TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING
REGISTRAR'S NOTICE:
Forms used in administering the regulation have been filed by the agency. The
forms are not being published; however, online users of this issue of the
Virginia Register of Regulations may click on the name of a form with a
hyperlink to access it. The forms are also available from the agency contact or
may be viewed at the Office of the Registrar of Regulations, 900 East Main
Street, 11th Floor, Richmond, Virginia 23219.
Titles of Regulations: 18VAC95-20. Regulations
Governing the Practice of Nursing Home Administrators.
18VAC95-30. Regulations Governing the Practice of Assisted
Living Facility Administrators.
Agency Contact: Corie Tillman Wolf, Executive Director,
Board of Long-Term Care Administrators, 9960 Mayland Drive, Suite 300,
Richmond, VA 23233-1463, telephone (804) 367-4546, or email corie.wolf@dhp.virginia.gov.
FORMS (18VAC95-20)
Nursing Home Administrator Application General Information
(rev. 9/08).
Nursing Home Administrator Application for Initial
Licensure (rev. 3/10).
License Verification Form (rev. 3/10).
Nursing Home Administrator-in-Training Application (rev.
3/10).
Nursing Home Administrator-in-Training – Notice of Change
of Status or Discontinuance (rev. 3/10).
Nursing Home Administrator Preceptor Application (rev.
3/10).
Nursing Home Administrator Application for Reinstatement
of License (rev. 3/10).
Nursing Home Administrator Application for Licensure by
Endorsement (rev. 3/10).
Nursing Home Administrator-in-Training Monthly Report
(rev. 4/10).
Nursing Home Administrator-in-Training Documentation of
Completion Form (rev. 3/10).
Domains of Practice (rev. 3/10).
Nursing Home Administrator Application - form available
online only at https://www.license.dhp.virginia.gov/apply/
Nursing Home Administrator-in-Training Application, online
form available at https://www.license.dhp.virginia.gov/apply/
Nursing
Home Administrator-in-Training Notice of Change of Status or Discontinuance
(rev. 3/2019)
Nursing Home Administrator Preceptor Application, online
form available at https://www.license.dhp.virginia.gov/apply/
Checklist
and Instructions for Nursing Home Administrator Reinstatement Application (rev.
3/2019)
Monthly
Report of Nursing Home Administrator-in-Training (rev. 3/2019)
Nursing
Home Administrator-in-Training Documentation of Completion Form (rev. 3/2019)
Proposed
AIT Program Training Plan Domains of Practice (rev. 3/2019)
Continued
Competency Activity and Assessment Form for Nursing Home Administrators (rev.
10/2014)
Continued
Education (CE) Credit Form for Voluntary Practice (eff. 2/2018)
FORMS (18VAC95-30)
Checklist for Endorsement or Credentials Application to
Practice as an Assisted Living Facility Administrator (rev. 3/10).
Checklist for Initial Licensure by Education to Practice
as an Assisted Living Facility Administrator (rev. 3/10).
Assisted Living Facility Administrator Application for
Licensure (rev. 3/10).
Assisted Living Facility Administrator
Administrator-in-Training Application (rev. 4/10).
Monthly Report of Assisted Living Facility
Administrator-in-Training (rev. 3/10).
Completion of Assisted Living Facility
Administrator-in-Training (rev. 3/10).
Endorsement Certification Form (rev. 8/07).
Assisted Living Facility Administrator Preceptor
Application (rev. 4/10).
Domains of Practice (rev. 11/09).
Assisted
Living Facility Administrators Education and Experience Matrix (rev. 3/2019)
Assisted Living Facility Administrator Application for
Licensure - form available online only at https://www.dhp.virginia.gov/nha/nha_forms.htm#alfa
Assisted Living Facility Administrator
Administrator-in-Training Application - form available online only at https://www.dhp.virginia.gov/nha/nha_forms.htm%23alfa
Monthly
Report of Assisted Living Facility Administrator-in-Training (rev. 3/2019)
Assisted
Living Facility Administrator-in-Training Documentation of Completion Form
(rev. 3/2019)
Assisted
Living Facility Administrator-in-Training Notice of Change of Status or
Discontinuance (rev. 3/2019)
Assisted Living Facility Administrator Preceptor Application
- form only available online at https://www.dhp.virginia.gov/nha/nha_forms.htm#alfa
Proposed
AIT Training Plan Domains of Practice (rev. 3/2019)
Checklist
and Instructions for Assisted Living Facility Administrator Reinstatement
Application (rev. 3/2019)
Checklist
and Instructions for Assisted Living Facility Administrator Preceptor
Reinstatement Application (rev. 3/2019)
Checklist
and Instructions for Acting Assisted Living Facility Administrator-in-Training
(rev. 3/2019)
Continuing
Competency Activity and Assessment Form for Assisted Living Facility
Administrators (rev. 9/2010)
Continuing
Education (CE) Credit Form for Volunteer Practice (eff. 2/2018)
Name/Address
Change Form (rev. 3/2019)
Request
for Verification of Virginia NHA or ALFA License (eff. 3/2019)
VA.R. Doc. No. R19-5868; Filed April 12, 2019, 8:56 a.m.