Title of Regulation: 12VAC5-230. State Medical Facilities Plan (amending 12VAC5-230-10, 12VAC5-230-420, 12VAC5-230-610, 12VAC5-230-620).

Statutory Authority: § 32.1-102.2 of the Code of Virginia.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: March 9, 2018.

Agency Contact: Domica Winstead, Policy Analyst, Department of Health, 3600 West Broad Street, Richmond, VA 23230, telephone (804) 367-2157, FAX (804) 527-4502, or email domica.winstead@vdh.virginia.gov.

Basis: The regulation is promulgated under the authority of § 32.1-102.2 of the Code of Virginia. Section 32.1-102.2 of the Code of Virginia requires the Board of Health to promulgate regulations that establish concise procedures for the prompt review of applications for certificates of public need consistent with Article 1.1 (§ 32.1-102.1 et seq.) of Chapter 4 of Title 32.1 of the Code of Virginia. Section 32.1-102.2 of the Code of Virginia further requires the board to promulgate regulations that establish specific criteria for determining need in rural areas, giving due consideration to distinct and unique geographic, socioeconomic, cultural, transportation, and other barriers to access to care in such areas.

Purpose: The purpose of this regulatory action is to update definitions related to cardiac catheterization and update the occupancy standard utilized for determining the need for new nursing home beds.

Updated regulations to implement the State Medical Facilities Plan are essential to protect the health of Virginians as the Department of Health has determined that excess capacity or underutilization of medical facilities are detrimental to both cost effectiveness and quality of medical services in Virginia; the department seeks to promote the availability and accessibility of proven technologies through planned geographical distribution of medical facilities; the department seeks to promote the development and maintenance of services and access to those services by all Virginians who need them without respect to their ability to pay; the department seeks to encourage the conversion of facilities to new and efficient uses and the reallocation of resources to meet evolving community needs; and the department discourages the proliferation of services that would undermine the ability of essential community providers to maintain their financial viability.

Substance: This regulatory action (i) amends the existing definitions for "cardiac catheterization" and "diagnostic equivalent procedure"; (ii) adds new definitions for "diagnostic cardiac catheterization," "complex therapeutic cardiac catheterization," and "simple therapeutic cardiac catheterization"; (iii) establishes requirements for proposals to provide simple and complex therapeutic cardiac catheterization; (iv) amends requirements for calculating need for additional nursing facility beds in a health planning district by requiring the analysis of both the average and median occupancy levels of Medicaid-certified nursing facility beds; and (v) reduces the occupancy level required to approve expansion of beds in an existing nursing facility from 93% to 90%.

Issues: The primary advantages of the regulatory action to the public are that the criteria for demonstrating public need for the included facilities will more closely reflect changes in technology, as well as application of service and utilization patterns, and will therefore help increase access to the services for the citizens of the Commonwealth. The Department of Health does not foresee any disadvantages to the public. The primary advantage to the agency and the Commonwealth is the promotion of access to health care services. There are no disadvantages associated with the proposed regulatory action in relation to the agency or the Commonwealth.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The State Board of Health (Board) proposes to 1) make a distinction between simple and complex cardiac catheterization procedures, 2) no longer require hospitals to have open heart surgery services on premises as a condition to perform diagnostic and simple cardiac catheterization procedures, provided they follow certain guidelines, 3) assign greater value of diagnostic equivalent procedures for complex and pediatric cardiac catheterization procedures relative to simple ones, 4) lower the statistical threshold occupancy rates used in determining the need for additional nursing home beds, and 5) add and revise certain statistical threshold values to improve measurement accuracy.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. Currently, all therapeutic cardiac catheterization procedures are considered the same in the regulation. The board proposes new definitions for simple (relieving coronary artery narrowing) and complex (correcting congenital or acquired structural valvular abnormalities) cardiac catheterization procedures to reflect current industry practices.

The board also proposes to no longer require, subject to a number of conditions, hospitals to have open heart surgery services on-site to perform simple procedures. Currently, only diagnostic and emergency therapeutic cardiac catheterization procedures can be performed without open heart surgery services back-up. According to the Virginia Department of Health (VDH), there are 29 hospitals with cardiac catheterization laboratories that do not have on-site open heart surgery services but may start performing elective simple therapeutic procedures under the proposed regulation provided they adhere to certain guidelines. This change would benefit those affected hospitals in that they would be allowed to offer these procedures if they wish. This change will likely also improve access to these services as most of the hospitals without on-site heart surgery services tend to be in rural areas.

VDH believes that the risks of taking the time to transfer the patient with a simple cardiac issue to a hospital with an open heart surgery back-up outweigh the risks of getting the procedure done sooner at a hospital without one. Thus, outcomes are expected to be better if patients get simple therapeutic procedures without being transferred. In addition, elective simple procedures can be performed without open heart surgery back-up only if certain conditions are met. Those conditions are set by the American Heart Association/American Stroke Association's Percutaneous Coronary Intervention without Surgical Back-up Policy Guidance. This policy guidance includes ten requirements to improve the chances of a favorable outcome when simple elective procedures are performed without an open heart surgery back-up.

The Board further proposes to give greater relative value to complex and pediatric diagnostic equivalent procedures (DEP). DEP is a measure of the relative complexity of various cardiac catheterization procedures. Currently, a diagnostic procedure equals 1 DEP, a cardiac procedure (simple or complex) equals 2 DEPs, and a same session procedure (diagnostic and simple or complex procedure) equals 3 DEPs. Under the proposed regulation, diagnostic procedure will stay at 1 DEP, a simple therapeutic procedure will equal 2 DEPs, a same session diagnostic and simple therapeutic procedure will equal 3 DEPs, and a complex therapeutic procedure will equal 5 DEPs. If any of the procedures is for a pediatric patient, it will equal twice as many DEPs (i.e., a pediatric diagnostic procedure will equal 2 DEPs, a simple therapeutic pediatric procedure will equal 4 DEPs, a same session pediatric diagnostic and simple therapeutic procedure will equal 6 DEPs, and a pediatric complex therapeutic procedure will equal 10 DEPs). According to VDH, pediatric procedures frequently require continuous anesthesia services and therefore tend to be complex.

The proposed greater DEP values for complex therapeutic and pediatric procedures will make it easier to demonstrate the need for expansion (12VAC5-230-390) or the need for new cardiac catheterization services (12VAC5-230-400) and the need for new open heart surgery services (12VAC5-230-450) because DEP thresholds for new or expansion of services are not changing. For example, if currently 500 diagnostics (500 DEPs), 200 simple (400 DEPs), and 100 complex (200 DEPs) procedures are performed on average per facility in a planning district, the average facility will have a total of 1,100 DEPs and no facility would qualify an expansion of services under 12VAC5-230-390 because on average there will be less than 1,200 cardiac catheterization DEPs per facility. However, under the proposed regulation, the same district will have an average of 1,400 DEPs (500 DEPs+400 DEPs+500 DEPs) per hospital and will satisfy that criteria for expansion. This proposed change will make it easier to demonstrate the need for additional cardiac catheterization and open heart surgery services. Ease of demonstration may reduce a barrier to entry into the catheterization and open heart surgery industry and promote competition. However, VDH notes that the expected impact may be limited because the majority of procedures are diagnostic and simple therapeutic.

Moreover, the Board proposes to lower the statistical threshold occupancy rate used in determining the need for additional Medicaid certified nursing home bed capacity. Currently, a health planning district must have at least 93% average annual occupancy rate to demonstrate the need for new or expansion of existing number of beds. The Board proposes to reduce the average annual occupancy rate to 90%. According to VDH, the Centers for Medicare and Medicaid Services now pay for Medicare short-stay rehabilitation patients in nursing facilities, which has caused facilities to reserve beds for those patients and served to help reduce the average length of stays and occupancy levels. The proposed change is expected to offset that reduction and provide a more accurate assessment of the need for additional nursing facility beds in each planning district. A lower statistical threshold to demonstrate the need for additional bed capacity than the current threshold should somewhat help ease a potential barrier to entry and promote competition in the nursing home industry.

Finally, the Board proposes to add and revise certain statistical threshold values to improve measurement accuracy. For example, the Board proposes to require in the case of determining the need for new beds, that the median annual occupancy rate in the district be at least 93% in addition to meeting the revised 90% average annual occupancy rate. Using median and average occupancy rates together is expected to better assess the need for new beds in the district given the statistical characteristics of this particular data set. Similarly, the Board proposes to include in the sample occupancy data from which the occupancy rates are calculated, facilities that have been in operation at least one year as opposed to at least three years as currently required. VDH reports that a facility reaches its full capacity within a year, and the current requirement does not allow useful data from the second and third years to be used in calculating bed need in the district.

Businesses and Entities Affected. The proposed changes apply to 105 hospitals that are either currently providing or may seek to provide cardiac catheterization services. Of these, there are 29 hospitals with cardiac catheterization laboratories that do not have on-site open heart surgery services but may start performing elective simple therapeutic procedures under the proposed regulation provided they adhere to certain guidelines.

Also, the proposed regulation applies to the 284 existing nursing homes in Virginia. The number of potential nursing home applicants for the development of nursing homes in Virginia is not known.

Localities Particularly Affected. The proposed changes do not affect a particular locality more than others.

Projected Impact on Employment. The proposed regulation would allow 29 hospitals that do not have on-site open heart surgery services to start performing elective simple therapeutic procedures. This change may shift some of the elective simple therapeutic procedures being performed at hospitals with open heart surgery back-up to hospitals without such a back-up and accordingly shift demand for labor involved in performing such procedures among the hospitals.

The proposed greater DEP values for more complex and pediatric procedures would make it easier to demonstrate the need for such services and reduce a potential barrier to entry into cardiac catheterization and open heart surgery services. Similarly, a lower statistical threshold to demonstrate the need for additional bed capacity should somewhat help ease a potential barrier to entry. A reduction in barriers to entry may lead to additional employment in those areas.

Effects on the Use and Value of Private Property. The shift of elective simple therapeutic procedures from hospitals that have open heart surgery back-up to hospitals without may affect their asset values accordingly.

Real Estate Development Costs. No impact on real estate development costs is expected.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. Only one nursing home is considered a small business. The costs and other effects on that nursing home are the same as those discussed above.

Alternative Method that Minimizes Adverse Impact. No direct adverse impact on small businesses is expected.

Adverse Impacts:

Businesses. The indirect adverse impact on hospitals that have open heart back-up services are the same as those discussed above.

Localities. The proposed amendments will not adversely affect localities.

Other Entities. The proposed amendments will not adversely affect other entities.

Agency's Response to Economic Impact Analysis: The Virginia Department of Health concurs with the results of the analysis.

Summary:

The proposed amendments (i) make a distinction between simple and complex cardiac catheterization procedures, (ii) no longer require hospitals to have open heart surgery services on premises as a condition to perform diagnostic and simple cardiac catheterization procedures, provided they follow certain guidelines, (iii) assign greater value of diagnostic equivalent procedures for complex and pediatric cardiac catheterization procedures relative to simple ones, (iv) lower the statistical threshold occupancy rates used in determining the need for additional nursing home beds, and (v) add and revise certain statistical threshold values to improve measurement accuracy.

Part I
Definitions and General Information

12VAC5-230-10. Definitions.

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

"Acute psychiatric services" means hospital-based inpatient psychiatric services provided in distinct inpatient units in general hospitals or freestanding psychiatric hospitals.

"Acute substance abuse disorder treatment services" means short-term hospital-based inpatient treatment services with access to the resources of (i) a general hospital, (ii) a psychiatric unit in a general hospital, (iii) an acute care addiction treatment unit in a general hospital licensed by the Department of Health, or (iv) a chemical dependency specialty hospital with acute care medical and nursing staff and life support equipment licensed by the Department of Mental Behavioral Health, Mental Retardation and Substance Abuse Developmental Services.

"Bassinet" means an infant care station, including warming stations and isolettes.

"Bed" means that unit, within the complement of a medical care facility, subject to COPN review as required by Article 1.1 (§ 32.1-102.1 et seq.) of the Code of Virginia and designated for use by patients of the facility or service. For the purposes of this chapter, bed does include cribs and bassinets used for pediatric patients, but does not include cribs and bassinets in the newborn nursery or neonatal special care setting.

"Cardiac catheterization" means a an invasive procedure where a flexible tube is inserted into the patient through an extremity blood vessel and advanced under fluoroscopic guidance into the heart chambers or coronary arteries. Cardiac A cardiac catheterization may include therapeutic intervention, be conducted for diagnostic or therapeutic purposes but does not include a simple right heart catheterization for monitoring purposes as might be performed in an electrophysiology laboratory, pulmonary angiography as an isolated procedure, or cardiac pacing through a right electrode catheter.

"Commissioner" means the State Health Commissioner.

"Competing applications" means applications for the same or similar services and facilities that are proposed for the same health planning district, or same health planning region for projects reviewed on a regional basis, and are in the same batch review cycle.

"Complex therapeutic cardiac catheterization" means the performance of cardiac catheterization for the purpose of correcting or improving certain conditions that have been determined to exist in the heart or great arteries or veins of the heart, specifically catheter-based procedures for structural treatment to correct congenital or acquired structural or valvular abnormalities.

"Computed tomography" or "CT" means a noninvasive diagnostic technology that uses computer analysis of a series of cross-sectional scans made along a single axis of a bodily structure or tissue to construct an image of that structure.

"Continuing care retirement community" or "CCRC" means a retirement community consistent with the requirements of Chapter 49 (§ 38.2-4900 et seq.) of Title 38.2 of the Code of Virginia.

"COPN" means a Medical Care Facilities Certificate of Public Need for a project as required in Article 1.1 (§ 32.1-102.1 et seq.) of Chapter 4 of Title 32.1 of the Code of Virginia.

"COPN program" means the Medical Care Facilities Certificate of Public Need Program implementing Article 1.1 (§ 32.1-102.1 et seq.) of Chapter 4 of Title 32.1 of the Code of Virginia.

"DEP" means diagnostic equivalent procedure, a method for weighing the relative value of various cardiac catheterization procedures as follows: a diagnostic procedure cardiac catheterization equals 1 DEP, a simple therapeutic procedure cardiac catheterization equals 2 DEPs, a same session procedure (diagnostic and simple therapeutic) equals 3 DEPs, and a pediatric procedure complex therapeutic cardiac catheterization equals 2 5 DEPs. A multiplier of 2 will be applied for a pediatric procedure (i.e., a pediatric diagnostic cardiac catheterization equals 2 DEPs, a pediatric simple therapeutic cardiac catheterization equals 4 DEPs, and a pediatric complex therapeutic cardiac catheterization equals 10 DEPs.)

"Diagnostic cardiac catheterization" means the performance of cardiac catheterization for the purpose of detecting and identifying defects in the great arteries or veins of the heart or abnormalities in the heart structure, whether congenital or acquired.

"Direction" means guidance, supervision, or management of a function or activity.

"Gamma knife^®" means the name of a specific instrument used in stereotactic radiosurgery.

"Health planning district" means the same contiguous areas designated as planning districts by the Virginia Department of Housing and Community Development or its successor.

"Health planning region" means a contiguous geographic area of the Commonwealth as designated by the State Board of Health with a population base of at least 500,000 persons, characterized by the availability of multiple levels of medical care services, reasonable travel time for tertiary care, and congruence with planning districts.

"Health system" means an organization of two or more medical care facilities, including but not limited to hospitals, that are under common ownership or control and are located within the same health planning district, or health planning region for projects reviewed on a regional basis.

"Hospital" means a medical care facility licensed as an inpatient hospital or outpatient surgical center by the Department of Health or as a psychiatric hospital by the Department of Mental Behavioral Health, Mental Retardation, and Substance Abuse Developmental Services.

"ICF/MR" means an intermediate care facility for the mentally retarded.

"Indigent" means any person whose gross family income is equal to or less than 200% of the federal Nonfarm Poverty Level or income levels A through E of 12VAC5-200-10 and who is uninsured.

"Inpatient" means a patient who is hospitalized longer than 24 hours for health or health related services.

"Intensive care beds" or "ICU" means inpatient beds located in the following units or categories:

1. General intensive care units are those units where patients are concentrated by reason of serious illness or injury regardless of diagnosis. Special lifesaving techniques and equipment are immediately available and patients are under continuous observation by nursing staff;

2. Cardiac care units, also known as Coronary Care Units or CCUs, are units staffed and equipped solely for the intensive care of cardiac patients; and

3. Specialized intensive care units are any units with specialized staff and equipment for the purpose of providing care to seriously ill or injured patients based on age selected categories of diagnoses, including units established for burn care, trauma care, neurological care, pediatric care, and cardiac surgery recovery, but does not include bassinets in neonatal special care units.

"Lithotripsy" means a noninvasive therapeutic procedure to (i) crush renal and biliary stones using shock waves, (i.e., renal lithotripsy) or (ii) treat certain musculoskeletal conditions and to relieve the pain associated with tendonitis, (i.e., orthopedic lithotripsy).

"Long-term acute care hospital" or "LTACH" means an inpatient hospital that provides care for patients who require a length of stay greater than 25 days and is, or proposes to be, certified by the Centers for Medicare and Medicaid Services as a long-term care inpatient hospital pursuant to 42 CFR Part 412. An LTACH may be either a free standing freestanding facility or located within an existing or host hospital.

"Magnetic resonance imaging" or "MRI" means a noninvasive diagnostic technology using a nuclear spectrometer to produce electronic images of specific atoms and molecular structures in solids, especially human cells, tissues and organs.

"Medical rehabilitation" means those services provided consistent with 42 CFR 412.23 and 412.24.

"Medical/surgical" means those services available for the care and treatment of patients not requiring specialized services.

"Minimum survival rates" means the base percentage of transplant recipients who survive at least one year or for such other period of time as specified by the United Network for Organ Sharing (UNOS).

"Neonatal special care" means care for infants in one or more of the higher service levels designated in 12VAC5-410-443 of the Rules and Regulations for the Licensure of Hospitals.

"Nursing facility" means those facilities or components thereof licensed to provide long-term nursing care.

"Obstetrical services" means the distinct organized program, equipment and care related to pregnancy and the delivery of newborns in inpatient facilities.

"Off-site replacement" means the relocation of existing beds or services from an existing medical care facility site to another location within the same health planning district.

"Open heart surgery" means a surgical procedure requiring the use or immediate availability of a heart-lung bypass machine or "pump." The use of the pump during the procedure distinguishes "open heart" from "closed heart" surgery.

"Operating room" means a room used solely or principally for the provision of surgical procedures involving the administration of anesthesia, multiple personnel, recovery room access, and a fully controlled environment.

"Operating room use" means the amount of time a patient occupies an operating room and includes room preparation and cleanup time.

"Operating room visit" means one session in one operating room in an inpatient hospital or outpatient surgical center, which may involve several procedures. Operating room visit may be used interchangeably with "operation" or "case."

"Outpatient" means a patient who visits a hospital, clinic, or associated medical care facility for diagnosis or treatment, but is not hospitalized 24 hours or longer.

"Pediatric" means patients younger than 18 years of age. Newborns in nurseries are excluded from this definition.

"Perinatal services" means those resources and capabilities that all hospitals offering general level newborn services as described in 12VAC5-410-443 of the Rules and Regulations for the Licensure of Hospitals must provide routinely to newborns.

"PET/CT scanner" means a single machine capable of producing a PET image with a concurrently produced CT image overlay to provide anatomic definition to the PET image. For the purpose of granting a COPN, the State Board of Health pursuant to § 32.1-102.2 A 6 of the Code of Virginia has designated PET/CT as a specialty clinical service. A PET/CT scanner shall be reviewed under the PET criteria as an enhanced PET scanner unless the CT unit will be used independently. In such cases, a PET/CT scanner that will be used to take independent PET and CT images will be reviewed under the applicable PET and CT services criteria.

"Planning horizon year" means the particular year for which bed or service needs are projected.

"Population" means the census figures shown in the most current series of projections published by a demographic entity as determined by the commissioner.

"Positron emission tomography" or "PET" means a noninvasive diagnostic or imaging modality using the computer-generated image of local metabolic and physiological functions in tissues produced through the detection of gamma rays emitted when introduced radio-nuclids radionuclides decay and release positrons. A PET device or scanner may include an integrated CT to provide anatomic structure definition.

"Primary service area" means the geographic territory from which 75% of the patients of an existing medical care facility originate with respect to a particular service being sought in an application.

"Procedure" means a study or treatment or a combination of studies and treatments identified by a distinct ICD-9 ICD-10 or CPT code performed in a single session on a single patient.

"Qualified" means meeting current legal requirements of licensure, registration, or certification in Virginia or having appropriate training, including competency testing, and experience commensurate with assigned responsibilities.

"Radiation therapy" means treatment using ionizing radiation to destroy diseased cells and for the relief of symptoms. Radiation therapy may be used alone or in combination with surgery or chemotherapy.

"Relevant reporting period" means the most recent 12-month period, prior to the beginning of the applicable batch review cycle, for which data is available from VHI or a demographic entity as determined by the commissioner.

"Rural" means territory, population, and housing units that are classified as "rural" by the Bureau of the Census of the United States U.S. Department of Commerce, Economic and Statistics Administration.

"Simple therapeutic cardiac catheterization" means the performance of cardiac catheterization for the purpose of correcting or improving certain conditions that have been determined to exist in the heart, specifically catheter-based treatment procedures for relieving coronary artery narrowing.

"SMFP" means the state medical facilities plan as contained in Article 1.1 (§ 32.1-102.1 et seq.) of Chapter 4 of Title 32.1 of the Code of Virginia used to make medical care facilities and services needs decisions.

"Stereotactic radiosurgery" or "SRS" means the use of external radiation in conjunction with a stereotactic guidance device to very precisely deliver a therapeutic dose to a tissue volume. SRS may be delivered in a single session or in a fractionated course of treatment up to five sessions.

"Stereotactic radiotherapy" or "SRT" means more than one session of stereotactic radiosurgery.

"Substance abuse disorder treatment services" means services provided to individuals for the prevention, diagnosis, treatment, or palliation of chemical dependency, which may include attendant medical and psychiatric complications of chemical dependency. Substance abuse disorder treatment services are licensed by the Department of Mental Behavioral Health, Mental Retardation, and Substance Abuse Developmental Services.

"Supervision" means to direct and watch over the work and performance of others.

"Use rate" means the rate at which an age cohort or the population uses medical facilities and services. The rates are determined from periodic patient origin surveys conducted for the department by the regional health planning agencies, or other health statistical reports authorized by Chapter 7.2 (§ 32.1-276.2 et seq.) of Title 32.1 of the Code of Virginia.

"VHI" means the health data organization defined in § 32.1-276.4 of the Code of Virginia and under contract with the Virginia Department of Health.

12VAC5-230-420. Nonemergent cardiac catheterization.

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.

A. Simple therapeutic cardiac catheterization. Proposals to provide simple therapeutic cardiac catheterization are not required to offer open heart surgery service available on-site in the same hospital in which the proposed simple therapeutic service will be located. However, these programs shall adhere to the requirements described in subdivisions 1 through 9 of this subsection.

The programs shall:

1. Participate in the Virginia Heart Attack Coalition, the Virginia Cardiac Services Quality Initiative, and the Action Registry-Get with the Guidelines or National Cardiovascular Data Registry to monitor quality and outcomes;

2. Adhere to strict patient-selection criteria;

3. Perform annual institutional volumes of 300 cardiac catheterization procedures, of which at least 75 should be PCI or as dictated by American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Cardiac Catheterization and Cardiac Catheterization Laboratories effective 1991;

4. Use only AHA/ACC-qualified operators who meet the standards for training and competency;

5. Demonstrate appropriate planning for program development and complete both a primary PCI development program and an elective PCI development program that includes routine care process and case selection review;

6. Develop and maintain a quality and error management program;

7. Provide PCI 24 hours a day, seven days a week;

8. Develop and maintain necessary agreements with a tertiary facility that must agree to accept emergent and nonemergent transfers for additional medical care, cardiac surgery, or intervention; and

9. Develop and maintain agreements with an ambulance service capable of advanced life support and intra-aortic balloon pump transfer that guarantees a 30-minute or less response time.

B. Complex therapeutic cardiac catheterization. Proposals to provide complex therapeutic cardiac catheterization should be approved only when open heart surgery services are available on-site in the same hospital in which the proposed complex therapeutic service will be located. Additionally, these complex therapeutic cardiac catheterization programs will be required to participate in the Virginia Cardiac Services Quality Initiative and the Virginia Heart Attack Coalition.

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

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 existing and authorized beds for the health planning district; and

2. The average median annual occupancy of all existing and authorized Medicaid-certified nursing facility beds in the health planning district was at least 93%, and the average annual occupancy of all existing and authorized Medicaid-certified nursing facility beds in the health planning district was at least 90%, 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 one year in the health planning district, their occupancy can shall be excluded from the calculation of average occupancy if the facilities 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 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.

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

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 a median annual occupancy rate in excess of 93% of all existing and authorized Medicaid-certified nursing facility beds and an annual average occupancy rate of at least 90% of all existing and authorized Medicaid-certified nursing facility beds for each of 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. Preference may be given 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. Expansion of services.

Proposals to increase an existing nursing facility facility's 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% 90% in the relevant reporting period as reported to VHI.

Note: Exceptions will be considered for facilities that operated at less than 93% 90% average annual occupancy in the most recent year for which bed utilization has been reported when the facility offers short stay services causing an average annual occupancy lower than 93% 90% for the facility.

DOCUMENTS INCORPORATED BY REFERENCE (12VAC5-230)

ACC/AHA Guidelines for Cardiac Catheterization and Cardiac Catheterization Laboratories, American College of Cardiology/American Heart Association Ad Hoc Task Force on Cardiac Catheterization, JACC Vol. 18 No. 5, November 1, 1991: 1149-82