the benefits that may accrue to the public in the form of increased safety or competency that may arise because of licensure will outweigh these costs.

Businesses and Entities Affected. The Department of Health Professions (DHP) reports the number of individuals that will be affected by these proposed regulations is unknown. In 2010, 293 individuals holding Registered Polysomnographic Technologists certification had Virginia mailing addresses but some of these are likely respiratory care professionals who would not need to obtain further licensure. Additionally, there are other individuals who do not currently hold any licensure who would need to be licensed to continue working in this field. DHP estimates that fewer than 300 people in the Commonwealth would qualify for licensure without further training and certification.

Localities Particularly Affected. No locality will be particularly affected by this proposed regulatory action.

Projected Impact on Employment. This proposed regulatory action is likely to cut the number of individuals who are eligible to work as technicians for hospitals and sleep disorder clinics.

Effects on the Use and Value of Private Property. These proposed regulatory changes may drive up the costs of acquiring sleep disorder technician services and, therefore, drive up the costs of running sleep disorder clinics.

Small Businesses: Costs and Other Effects. DHP reports that few or no small businesses will be affected by these proposed regulations.

Small Businesses: Alternative Method that Minimizes Adverse Impact. No DHP reports that few or no small businesses will be affected by these proposed regulations.

Real Estate Development Costs. This regulatory action will likely have no effect on real estate development costs in the Commonwealth.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the Board he economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 14 (10). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB's best estimate of these economic impacts.

Agency's Response to Economic Impact Analysis: The Board of Medicine concurs with the economic impact analysis on 18VAC85-140, proposed regulations for the licensure of polysomnographic technologists.

Summary:

As required by Chapter 838 of the 2010 Acts of Assembly, the Board of Medicine proposes regulations governing the licensure of individuals who, under the direction of a licensed physician, monitor, test, and treat those suffering from sleep disorders. The proposed regulations establish requirements for minimal competency for practice and continued competency for renewal of licensure, supervisory responsibilities, and standards of conduct for safe practice of polysomnographic technologists.

CHAPTER 140
REGULATIONS GOVERNING THE PRACTICE OF POLYSOMNOGRAPHIC TECHNOLOGISTS

Part I
General Provisions

18VAC85-140-10. Definitions.

A. The following word and term when used in this chapter shall have the meaning ascribed to it in § 54.1-2900 of the Code of Virginia:

"Board"

B. The following words and terms when used in this chapter shall have the meanings ascribed to them in § 54.1-2957.15 of the Code of Virginia:

"Polysomnographic technology"

"Practice of polysomnographic technology"

C. The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Active practice" means a minimum of 160 hours of professional practice as a polysomnographic technologist within the 24-month period immediately preceding application for reinstatement or reactivation of licensure. The active practice of polysomnographic technology may include supervisory, administrative, educational, or consultative activities or responsibilities for the delivery of such services.

"Advisory board" means the Advisory Board on Polysomnographic Technology to the Board of Medicine as specified in § 54.1-2957.14 of the Code of Virginia.

18VAC85-140-20. Public participation.

A separate board regulation, 18VAC85-11, provides for involvement of the public in the development of all regulations of the Virginia Board of Medicine.

18VAC85-140-30. Current name and address.

Each licensee shall furnish the board his current name and address of record. All notices required by law or by this chapter to be given by the board to any such licensee shall be validly given when mailed to the latest address of record provided or served to the licensee. Any change of name or change in the address of record or public address, if different from the address of record, shall be furnished to the board within 30 days of such change.

18VAC85-140-40. Fees.

The following fees are required:

1. The application fee, payable at the time the application is filed, shall be $130.

2. The biennial fee for renewal of active licensure shall be $135 and for renewal of inactive licensure shall be $70, payable in each odd-numbered year in the license holder's birth month.

3. The additional fee for late renewal of licensure within one renewal cycle shall be $50.

4. The fee for reinstatement of a license that has lapsed for a period of two years or more shall be $180 and must be submitted with an application for licensure reinstatement.

5. The fee for reinstatement of a license pursuant to § 54.1-2408.2 of the Code of Virginia shall be $2,000.

6. The fee for a duplicate license shall be $5.00, and the fee for a duplicate wall certificate shall be $15.

7. The fee for a returned check shall be $35.

8. The fee for a letter of good standing or verification to another jurisdiction shall be $10.

Part II
Requirements for Licensure as a Polysomnographic Technologist

18VAC85-140-50. Application requirements.

An applicant for licensure shall submit the following on forms provided by the board:

1. A completed application and a fee as prescribed in 18VAC85-140-40.

2. Verification of a professional credential in polysomnographic technology as required in 18VAC85-140-60.

3. Verification of practice as required on the application form.

4. If licensed or certified in any other jurisdiction, documentation of any disciplinary action taken or pending in that jurisdiction.

18VAC85-140-60. Licensure requirements.

A. An applicant for a license to practice as a polysomnographic technologist shall provide documentation of one of the following:

1. Current certification as a Registered Polysomnographic Technologist (RPSGT) by the Board of Registered Polysomnographic Technologists;

2. Documentation of the Sleep Disorders Specialist credential from the National Board of Respiratory Care (NBRC-SDS); or

3. A professional certification or credential approved by the board from an organization or entity that is a member of the National Organization for Competency Assurance.

B. An applicant for licensure shall provide documentation of current certification in Basic Cardiac Life Support with a hands-on practice training evaluation segment.

Part III
Renewal and Reinstatement

18VAC85-140-70. Renewal of license.

A. Every licensed polysomnographic technologist who intends to maintain an active license shall biennially renew his license each odd-numbered year during his birth month and shall:

1. Submit the prescribed renewal fee;

2. Attest to having current certification in Basic Cardiac Life Support (BCLS) with hands-on practice training evaluation segment; and

3. Attest to having met the continuing education requirements of 18VAC85-140-100.

B. The license of a polysomnographic technologist is lapsed if the license has not been renewed by the first day of the month following the month in which renewal is required. Practice with a lapsed license may be grounds for disciplinary action. A license that is lapsed for two years or less may be renewed by payment of the renewal fee and a late fee as prescribed in 18VAC85-140-40 and attestation of compliance with continuing education requirements and current BCLS certification.

18VAC85-140-80. Inactive license.

A licensed polysomnographic technologist who holds a current, unrestricted license in Virginia shall, upon a request at the time of renewal and submission of the required fee, be issued an inactive license. The holder of an inactive license shall not be entitled to perform any act requiring a license to practice polysomnographic technology in Virginia.

18VAC85-140-90. Reactivation or reinstatement.

A. To reactivate an inactive license or to reinstate a license that has been lapsed for more than two years, a polysomnographic technologist shall submit an attestation of current certification in Basic Cardiac Life Support (BCLS) with hands-on practice training evaluation segment and evidence of competency to return to active practice to include one of the following:

1. Information on continued active practice in another jurisdiction during the period in which the license has been inactive or lapsed;

2. Attestation of at least 10 hours of continuing education for each year in which the license has been inactive or lapsed, not to exceed three years; or

3. Recertification by passage of an examination for the Registered Polysomnographic Technologist (RPSGT), the Sleep Disorders Specialist credential from the National Board of Respiratory Care (NBRC-SDS), or other credential approved by the board for initial licensure.

B. To reactivate an inactive license, a polysomnographic technologist shall pay a fee equal to the difference between the current renewal fee for inactive licensure and the renewal fee for active licensure.

C. To reinstate a license that has been lapsed for more than two years, a polysomnographic technologist shall file an application for reinstatement and pay the fee for reinstatement of his licensure as prescribed in 18VAC85-140-40. The board may specify additional requirements for reinstatement of a license so lapsed to include education, experience, or reexamination.

D. A polysomnographic technologist whose licensure has been revoked by the board and who wishes to be reinstated shall make a new application to the board, fulfill additional requirements as specified in the order from the board, and make payment of the fee for reinstatement of his licensure as prescribed in 18VAC85-140-40 pursuant to § 54.1-2408.2 of the Code of Virginia.

E. The board reserves the right to deny a request for reactivation or reinstatement to any licensee who has been determined to have committed an act in violation of § 54.1-2915 of the Code of Virginia or any provisions of this chapter.

18VAC85-140-100. Continuing education requirements.

A. In order to renew an active license as a polysomnographic technologist, a licensee shall attest to having successfully completed 20 hours of continuing education in courses directly related to the practice of polysomnographic technology as approved and documented by a provider recognized by one of the following:

1. The Board of Registered Polysomnographic Technologists Education Advisory Board (BRPT-EAC);

2. The American Academy of Sleep Medicine (AASM);

3. The American Medical Association for Category 1 continuing medical education credit;

4. The American Association of Sleep Technologists (AAST);

5. The American Society of Electroneurodiagnostic Technologists, Inc. (ASET);

6. The American Association for Respiratory Care (AARC);

7. The American Nurses Association (ANA); or

8. The American College of Chest Physicians (ACCP).

B. A practitioner shall be exempt from the continuing education requirements for the first biennial renewal following the date of initial licensure in Virginia.

C. The practitioner shall retain the completed form with all supporting documentation in his records for a period of four years following the renewal of an active license.

D. The board shall periodically conduct a random audit of its active licensees to determine compliance. The practitioners selected for the audit shall provide all supporting documentation within 30 days of receiving notification of the audit.

E. Failure to comply with these requirements may subject the licensee to disciplinary action by the board.

F. The board may grant an extension of the deadline for continuing competency requirements, for up to one year, for good cause shown upon a written request from the licensee prior to the renewal date.

G. The board may grant an exemption for all or part of the requirements for circumstances beyond the control of the licensee, such as temporary disability, mandatory military service, or officially declared disasters.

Part IV
Scope of Practice

18VAC85-140-110. General responsibility.

A polysomnographic technologist shall engage in the practice of polysomnographic technology, as defined in § 54.1-2957.15 of the Code of Virginia, upon receipt of written or verbal orders from a qualified practitioner and under qualified medical direction. The practice of polysomnographic technology may include supervisory, administrative, educational, or consultative activities or responsibilities for the delivery of such services.

18VAC85-140-120. Supervisory responsibilities.

A. A polysomnographic technologist shall be responsible for supervision of unlicensed polysomnographic personnel who work under his direction and shall be ultimately responsible and accountable for patient care and outcomes under his clinical supervision.

B. Delegation to unlicensed polysomnographic personnel shall:

1. Not include delegation of the discretionary aspects of the initial assessment, evaluation, or development of a treatment plan for a patient nor shall it include any task requiring a clinical decision or the knowledge, skills, and judgment of a licensed polysomnographic technologist.

2. Only be made if, in the judgment of the polysomnographic technologist, the task or procedures do not require the exercise of professional judgment, can be properly and safely performed by appropriately trained unlicensed personnel, and the delegation does not jeopardize the health or safety of the patient.

3. Be communicated on a patient-specific basis with clear, specific instructions for performance of activities, potential complications, and expected results.

C. The frequency, methods, and content of supervision are dependent on the complexity of patient needs, number and diversity of patients, demonstrated competency and experience of the unlicensed personnel, and the type and requirements of the practice setting.

D. The polysomnographic technologist providing clinical supervision shall routinely meet with any unlicensed personnel to review and evaluate patient care and treatment.

E. The polysomnographic technologist shall review notes on patient care entered by unlicensed personnel prior to reporting study results to the supervising physician and shall, by some method, document in a patient record that such a review has occurred.

Part V
Standards of Professional Conduct

18VAC85-140-130. Confidentiality.

A practitioner shall not willfully or negligently breach the confidentiality between a practitioner and a patient. A breach of confidentiality that is required or permitted by applicable law or beyond the control of the practitioner shall not be considered negligent or willful.

18VAC85-140-140. Patient records.

A. A practitioner shall comply with the provisions of § 32.1-127.1:03 of the Code of Virginia related to the confidentiality and disclosure of patient records.

B. A practitioner shall provide patient records to another practitioner or to the patient or his personal representative in a timely manner in accordance with provisions of § 32.1-127.1:03 of the Code of Virginia.

C. A practitioner shall properly manage and keep timely, accurate, legible, and complete patient records.

D. A practitioner who is employed by a health care institution or other entity in which the individual practitioner does not own or maintain his own records shall maintain patient records in accordance with the policies and procedures of the employing entity.

E. A practitioner who is self-employed or employed by an entity in which the individual practitioner owns and is responsible for patient records shall:

1. Maintain a patient record for a minimum of six years following the last patient encounter with the following exceptions:

a. Records of a minor child, including immunizations, shall be maintained until the child reaches the age of 18 years or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child;

b. Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or

c. Records that are required by contractual obligation or federal law may need to be maintained for a longer period of time.

2. Post information or in some manner inform all patients concerning the time frame for record retention and destruction. Patient records shall only be destroyed in a manner that protects patient confidentiality, such as by incineration or shredding.

3. When closing, selling, or relocating his practice, meet the requirements of § 54.1-2405 of the Code of Virginia for giving notice that copies of records can be sent to any like-regulated provider of the patient's choice or provided to the patient.

18VAC85-140-150. Practitioner-patient communication; termination of relationship.

A. Communication with patients.

1. Except as provided in § 32.1-127.1:03 F of the Code of Virginia, a practitioner shall accurately present information to a patient or his legally authorized representative in understandable terms and encourage participation in decisions regarding the patient's care.

2. A practitioner shall not deliberately make a false or misleading statement regarding the practitioner's skill or the efficacy or value of a medication, treatment, or procedure provided or directed by the practitioner in the treatment of any disease or condition.

3. Before an invasive procedure is performed, informed consent shall be obtained from the patient in accordance with the policies of the health care entity. Practitioners shall inform patients of the risks, benefits, and alternatives of the recommended procedure that a reasonably prudent practitioner practicing polysomnographic technology in Virginia would tell a patient.

a. In the instance of a minor or a patient who is incapable of making an informed decision on his own behalf or is incapable of communicating such a decision due to a physical or mental disorder, the legally authorized person available to give consent shall be informed and the consent documented.

b. An exception to the requirement for consent prior to performance of an invasive procedure may be made in an emergency situation when a delay in obtaining consent would likely result in imminent harm to the patient.

c. For the purposes of this provision, "invasive procedure" means any diagnostic or therapeutic procedure performed on a patient that is not part of routine, general care and for which the usual practice within the health care entity is to document specific informed consent from the patient or surrogate decision maker prior to proceeding.

4. Practitioners shall adhere to requirements of § 32.1-162.18 of the Code of Virginia for obtaining informed consent from patients prior to involving them as subjects in human research with the exception of retrospective chart reviews.

B. Termination of the practitioner-patient relationship.

1. The practitioner or the patient may terminate the relationship. In either case, the practitioner shall make the patient record available, except in situations where denial of access is allowed by law.

2. A practitioner shall not terminate the relationship or make his services unavailable without documented notice to the patient that allows for a reasonable time to obtain the services of another practitioner.

18VAC85-140-160. Practitioner responsibility.

A. A practitioner shall not:

1. Perform procedures or techniques that are outside the scope of his practice or for which he is not trained and individually competent;

2. Knowingly allow subordinates to jeopardize patient safety or provide patient care outside of the subordinate's scope of practice or area of responsibility. Practitioners shall delegate patient care only to subordinates who are properly trained and supervised;

3. Engage in an egregious pattern of disruptive behavior or interaction in a health care setting that interferes with patient care or could reasonably be expected to adversely impact the quality of care rendered to a patient; or

4. Exploit the practitioner-patient relationship for personal gain.

B. Advocating for patient safety or improvement in patient care within a health care entity shall not constitute disruptive behavior provided the practitioner does not engage in behavior prohibited in subdivision A 3 of this section.

18VAC85-140-170. Solicitation or remuneration in exchange for referral.

A practitioner shall not knowingly and willfully solicit or receive any remuneration, directly or indirectly, in return for referring an individual to a facility or institution as defined in § 37.2-100 of the Code of Virginia or hospital as defined in § 32.1-123 of the Code of Virginia.

"Remuneration" means compensation, received in cash or in kind, but shall not include any payments, business arrangements, or payment practices allowed by 42 USC § 1320 a-7b(b), as amended, or any regulations promulgated thereto.

18VAC85-140-180. Sexual contact.

A. For purposes of § 54.1-2915 A 12 and A 19 of the Code of Virginia and this section, "sexual contact" includes but is not limited to sexual behavior or verbal or physical behavior that:

1. May reasonably be interpreted as intended for the sexual arousal or gratification of the practitioner, the patient, or both; or

2. May reasonably be interpreted as romantic involvement with a patient regardless of whether such involvement occurs within the professional setting or outside of it.

B. Sexual contact with a patient.

1. The determination of when a person is a patient for purposes of § 54.1-2915 A 19 of the Code of Virginia is made on a case-by-case basis with consideration given to the nature, extent, and context of the professional relationship between the practitioner and the person. The fact that a person is not actively receiving treatment or professional services from a practitioner is not determinative of this issue. A person is presumed to remain a patient until the practitioner-patient relationship is terminated.

2. The consent to, initiation of, or participation in sexual behavior or involvement with a practitioner by a patient neither changes the nature of the conduct nor negates the statutory prohibition.

C. Sexual contact between a practitioner and a former patient after termination of the practitioner-patient relationship may still constitute unprofessional conduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from the professional relationship.

D. Sexual contact between a practitioner and a key third party shall constitute unprofessional conduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence derived from the professional relationship or if the contact has had or is likely to have an adverse effect on patient care. For purposes of this section, "key third party of a patient" means spouse or partner, parent or child, guardian, or legal representative of the patient.

E. Sexual contact between a supervisor and a trainee shall constitute unprofessional conduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence derived from the professional relationship or if the contact has had or is likely to have an adverse effect on patient care.

18VAC85-140-190. Refusal to provide information.

A practitioner shall not willfully refuse to provide information or records as requested or required by the board or its representative pursuant to an investigation or to the enforcement of a statute or regulation.

FORMS (18VAC85-140)

Instructions for Completing an Application to Practice Polysomnographic Technology in Virginia (undated)

Form A, Claims History (rev. 08/13)

Form B, Employment Activity (rev. 08/13)

Form C, Verification Form (rev. 08/13)