Group Ceiling	Hospital's Allowable Cost Per Day	$	Difference % or Ceiling	$	Sliding Scale Incentive % of Difference
$230.00	$230.00	-0-	-0-	-0-	-0-
230.00	207.00	23.00	10%	2.30	10%
230.00	172.00	57.50	25%	14.38	25%
230.00	143.00	76.00	33%	19.00	25%

F. There will be special consideration for exception to the median operating cost limits in those instances where extensive neonatal care is provided.

G. F. Disproportionate share hospitals defined.

The following criteria shall be met before a hospital is determined to be eligible for a disproportionate share payment adjustment.

1. Criteria.

a. A Medicaid inpatient utilization rate in excess of 8% for hospitals receiving Medicaid payments in the Commonwealth, or a low-income patient utilization rate exceeding 25% (as defined in the Omnibus Budget Reconciliation Act of 1987 and as amended by the Medicare Catastrophic Coverage Act of 1988); and

b. At least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to such services under a State Medicaid plan. In the case of a hospital located in a rural area (that is, an area outside of a Metropolitan Statistical Area, as defined by the Executive Office of Management and Budget), the term "obstetrician" includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.

c. Subdivision 1 b of this subsection does not apply to a hospital:

(1) At which the inpatients are predominantly individuals under 18 years of age; or

(2) Which does not offer nonemergency obstetric services as of December 21, 1987.

2. Payment adjustment.

a. Hospitals which have a disproportionately higher level of Medicaid patients shall be allowed a disproportionate share payment adjustment based on the type of hospital and on the individual hospital's Medicaid utilization. There shall be two types of hospitals: (i) Type One, consisting of state-owned teaching hospitals, and (ii) Type Two, consisting of all other hospitals. The Medicaid utilization shall be determined by dividing the number of utilization Medicaid inpatient days by the total

number of inpatient days. Each hospital with a Medicaid utilization of over 8.0% shall receive a disproportionate share payment adjustment.

b. For Type One hospitals, the disproportionate share payment adjustment shall be equal to the product of (i) the hospital's Medicaid utilization in excess of 8.0% times 11, times (ii) the lower of the prospective operating cost rate or ceiling. For Type Two hospitals, the disproportionate share payment adjustment shall be equal to the product of (i) the hospital's Medicaid utilization in excess of 8.0% times (ii) the lower of the prospective operating cost rate or ceiling.

c. No payments made under subdivision 1 or 2 of this subsection shall exceed any applicable limitations upon such payments established by federal law or regulations.

H. G. Outlier adjustments.

1. DMAS shall pay to all enrolled hospitals an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after July 1, 1991, involving exceptionally high costs for individuals under one year of age.

2. DMAS shall pay to disproportionate share hospitals (as defined in paragraph G above) subsection F of this section) an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after July 1, 1991, involving exceptionally high costs for individuals under six years of age.

3. The outlier adjustment calculation.

a. Each eligible hospital which desires to be considered for the adjustment shall submit a log which contains the information necessary to compute the mean of its Medicaid per diem operating cost of treating individuals identified in subdivision H 1 or 2 above of this subsection. This log shall contain all Medicaid claims for such individuals, including, but not limited to: (i) the patient's name and Medicaid identification number; (ii) dates of service; (iii) the remittance date paid; (iv) the number of covered days; and (v) total charges for the length of stay. Each hospital shall then calculate the per diem operating cost (which excludes capital and education) of treating such patients by multiplying the charge for each patient by the Medicaid operating cost-to-charge ratio determined from its annual cost report.

b. Each eligible hospital shall calculate the mean of its Medicaid per diem operating cost of treating individuals identified in subdivision H 1 or 2 above of this subsection. Any hospital which qualifies for the extensive neonatal care provision (as governed by paragraph F, above) shall calculate a separate mean for the cost of providing extensive neonatal care to individuals identified in subdivision H 1 or 2 above.

c. Each eligible hospital shall calculate its threshold for payment of the adjustment, at a level equal to two and one-half standard deviations above the mean or means calculated in subdivision H 3 a (ii) above of this subsection.

d. DMAS shall pay as an outlier adjustment to each eligible hospital all per diem operating costs which exceed the applicable threshold or thresholds for that hospital.

4. Pursuant to 12VAC30-50-100, there is no limit on length of time for medically necessary stays for individuals under six years of age. This section provides that consistent with 42 CFR 441.57, payment of medical assistance services shall be made on behalf of individuals under 21 years of age, who are Medicaid eligible, for medically necessary stays in acute care facilities in excess of 21 days per admission when such services are rendered for the purpose of diagnosis and treatment of health conditions identified through a physical examination. Medical documentation justifying admission and the continued length of stay must be attached to or written on the invoice for review by medical staff to determine medical necessity. Medically unjustified days in such admissions will be denied.

Part V
Inpatient Hospital Payment System

Article 1
Application of Payment Methodologies

12VAC30-70-201. Application of payment methodologies.

A. The state agency will pay for inpatient hospital services in general acute care hospitals, rehabilitation hospitals, and freestanding psychiatric facilities licensed as hospitals under a prospective payment methodology. This methodology uses both per case and per diem payment methods. Article 2 (12VAC30-70-221 et seq.) describes the prospective payment methodology, including both the per case and the per diem methods.

B. Article 3 (12VAC30-70-400 et seq.) describes a per diem methodology that applied to a portion of payment to general acute care hospitals during state fiscal years 1997 and 1998, and that will continue to apply to patient stays with admission dates prior to July 1, 1996. Inpatient hospital services that are provided in long stay hospitals and state-owned rehabilitation hospitals shall be subject to the provisions of Supplement 3 (12VAC30-70-10 through 12VAC30-70-130).

C. Inpatient hospital facilities operated by the Department of Behavioral Health and Developmental Services (DBHDS) shall be reimbursed costs. Facilities may also receive disproportionate share hospital (DSH) payments. The criteria for DSH eligibility and the payment amount shall be based on subsection F of 12VAC30-70-50. If the DSH limit is exceeded by any facility, the excess DSH payments shall be distributed to all other qualifying DBHDS facilities in proportion to the amount of DSH they otherwise receive.

C. D. Transplant services shall not be subject to the provisions of this part. Reimbursement for covered liver, heart, and bone marrow/stem cell transplant services and any other medically necessary transplantation procedures that are determined to not be experimental or investigational shall be a fee based upon the greater of a prospectively determined, procedure-specific flat fee determined by the agency or a prospectively determined, procedure-specific percentage of usual and customary charges. The flat fee reimbursement will cover procurement costs; all hospital costs from admission to discharge for the transplant procedure; and total physician costs for all physicians providing services during the hospital stay, including radiologists, pathologists, oncologists, surgeons, etc. The flat fee reimbursement does not include pre- and post-hospitalization for the transplant procedure or pretransplant evaluation. If the actual charges are lower than the fee, the agency shall reimburse the actual charges. Reimbursement for approved transplant procedures that are performed out of state will be made in the same manner as reimbursement for transplant procedures performed in the Commonwealth. Reimbursement for covered kidney and cornea transplants is at the allowed Medicaid rate. Standards for coverage of organ transplant services are in 12VAC30-50-540 through 12VAC30-50-580.

D. E. Reduction of payments methodology.

1. For state fiscal years 2003 and 2004, the Department of Medical Assistance Services (DMAS) shall reduce payments to hospitals participating in the Virginia Medicaid Program by $8,935,825 total funds, and $9,227,815 total funds respectively. For purposes of distribution, each hospital's share of the total reduction amount shall be determined as provided in this subsection.

2. Determine base for revenue forecast.

a. DMAS shall use, as a base for determining the payment reduction distribution for hospitals Type I and Type II, net Medicaid inpatient operating reimbursement and outpatient reimbursed cost, as recorded by DMAS for state fiscal year 1999 from each individual hospital settled cost reports. This figure is further reduced by 18.73%, which represents the estimated statewide HMO average percentage of Medicaid business for those hospitals engaged in HMO contracts, to arrive at net baseline proportion of non-HMO hospital Medicaid business.

b. For freestanding psychiatric hospitals, DMAS shall use estimated Medicaid revenues for the six-month period (January 1, 2001, through June 30, 2001), times two, and adjusted for inflation by 4.3% for state fiscal year 2002, 3.1% for state fiscal year 2003, and 3.7% for state fiscal year 2004, as reported by DRI-WEFA, Inc.'s, hospital input price level percentage moving average.

3. Determine forecast revenue.

a. Each Type I hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 a of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type I hospitals.

b. Each Type II, including freestanding psychiatric, hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type II hospitals.

4. Each hospital's total yearly reduction amount is equal to their respective state fiscal year 2003 and 2004 forecast reimbursement as described in subdivision 3 of this subsection, times 3.235857% for state fiscal year 2003, and 3.235857%, for the first two quarters of state fiscal year 2004 and 2.88572% for the last two quarters of state fiscal year 2004, not to be reduced by more than $500,000 per year.

5. Reductions shall occur quarterly in four amounts as offsets to remittances. Each hospital's payment reduction shall not exceed that calculated in subdivision 4 of this subsection. Payment reduction offsets not covered by claims remittance by May 15, 2003, and 2004, will be billed by invoice to each provider with the remaining balances payable by check to the Department of Medical Assistance Services before June 30, 2003, or 2004, as applicable.

12VAC30-70-351. Updating rates for inflation.

A. Each July, the Virginia moving average values as compiled and published by Global Insight (or its successor), under contract with the department shall be used to update the base year standardized operating costs per case, as determined in 12VAC30-70-361, and the base year standardized operating costs per day, as determined in 12VAC30-70-371, to the midpoint of the upcoming state fiscal year. The most current table available prior to the effective date of the new rates shall be used to inflate base year amounts to the upcoming rate year. Thus, corrections made by Global Insight (or its successor), in the moving averages that were used to update rates for previous state fiscal years shall be automatically incorporated into the moving averages that are being used to update rates for the upcoming state fiscal year.

B. The inflation adjustment for hospital operating rates, disproportionate share hospitals (DSH) payments, and graduate medical education payments shall be eliminated zero percent for fiscal year (FY) 2010, with the exception of long stay hospitals. The elimination of the inflation adjustments shall not be applicable to re-basing in FY 2011.

C. In FY 2011, hospital operating rates shall be rebased; however the 2008 base year costs shall only be increased 2.58% for inflation. For FY 2011 there shall be no inflation adjustment for graduate medical education (GME) or freestanding psychiatric facility rates. The inflation adjustment shall be eliminated for hospital operating rates, GME payments, and freestanding psychiatric facility rates for FY 2012.

12VAC30-80-20. Services that are reimbursed on a cost basis.

A. Payments for services listed below shall be on the basis of reasonable cost following the standards and principles applicable to the Title XVIII Program with the exception provided for in subdivision D 2 1 d. The upper limit for reimbursement shall be no higher than payments for Medicare patients on a facility by facility basis in accordance with 42 CFR 447.321 and 42 CFR 447.325. In no instance, however, shall charges for beneficiaries of the program be in excess of charges for private patients receiving services from the provider. The professional component for emergency room physicians shall continue to be uncovered as a component of the payment to the facility.

B. Reasonable costs will be determined from the filing of a uniform cost report by participating providers. The cost reports are due not later than 90 150 days after the provider's fiscal year end. If a complete cost report is not received within 90 150 days after the end of the provider's fiscal year, the Program shall take action in accordance with its policies to assure that an overpayment is not being made. The cost report will be judged complete when DMAS has all of the following:

1. Completed cost reporting form(s) provided by DMAS, with signed certification(s);

2. The provider's trial balance showing adjusting journal entries;

3. The provider's financial statements including, but not limited to, a balance sheet, a statement of income and expenses, a statement of retained earnings (or fund balance), and a statement of changes in financial position;

4. Schedules that reconcile financial statements and trial balance to expenses claimed in the cost report;

5. Depreciation schedule or summary;

6. Home office cost report, if applicable; and

7. Such other analytical information or supporting documents requested by DMAS when the cost reporting forms are sent to the provider.

C. Item 398 D of the 1987 Appropriation Act (as amended), effective April 8, 1987, eliminated reimbursement of return on equity capital to proprietary providers.

D. The services that are cost reimbursed are:

1. Inpatient hospital services to persons over 65 years of age in tuberculosis and mental disease hospitals.

2. 1. Outpatient hospital services including rehabilitation hospital outpatient services and excluding laboratory.

a. Definitions. The following words and terms when used in this regulation shall have the following meanings when applied to emergency services unless the context clearly indicates otherwise:

"All-inclusive" means all emergency department and ancillary service charges claimed in association with the emergency room visit, with the exception of laboratory services.

"DMAS" means the Department of Medical Assistance Services consistent with Chapter 10 (§et seq.) (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.

"Emergency hospital services" means services that are necessary to prevent the death or serious impairment of the health of the recipient. The threat to the life or health of the recipient necessitates the use of the most accessible hospital available that is equipped to furnish the services.

"Recent injury" means an injury that has occurred less than 72 hours prior to the emergency department visit.

b. Scope. DMAS shall differentiate, as determined by the attending physician's diagnosis, the kinds of care routinely rendered in emergency departments and reimburse for nonemergency care rendered in emergency departments at a reduced rate.

(1) With the exception of laboratory services, DMAS shall reimburse at a reduced and all-inclusive reimbursement rate for all services, including those obstetric and pediatric procedures contained in 12VAC30-80-160, rendered in emergency departments that DMAS determines were nonemergency care.

(2) Services determined by the attending physician to be emergencies shall be reimbursed under the existing methodologies and at the existing rates.

(3) Services performed by the attending physician that may be emergencies shall be manually reviewed. If such services meet certain criteria, they shall be paid under the methodology for subdivision 2 1 b (2) of this subsection. Services not meeting certain criteria shall be paid under the methodology of subdivision 2 1 b (1) of this subsection. Such criteria shall include, but not be limited to:

(a) The initial treatment following a recent obvious injury.

(b) Treatment related to an injury sustained more than 72 hours prior to the visit with the deterioration of the symptoms to the point of requiring medical treatment for stabilization.

(c) The initial treatment for medical emergencies including indications of severe chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness, status epilepticus, or other conditions considered life threatening.

(d) A visit in which the recipient's condition requires immediate hospital admission or the transfer to another facility for further treatment or a visit in which the recipient dies.

(e) Services provided for acute vital sign changes as specified in the provider manual.

(f) Services provided for severe pain when combined with one or more of the other guidelines.

(4) Payment shall be determined based on ICD-9-CM diagnosis codes and necessary supporting documentation.

(5) DMAS shall review on an ongoing basis the effectiveness of this program in achieving its objectives and for its effect on recipients, physicians, and hospitals. Program components may be revised subject to achieving program intent, the accuracy and effectiveness of the ICD-9-CM code designations, and the impact on recipients and providers.

c. Limitation to 80% of allowable cost. Effective for services on and after July 1, 2003, reimbursement of Type Two hospitals for outpatient services shall be at 80% of allowable cost, with cost to be determined as provided in subsections A, B, and C of this section. For hospitals with fiscal years that do not begin on July 1, 2003, outpatient costs, both operating and capital, for the fiscal year in progress on that date shall be apportioned between the time period before and the time period after that date, based on the number of calendar months in the cost reporting period, falling before and after that date. Operating costs apportioned before that date shall be settled according to the principles in effect before that date, and those after at 80% of allowable cost. Capital costs apportioned before that date shall be settled according to the principles in effect before that date, and those after at 80% of allowable cost. Operating and capital costs of Type One hospitals shall continue to be reimbursed at 94.2% and 90% of cost respectively.

d. Outpatient reimbursement methodology prior to July 1, 2003. DMAS shall continue to reimburse for outpatient hospital services, with the exception of direct graduate medical education for interns and residents, at 100% of reasonable costs less a 10% reduction for allowable capital costs and a 5.8% reduction for allowable operating costs. This methodology shall continue to be in effect after July 1, 2003, for Type One hospitals.

e. Payment for direct medical education costs of nursing schools, paramedical programs and graduate medical education for interns and residents.

(1) Direct medical education costs of nursing schools and paramedical programs shall continue to be paid on an allowable cost basis.

(2) Effective with cost reporting periods beginning on or after July 1, 2002, direct graduate medical education (GME) costs for interns and residents shall be reimbursed on a per-resident prospective basis. See 12VAC30-70-281 for prospective payment methodology for graduate medical education for interns and residents.

3. 2. Rehabilitation agencies operated by community services boards. For reimbursement methodology applicable to other rehabilitation agencies, see 12VAC30-80-200. Reimbursement for physical therapy, occupational therapy, and speech-language therapy services shall not be provided for any sums that the rehabilitation provider collects, or is entitled to collect, from the NF or any other available source, and provided further, that this amendment shall in no way diminish any obligation of the NF to DMAS to provide its residents such services, as set forth in any applicable provider agreement.

4. Rehabilitation hospital outpatient services.

Part I
Methods and Standards for Establishing Payment Rates for Long-Term Care

12VAC30-90-10. Methods and standards for establishing payment rates for long-term care.

The policy and the method to be used in establishing payment rates for nursing facilities listed in § 1905(a) of the Social Security Act and included in this State Plan for Medical Assistance are described in the following paragraphs.

1. Reimbursement and payment criteria will be established which are designed to enlist participation of a sufficient number of providers of services in the Program so that eligible persons can receive the medical care and services included in the Plan to the extent these are available to the general population.

2. Participation in the Program will be limited to providers of services who accept, as payment in full, the amounts so paid.

3. Payment for care of service will not exceed the amounts indicated to be reimbursed in accord with the policy and the methods described in the Plan and payments will not be made in excess of the upper limits described in 42 CFR 447.253(b)(2). The state agency has continuing access to data identifying the maximum charges allowed. Such data will be made available to the Secretary of Health and Human Services upon request.

4. Payments for services to nursing facilities shall be on the basis of reasonable cost in accordance with the standards and principles set forth in 42 CFR 447.252 as follows:

a. A uniform annual cost report which itemizes allowable cost will be required to be filed within 150 days of each provider's fiscal year end.

b. The determination of allowable costs will be in accordance with Medicare principles as established in the Provider Reimbursement Manual (PRM-15) except where otherwise noted in this Plan.

c. Field audits will be conducted on the cost data submitted by the provider to verify the accuracy and reasonableness of such data. Audits will be conducted for each facility on a periodic basis as determined from internal desk audits and more often as required. Audit procedures are in conformance with SSA standards set forth in PRM-13-2. Internal desk audits are conducted annually within six months of receipt of a completed cost report from the provider.

d. Reports of field audits are retained by the state agency for at least three years following submission of the report.

e. Facilities are paid on a cost-related basis in accordance with the methodology described in the Plan.

f. Modifications to the Plan for reimbursement will be submitted as Plan amendments.

g. Covered cost will include such items as:

(1) Cost of meeting certification standards.

(2) Routine services, which include items expense providers normally incur in the provision of services.

(3) The cost of such services provided by related organizations except as modified in the payment system at Part II (12VAC30-90-20 et seq.) of this chapter.

h. Bad debts, charity and courtesy allowances shall be excluded from allowable cost.

i. Effective for facility cost reporting periods beginning on or after October 1, 1978, the reimbursable amount will be determined prospectively on a facility by facility basis, except that mental institutions and mental retardation facilities shall continue to be reimbursed retrospectively operated by the Department of Behavioral Health and Developmental Services and effective July 1, 2002, the Virginia Veterans Care Center nursing facility by the Department of Veterans Services shall be reimbursed retrospectively. The prospective rate will be based on the prior period's actual cost (as determined by an annual cost report and verified by audit as set forth in subdivision 4 c of this section) plus an inflation factor. Payments will be made to facilities no less than monthly.

j. The payment level calculated by the prospective rate will be adequate to reimburse in full such actual allowable costs that an economically and efficiently operated facility must incur. In addition, an incentive plan will be established as described in the payment system at 12VAC30-90-20 et seq 12VAC30-90.

k. Upper limits for payment within the prospective payment system shall be as follow:

(1) Allowable cost shall be determined in accordance with Medicare principles as defined in PRM-15, except as may be modified in this plan.

(2) Reimbursement for operating costs will be limited to regional ceilings.

(3) Reimbursement, in no instance, will exceed the charges for private patients receiving the same services. In accordance with § 1903(a)(2)(B) of the Social Security Act, nursing facility costs incurred in relation to training and competency evaluation of nurse aides will be considered as State administrative expenses and, as such, shall be exempted from this provision.

l. In accordance with 42 CFR 447.205, an opportunity for public comment was permitted before final implementation of rate setting processes.

m. A detailed description of the prospective reimbursement formula is attached for supporting detail.

n. Item 398D of the 1987 Appropriation Act (as amended), effective April 8, 1987, eliminated reimbursement of return on equity capital to proprietary providers.

5. Reimbursement of nonenrolled long term care facilities.

a. Nonenrolled providers of institutional long term care services shall be reimbursed based upon the average per diem cost, updated annually, reimbursed to enrolled nursing facility providers.

b. Prior approval must be received from the DMAS for recipients to receive institutional services from nonenrolled long-term care facilities. Prior approval can only be granted:

(1) When the nonenrolled long-term care facility with an available bed is closer to the recipient's Virginia residence than the closest facility located in Virginia with an available bed;

(2) When long-term care special services, such as intensive rehabilitation services, are not available in Virginia; or

(3) If there are no available beds in Virginia facilities.

6. Specialized care services. The payment methodology for specialized care services is contained in Part XVII (12VAC30-90-350 et seq.) of the Nursing Home Payment System.

12VAC30-90-20. Nursing home payment system; generally.

A. Effective July 1, 2001, the payment methodology for nursing facility (NF) reimbursement by the Virginia Department of Medical Assistance Services (DMAS) is set forth in this part.

B. Three separate cost components are used: plant or capital, as appropriate, cost; operating cost; and nurse aide training and competency evaluation program and competency evaluation program (NATCEPs) costs. The rates, which are determined on a facility-by-facility basis, shall be based on annual cost reports filed by each provider.

C. Effective July 1, 2001, in determining the ceiling limitations, there shall be direct patient care medians established for nursing facilities in the Virginia portion of the Washington DC-MD-VA Metropolitan Statistical Area (MSA), the Richmond-Petersburg Metropolitan Statistical Area (MSA), and in the rest of the state. There shall be indirect patient care medians established for nursing facilities in the Virginia portion of the Washington DC-MD-VA MSA, for NFs with less than 61 beds in the rest of the state, and for NFs with more than 60 beds in the rest of the state. The Washington DC-MD-VA MSA and the Richmond-Petersburg MSA shall include those cities and counties as listed and changed from time to time by the Health Care Financing Administration (HCFA) Centers for Medicare and Medicaid Services (CMS). A nursing facility located in a jurisdiction which HCFA CMS adds to or removes from the Washington DC-MD-VA MSA or the Richmond-Petersburg MSA shall be placed in its new peer group, for purposes of reimbursement, at the beginning of its next fiscal year following the effective date of HCFA's final rule.

D. Institutions for mental diseases providing nursing services for individuals age 65 and older Nursing facilities operated by the Department of Behavioral Health and Developmental Services and the Department of Veterans Services shall be exempt from the prospective payment system as defined in Articles 1 (12VAC30-90-29), 3 (12VAC39-90-35 et seq.) (12VAC30-90-35 et seq.), 4 (12VAC39-90-40 et seq.) (12VAC30-90-40 et seq.), 6 (12VAC30-90-60 et seq.), and 8 (12VAC30-90-80 et seq.) of this subpart, as are mental retardation facilities and effective July 1, 2002, as is the Virginia Veterans Care Center nursing facility. All other sections of this payment system relating to reimbursable cost limitations shall apply. These facilities shall continue to be reimbursed retrospectively on the basis of reasonable costs in accordance with Medicare principles of reimbursement and Medicaid principles of reimbursement in effect on June 30, 2000, except that those that are defined as skilled nursing facilities (SNFs) and are operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services shall not be subject to the routine cost limits that are normally required and applicable under Medicare principles of reimbursement. Reimbursement to Intermediate Care Facilities for the Mentally Retarded (ICF/MR) shall be reimbursed retrospectively on the basis of reasonable costs in accordance with Medicare principles of reimbursement but limited to the highest rate paid to a state ICF/MR institution, approved each July 1 by DMAS.

E. Except as specifically modified herein, Medicare principles of reimbursement, as amended from time to time, shall be used to establish the allowable costs in the rate calculations. Allowable costs must be classified in accordance with the DMAS uniform chart of accounts (see 12VAC30-90-270 through 12VAC30-90-276) and must be identifiable and verifiable by contemporaneous documentation.

All matters of reimbursement which are part of the DMAS reimbursement system shall supersede Medicare principles of reimbursement. Wherever the DMAS reimbursement system conflicts with Medicare principles of reimbursement, the DMAS reimbursement system shall take precedence. Appendices are a part of the DMAS reimbursement system.

Article 6
New Nursing Facilities

12VAC30-90-60. Interim rate.

A. A new facility shall be defined as follows:

1. A facility that is newly enrolled and new construction has taken place through the COPN process; or

2. A facility that is newly enrolled which was previously denied payments for new admissions and was subsequently terminated from the program.

B. Upon a showing of good cause, and approval of DMAS, an existing NF that expands its bed capacity by 50% or more shall have the option of retaining its prospective rate or being treated as a new NF.

C. A replacement facility or one that has changed location may not be considered a new facility if it serves the same inpatient population. An exception may be granted by DMAS if the provider can demonstrate that the occupancy substantially changed as a result of the facility being replaced or changing location. A decline in the replacement facility's total occupancy of 20 percentage points, in the replacement facility's first cost reporting period, shall be considered to indicate a substantial change when compared to the lower of the old facility's previous two prior cost reporting periods. The replacement facility shall receive the previous operator's operating rates if it does not qualify to be considered a new facility.

D. A change in either ownership or adverse financial conditions (e.g., bankruptcy), or both, of a provider does not change a nursing facility's status to be considered a new facility.

E. Effective July 1, 2001, for all new NFs the 90% occupancy requirement for indirect and capital costs shall be waived for establishing the first cost reporting period interim rate. This first cost reporting period shall not exceed 13 months from the date of the NFs certification.

F. The 90% occupancy requirement for indirect and capital costs shall be applied to the first and subsequent cost reporting periods' actual indirect and capital costs for establishing such NFs second and future cost reporting periods' prospective reimbursement rates. The 90% occupancy requirement shall be considered as having been satisfied if the new NF achieved a 90% occupancy at any point in time during the first cost reporting period.

1. The department may grant an exception to the minimum occupancy requirement for reimbursement purposes for beds taken out of service for the purpose of renovation. In this case, the occupancy requirement shall be calculated as 90% of available bed days for the period of the exception plus 90% of licensed bed days for the remainder of the cost report year.

2. The provider shall notify DMAS and the Virginia Department of Health (VDH), Division of Long Term Care Services, Office of Licensure and Certification in advance and present a renovation plan including a reasonable timetable for when the beds will be placed back into service.

3. The provider shall keep the appropriate documentation of available beds and days during the renovation period, which will provide the evidence of the beds and days taken out of service for renovation purposes. This supporting documentation, along with a copy of the provider's notification letter to the VDH Division of Long Term Care Services, Office of Licensure and Certification shall be submitted with the filing of the provider's cost report, as applicable. The provider's notification letter shall account for the number of beds not in use for the defined period of time.

G. A new NFs interim rate for the first cost reporting period shall be determined based upon the lower of its anticipated allowable cost determined from a detailed budget (or pro forma cost report) prepared by the provider and accepted by DMAS, or the appropriate operating ceilings or charges.

H. Effective July 1, 2001, on the first day of its second cost reporting period, a new nursing facility's interim plant or capital, as appropriate, rate shall be converted to a per diem amount by dividing its allowable plant/capital costs for its first cost reporting period by 90% of the potential number of patient days for all licensed beds during the first cost reporting period.

I. During its first semiannual period of operation, a newly constructed or newly enrolled NF shall have an assigned CMI based upon its peer group's normalized average Medicaid CMI for direct patient care. An expanded NF receiving new NF treatment shall receive the CMI calculated for its last semiannual period prior to obtaining new NF status.

Group Ceiling	Hospital's Allowable Cost Per Day	$	Difference % or Ceiling	$	Sliding Scale Incentive % of Difference
$230.00	$230.00	-0-	-0-	-0-	-0-
230.00	207.00	23.00	10%	2.30	10%
230.00	172.00	57.50	25%	14.38	25%
230.00	143.00	76.00	33%	19.00	25%

F. There will be special consideration for exception to the median operating cost limits in those instances where extensive neonatal care is provided.

G. F. Disproportionate share hospitals defined.

The following criteria shall be met before a hospital is determined to be eligible for a disproportionate share payment adjustment.

1. Criteria.

a. A Medicaid inpatient utilization rate in excess of 8% for hospitals receiving Medicaid payments in the Commonwealth, or a low-income patient utilization rate exceeding 25% (as defined in the Omnibus Budget Reconciliation Act of 1987 and as amended by the Medicare Catastrophic Coverage Act of 1988); and

b. At least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to such services under a State Medicaid plan. In the case of a hospital located in a rural area (that is, an area outside of a Metropolitan Statistical Area, as defined by the Executive Office of Management and Budget), the term "obstetrician" includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.

c. Subdivision 1 b of this subsection does not apply to a hospital:

(1) At which the inpatients are predominantly individuals under 18 years of age; or

(2) Which does not offer nonemergency obstetric services as of December 21, 1987.

2. Payment adjustment.

a. Hospitals which have a disproportionately higher level of Medicaid patients shall be allowed a disproportionate share payment adjustment based on the type of hospital and on the individual hospital's Medicaid utilization. There shall be two types of hospitals: (i) Type One, consisting of state-owned teaching hospitals, and (ii) Type Two, consisting of all other hospitals. The Medicaid utilization shall be determined by dividing the number of utilization Medicaid inpatient days by the total

number of inpatient days. Each hospital with a Medicaid utilization of over 8.0% shall receive a disproportionate share payment adjustment.

b. For Type One hospitals, the disproportionate share payment adjustment shall be equal to the product of (i) the hospital's Medicaid utilization in excess of 8.0% times 11, times (ii) the lower of the prospective operating cost rate or ceiling. For Type Two hospitals, the disproportionate share payment adjustment shall be equal to the product of (i) the hospital's Medicaid utilization in excess of 8.0% times (ii) the lower of the prospective operating cost rate or ceiling.

c. No payments made under subdivision 1 or 2 of this subsection shall exceed any applicable limitations upon such payments established by federal law or regulations.

H. G. Outlier adjustments.

1. DMAS shall pay to all enrolled hospitals an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after July 1, 1991, involving exceptionally high costs for individuals under one year of age.

2. DMAS shall pay to disproportionate share hospitals (as defined in paragraph G above) subsection F of this section) an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after July 1, 1991, involving exceptionally high costs for individuals under six years of age.

3. The outlier adjustment calculation.

a. Each eligible hospital which desires to be considered for the adjustment shall submit a log which contains the information necessary to compute the mean of its Medicaid per diem operating cost of treating individuals identified in subdivision H 1 or 2 above of this subsection. This log shall contain all Medicaid claims for such individuals, including, but not limited to: (i) the patient's name and Medicaid identification number; (ii) dates of service; (iii) the remittance date paid; (iv) the number of covered days; and (v) total charges for the length of stay. Each hospital shall then calculate the per diem operating cost (which excludes capital and education) of treating such patients by multiplying the charge for each patient by the Medicaid operating cost-to-charge ratio determined from its annual cost report.

b. Each eligible hospital shall calculate the mean of its Medicaid per diem operating cost of treating individuals identified in subdivision H 1 or 2 above of this subsection. Any hospital which qualifies for the extensive neonatal care provision (as governed by paragraph F, above) shall calculate a separate mean for the cost of providing extensive neonatal care to individuals identified in subdivision H 1 or 2 above.

c. Each eligible hospital shall calculate its threshold for payment of the adjustment, at a level equal to two and one-half standard deviations above the mean or means calculated in subdivision H 3 a (ii) above of this subsection.

d. DMAS shall pay as an outlier adjustment to each eligible hospital all per diem operating costs which exceed the applicable threshold or thresholds for that hospital.

4. Pursuant to 12VAC30-50-100, there is no limit on length of time for medically necessary stays for individuals under six years of age. This section provides that consistent with 42 CFR 441.57, payment of medical assistance services shall be made on behalf of individuals under 21 years of age, who are Medicaid eligible, for medically necessary stays in acute care facilities in excess of 21 days per admission when such services are rendered for the purpose of diagnosis and treatment of health conditions identified through a physical examination. Medical documentation justifying admission and the continued length of stay must be attached to or written on the invoice for review by medical staff to determine medical necessity. Medically unjustified days in such admissions will be denied.

Part V
Inpatient Hospital Payment System

Article 1
Application of Payment Methodologies

12VAC30-70-201. Application of payment methodologies.

A. The state agency will pay for inpatient hospital services in general acute care hospitals, rehabilitation hospitals, and freestanding psychiatric facilities licensed as hospitals under a prospective payment methodology. This methodology uses both per case and per diem payment methods. Article 2 (12VAC30-70-221 et seq.) describes the prospective payment methodology, including both the per case and the per diem methods.

B. Article 3 (12VAC30-70-400 et seq.) describes a per diem methodology that applied to a portion of payment to general acute care hospitals during state fiscal years 1997 and 1998, and that will continue to apply to patient stays with admission dates prior to July 1, 1996. Inpatient hospital services that are provided in long stay hospitals and state-owned rehabilitation hospitals shall be subject to the provisions of Supplement 3 (12VAC30-70-10 through 12VAC30-70-130).

C. Inpatient hospital facilities operated by the Department of Behavioral Health and Developmental Services (DBHDS) shall be reimbursed costs. Facilities may also receive disproportionate share hospital (DSH) payments. The criteria for DSH eligibility and the payment amount shall be based on subsection F of 12VAC30-70-50. If the DSH limit is exceeded by any facility, the excess DSH payments shall be distributed to all other qualifying DBHDS facilities in proportion to the amount of DSH they otherwise receive.

C. D. Transplant services shall not be subject to the provisions of this part. Reimbursement for covered liver, heart, and bone marrow/stem cell transplant services and any other medically necessary transplantation procedures that are determined to not be experimental or investigational shall be a fee based upon the greater of a prospectively determined, procedure-specific flat fee determined by the agency or a prospectively determined, procedure-specific percentage of usual and customary charges. The flat fee reimbursement will cover procurement costs; all hospital costs from admission to discharge for the transplant procedure; and total physician costs for all physicians providing services during the hospital stay, including radiologists, pathologists, oncologists, surgeons, etc. The flat fee reimbursement does not include pre- and post-hospitalization for the transplant procedure or pretransplant evaluation. If the actual charges are lower than the fee, the agency shall reimburse the actual charges. Reimbursement for approved transplant procedures that are performed out of state will be made in the same manner as reimbursement for transplant procedures performed in the Commonwealth. Reimbursement for covered kidney and cornea transplants is at the allowed Medicaid rate. Standards for coverage of organ transplant services are in 12VAC30-50-540 through 12VAC30-50-580.

D. E. Reduction of payments methodology.

1. For state fiscal years 2003 and 2004, the Department of Medical Assistance Services (DMAS) shall reduce payments to hospitals participating in the Virginia Medicaid Program by $8,935,825 total funds, and $9,227,815 total funds respectively. For purposes of distribution, each hospital's share of the total reduction amount shall be determined as provided in this subsection.

2. Determine base for revenue forecast.

a. DMAS shall use, as a base for determining the payment reduction distribution for hospitals Type I and Type II, net Medicaid inpatient operating reimbursement and outpatient reimbursed cost, as recorded by DMAS for state fiscal year 1999 from each individual hospital settled cost reports. This figure is further reduced by 18.73%, which represents the estimated statewide HMO average percentage of Medicaid business for those hospitals engaged in HMO contracts, to arrive at net baseline proportion of non-HMO hospital Medicaid business.

b. For freestanding psychiatric hospitals, DMAS shall use estimated Medicaid revenues for the six-month period (January 1, 2001, through June 30, 2001), times two, and adjusted for inflation by 4.3% for state fiscal year 2002, 3.1% for state fiscal year 2003, and 3.7% for state fiscal year 2004, as reported by DRI-WEFA, Inc.'s, hospital input price level percentage moving average.

3. Determine forecast revenue.

a. Each Type I hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 a of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type I hospitals.

b. Each Type II, including freestanding psychiatric, hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type II hospitals.

4. Each hospital's total yearly reduction amount is equal to their respective state fiscal year 2003 and 2004 forecast reimbursement as described in subdivision 3 of this subsection, times 3.235857% for state fiscal year 2003, and 3.235857%, for the first two quarters of state fiscal year 2004 and 2.88572% for the last two quarters of state fiscal year 2004, not to be reduced by more than $500,000 per year.

5. Reductions shall occur quarterly in four amounts as offsets to remittances. Each hospital's payment reduction shall not exceed that calculated in subdivision 4 of this subsection. Payment reduction offsets not covered by claims remittance by May 15, 2003, and 2004, will be billed by invoice to each provider with the remaining balances payable by check to the Department of Medical Assistance Services before June 30, 2003, or 2004, as applicable.

12VAC30-70-351. Updating rates for inflation.

A. Each July, the Virginia moving average values as compiled and published by Global Insight (or its successor), under contract with the department shall be used to update the base year standardized operating costs per case, as determined in 12VAC30-70-361, and the base year standardized operating costs per day, as determined in 12VAC30-70-371, to the midpoint of the upcoming state fiscal year. The most current table available prior to the effective date of the new rates shall be used to inflate base year amounts to the upcoming rate year. Thus, corrections made by Global Insight (or its successor), in the moving averages that were used to update rates for previous state fiscal years shall be automatically incorporated into the moving averages that are being used to update rates for the upcoming state fiscal year.

B. The inflation adjustment for hospital operating rates, disproportionate share hospitals (DSH) payments, and graduate medical education payments shall be eliminated zero percent for fiscal year (FY) 2010, with the exception of long stay hospitals. The elimination of the inflation adjustments shall not be applicable to re-basing in FY 2011.

C. In FY 2011, hospital operating rates shall be rebased; however the 2008 base year costs shall only be increased 2.58% for inflation. For FY 2011 there shall be no inflation adjustment for graduate medical education (GME) or freestanding psychiatric facility rates. The inflation adjustment shall be eliminated for hospital operating rates, GME payments, and freestanding psychiatric facility rates for FY 2012.

12VAC30-80-20. Services that are reimbursed on a cost basis.

A. Payments for services listed below shall be on the basis of reasonable cost following the standards and principles applicable to the Title XVIII Program with the exception provided for in subdivision D 2 1 d. The upper limit for reimbursement shall be no higher than payments for Medicare patients on a facility by facility basis in accordance with 42 CFR 447.321 and 42 CFR 447.325. In no instance, however, shall charges for beneficiaries of the program be in excess of charges for private patients receiving services from the provider. The professional component for emergency room physicians shall continue to be uncovered as a component of the payment to the facility.

B. Reasonable costs will be determined from the filing of a uniform cost report by participating providers. The cost reports are due not later than 90 150 days after the provider's fiscal year end. If a complete cost report is not received within 90 150 days after the end of the provider's fiscal year, the Program shall take action in accordance with its policies to assure that an overpayment is not being made. The cost report will be judged complete when DMAS has all of the following:

1. Completed cost reporting form(s) provided by DMAS, with signed certification(s);

2. The provider's trial balance showing adjusting journal entries;

3. The provider's financial statements including, but not limited to, a balance sheet, a statement of income and expenses, a statement of retained earnings (or fund balance), and a statement of changes in financial position;

4. Schedules that reconcile financial statements and trial balance to expenses claimed in the cost report;

5. Depreciation schedule or summary;

6. Home office cost report, if applicable; and

7. Such other analytical information or supporting documents requested by DMAS when the cost reporting forms are sent to the provider.

C. Item 398 D of the 1987 Appropriation Act (as amended), effective April 8, 1987, eliminated reimbursement of return on equity capital to proprietary providers.

D. The services that are cost reimbursed are:

1. Inpatient hospital services to persons over 65 years of age in tuberculosis and mental disease hospitals.

2. 1. Outpatient hospital services including rehabilitation hospital outpatient services and excluding laboratory.

a. Definitions. The following words and terms when used in this regulation shall have the following meanings when applied to emergency services unless the context clearly indicates otherwise:

"All-inclusive" means all emergency department and ancillary service charges claimed in association with the emergency room visit, with the exception of laboratory services.

"DMAS" means the Department of Medical Assistance Services consistent with Chapter 10 (§et seq.) (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.

"Emergency hospital services" means services that are necessary to prevent the death or serious impairment of the health of the recipient. The threat to the life or health of the recipient necessitates the use of the most accessible hospital available that is equipped to furnish the services.

"Recent injury" means an injury that has occurred less than 72 hours prior to the emergency department visit.

b. Scope. DMAS shall differentiate, as determined by the attending physician's diagnosis, the kinds of care routinely rendered in emergency departments and reimburse for nonemergency care rendered in emergency departments at a reduced rate.

(1) With the exception of laboratory services, DMAS shall reimburse at a reduced and all-inclusive reimbursement rate for all services, including those obstetric and pediatric procedures contained in 12VAC30-80-160, rendered in emergency departments that DMAS determines were nonemergency care.

(2) Services determined by the attending physician to be emergencies shall be reimbursed under the existing methodologies and at the existing rates.

(3) Services performed by the attending physician that may be emergencies shall be manually reviewed. If such services meet certain criteria, they shall be paid under the methodology for subdivision 2 1 b (2) of this subsection. Services not meeting certain criteria shall be paid under the methodology of subdivision 2 1 b (1) of this subsection. Such criteria shall include, but not be limited to:

(a) The initial treatment following a recent obvious injury.

(b) Treatment related to an injury sustained more than 72 hours prior to the visit with the deterioration of the symptoms to the point of requiring medical treatment for stabilization.

(c) The initial treatment for medical emergencies including indications of severe chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness, status epilepticus, or other conditions considered life threatening.

(d) A visit in which the recipient's condition requires immediate hospital admission or the transfer to another facility for further treatment or a visit in which the recipient dies.

(e) Services provided for acute vital sign changes as specified in the provider manual.

(f) Services provided for severe pain when combined with one or more of the other guidelines.

(4) Payment shall be determined based on ICD-9-CM diagnosis codes and necessary supporting documentation.

(5) DMAS shall review on an ongoing basis the effectiveness of this program in achieving its objectives and for its effect on recipients, physicians, and hospitals. Program components may be revised subject to achieving program intent, the accuracy and effectiveness of the ICD-9-CM code designations, and the impact on recipients and providers.

c. Limitation to 80% of allowable cost. Effective for services on and after July 1, 2003, reimbursement of Type Two hospitals for outpatient services shall be at 80% of allowable cost, with cost to be determined as provided in subsections A, B, and C of this section. For hospitals with fiscal years that do not begin on July 1, 2003, outpatient costs, both operating and capital, for the fiscal year in progress on that date shall be apportioned between the time period before and the time period after that date, based on the number of calendar months in the cost reporting period, falling before and after that date. Operating costs apportioned before that date shall be settled according to the principles in effect before that date, and those after at 80% of allowable cost. Capital costs apportioned before that date shall be settled according to the principles in effect before that date, and those after at 80% of allowable cost. Operating and capital costs of Type One hospitals shall continue to be reimbursed at 94.2% and 90% of cost respectively.

d. Outpatient reimbursement methodology prior to July 1, 2003. DMAS shall continue to reimburse for outpatient hospital services, with the exception of direct graduate medical education for interns and residents, at 100% of reasonable costs less a 10% reduction for allowable capital costs and a 5.8% reduction for allowable operating costs. This methodology shall continue to be in effect after July 1, 2003, for Type One hospitals.

e. Payment for direct medical education costs of nursing schools, paramedical programs and graduate medical education for interns and residents.

(1) Direct medical education costs of nursing schools and paramedical programs shall continue to be paid on an allowable cost basis.

(2) Effective with cost reporting periods beginning on or after July 1, 2002, direct graduate medical education (GME) costs for interns and residents shall be reimbursed on a per-resident prospective basis. See 12VAC30-70-281 for prospective payment methodology for graduate medical education for interns and residents.

3. 2. Rehabilitation agencies operated by community services boards. For reimbursement methodology applicable to other rehabilitation agencies, see 12VAC30-80-200. Reimbursement for physical therapy, occupational therapy, and speech-language therapy services shall not be provided for any sums that the rehabilitation provider collects, or is entitled to collect, from the NF or any other available source, and provided further, that this amendment shall in no way diminish any obligation of the NF to DMAS to provide its residents such services, as set forth in any applicable provider agreement.

4. Rehabilitation hospital outpatient services.

Part I
Methods and Standards for Establishing Payment Rates for Long-Term Care

12VAC30-90-10. Methods and standards for establishing payment rates for long-term care.

The policy and the method to be used in establishing payment rates for nursing facilities listed in § 1905(a) of the Social Security Act and included in this State Plan for Medical Assistance are described in the following paragraphs.

1. Reimbursement and payment criteria will be established which are designed to enlist participation of a sufficient number of providers of services in the Program so that eligible persons can receive the medical care and services included in the Plan to the extent these are available to the general population.

2. Participation in the Program will be limited to providers of services who accept, as payment in full, the amounts so paid.

3. Payment for care of service will not exceed the amounts indicated to be reimbursed in accord with the policy and the methods described in the Plan and payments will not be made in excess of the upper limits described in 42 CFR 447.253(b)(2). The state agency has continuing access to data identifying the maximum charges allowed. Such data will be made available to the Secretary of Health and Human Services upon request.

4. Payments for services to nursing facilities shall be on the basis of reasonable cost in accordance with the standards and principles set forth in 42 CFR 447.252 as follows:

a. A uniform annual cost report which itemizes allowable cost will be required to be filed within 150 days of each provider's fiscal year end.

b. The determination of allowable costs will be in accordance with Medicare principles as established in the Provider Reimbursement Manual (PRM-15) except where otherwise noted in this Plan.

c. Field audits will be conducted on the cost data submitted by the provider to verify the accuracy and reasonableness of such data. Audits will be conducted for each facility on a periodic basis as determined from internal desk audits and more often as required. Audit procedures are in conformance with SSA standards set forth in PRM-13-2. Internal desk audits are conducted annually within six months of receipt of a completed cost report from the provider.

d. Reports of field audits are retained by the state agency for at least three years following submission of the report.

e. Facilities are paid on a cost-related basis in accordance with the methodology described in the Plan.

f. Modifications to the Plan for reimbursement will be submitted as Plan amendments.

g. Covered cost will include such items as:

(1) Cost of meeting certification standards.

(2) Routine services, which include items expense providers normally incur in the provision of services.

(3) The cost of such services provided by related organizations except as modified in the payment system at Part II (12VAC30-90-20 et seq.) of this chapter.

h. Bad debts, charity and courtesy allowances shall be excluded from allowable cost.

i. Effective for facility cost reporting periods beginning on or after October 1, 1978, the reimbursable amount will be determined prospectively on a facility by facility basis, except that mental institutions and mental retardation facilities shall continue to be reimbursed retrospectively operated by the Department of Behavioral Health and Developmental Services and effective July 1, 2002, the Virginia Veterans Care Center nursing facility by the Department of Veterans Services shall be reimbursed retrospectively. The prospective rate will be based on the prior period's actual cost (as determined by an annual cost report and verified by audit as set forth in subdivision 4 c of this section) plus an inflation factor. Payments will be made to facilities no less than monthly.

j. The payment level calculated by the prospective rate will be adequate to reimburse in full such actual allowable costs that an economically and efficiently operated facility must incur. In addition, an incentive plan will be established as described in the payment system at 12VAC30-90-20 et seq 12VAC30-90.

k. Upper limits for payment within the prospective payment system shall be as follow:

(1) Allowable cost shall be determined in accordance with Medicare principles as defined in PRM-15, except as may be modified in this plan.

(2) Reimbursement for operating costs will be limited to regional ceilings.

(3) Reimbursement, in no instance, will exceed the charges for private patients receiving the same services. In accordance with § 1903(a)(2)(B) of the Social Security Act, nursing facility costs incurred in relation to training and competency evaluation of nurse aides will be considered as State administrative expenses and, as such, shall be exempted from this provision.

l. In accordance with 42 CFR 447.205, an opportunity for public comment was permitted before final implementation of rate setting processes.

m. A detailed description of the prospective reimbursement formula is attached for supporting detail.

n. Item 398D of the 1987 Appropriation Act (as amended), effective April 8, 1987, eliminated reimbursement of return on equity capital to proprietary providers.

5. Reimbursement of nonenrolled long term care facilities.

a. Nonenrolled providers of institutional long term care services shall be reimbursed based upon the average per diem cost, updated annually, reimbursed to enrolled nursing facility providers.

b. Prior approval must be received from the DMAS for recipients to receive institutional services from nonenrolled long-term care facilities. Prior approval can only be granted:

(1) When the nonenrolled long-term care facility with an available bed is closer to the recipient's Virginia residence than the closest facility located in Virginia with an available bed;

(2) When long-term care special services, such as intensive rehabilitation services, are not available in Virginia; or

(3) If there are no available beds in Virginia facilities.

6. Specialized care services. The payment methodology for specialized care services is contained in Part XVII (12VAC30-90-350 et seq.) of the Nursing Home Payment System.

12VAC30-90-20. Nursing home payment system; generally.

A. Effective July 1, 2001, the payment methodology for nursing facility (NF) reimbursement by the Virginia Department of Medical Assistance Services (DMAS) is set forth in this part.

B. Three separate cost components are used: plant or capital, as appropriate, cost; operating cost; and nurse aide training and competency evaluation program and competency evaluation program (NATCEPs) costs. The rates, which are determined on a facility-by-facility basis, shall be based on annual cost reports filed by each provider.

C. Effective July 1, 2001, in determining the ceiling limitations, there shall be direct patient care medians established for nursing facilities in the Virginia portion of the Washington DC-MD-VA Metropolitan Statistical Area (MSA), the Richmond-Petersburg Metropolitan Statistical Area (MSA), and in the rest of the state. There shall be indirect patient care medians established for nursing facilities in the Virginia portion of the Washington DC-MD-VA MSA, for NFs with less than 61 beds in the rest of the state, and for NFs with more than 60 beds in the rest of the state. The Washington DC-MD-VA MSA and the Richmond-Petersburg MSA shall include those cities and counties as listed and changed from time to time by the Health Care Financing Administration (HCFA) Centers for Medicare and Medicaid Services (CMS). A nursing facility located in a jurisdiction which HCFA CMS adds to or removes from the Washington DC-MD-VA MSA or the Richmond-Petersburg MSA shall be placed in its new peer group, for purposes of reimbursement, at the beginning of its next fiscal year following the effective date of HCFA's final rule.

D. Institutions for mental diseases providing nursing services for individuals age 65 and older Nursing facilities operated by the Department of Behavioral Health and Developmental Services and the Department of Veterans Services shall be exempt from the prospective payment system as defined in Articles 1 (12VAC30-90-29), 3 (12VAC39-90-35 et seq.) (12VAC30-90-35 et seq.), 4 (12VAC39-90-40 et seq.) (12VAC30-90-40 et seq.), 6 (12VAC30-90-60 et seq.), and 8 (12VAC30-90-80 et seq.) of this subpart, as are mental retardation facilities and effective July 1, 2002, as is the Virginia Veterans Care Center nursing facility. All other sections of this payment system relating to reimbursable cost limitations shall apply. These facilities shall continue to be reimbursed retrospectively on the basis of reasonable costs in accordance with Medicare principles of reimbursement and Medicaid principles of reimbursement in effect on June 30, 2000, except that those that are defined as skilled nursing facilities (SNFs) and are operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services shall not be subject to the routine cost limits that are normally required and applicable under Medicare principles of reimbursement. Reimbursement to Intermediate Care Facilities for the Mentally Retarded (ICF/MR) shall be reimbursed retrospectively on the basis of reasonable costs in accordance with Medicare principles of reimbursement but limited to the highest rate paid to a state ICF/MR institution, approved each July 1 by DMAS.

E. Except as specifically modified herein, Medicare principles of reimbursement, as amended from time to time, shall be used to establish the allowable costs in the rate calculations. Allowable costs must be classified in accordance with the DMAS uniform chart of accounts (see 12VAC30-90-270 through 12VAC30-90-276) and must be identifiable and verifiable by contemporaneous documentation.

All matters of reimbursement which are part of the DMAS reimbursement system shall supersede Medicare principles of reimbursement. Wherever the DMAS reimbursement system conflicts with Medicare principles of reimbursement, the DMAS reimbursement system shall take precedence. Appendices are a part of the DMAS reimbursement system.

Article 6
New Nursing Facilities

12VAC30-90-60. Interim rate.

A. A new facility shall be defined as follows:

1. A facility that is newly enrolled and new construction has taken place through the COPN process; or

2. A facility that is newly enrolled which was previously denied payments for new admissions and was subsequently terminated from the program.

B. Upon a showing of good cause, and approval of DMAS, an existing NF that expands its bed capacity by 50% or more shall have the option of retaining its prospective rate or being treated as a new NF.

C. A replacement facility or one that has changed location may not be considered a new facility if it serves the same inpatient population. An exception may be granted by DMAS if the provider can demonstrate that the occupancy substantially changed as a result of the facility being replaced or changing location. A decline in the replacement facility's total occupancy of 20 percentage points, in the replacement facility's first cost reporting period, shall be considered to indicate a substantial change when compared to the lower of the old facility's previous two prior cost reporting periods. The replacement facility shall receive the previous operator's operating rates if it does not qualify to be considered a new facility.

D. A change in either ownership or adverse financial conditions (e.g., bankruptcy), or both, of a provider does not change a nursing facility's status to be considered a new facility.

E. Effective July 1, 2001, for all new NFs the 90% occupancy requirement for indirect and capital costs shall be waived for establishing the first cost reporting period interim rate. This first cost reporting period shall not exceed 13 months from the date of the NFs certification.

F. The 90% occupancy requirement for indirect and capital costs shall be applied to the first and subsequent cost reporting periods' actual indirect and capital costs for establishing such NFs second and future cost reporting periods' prospective reimbursement rates. The 90% occupancy requirement shall be considered as having been satisfied if the new NF achieved a 90% occupancy at any point in time during the first cost reporting period.

1. The department may grant an exception to the minimum occupancy requirement for reimbursement purposes for beds taken out of service for the purpose of renovation. In this case, the occupancy requirement shall be calculated as 90% of available bed days for the period of the exception plus 90% of licensed bed days for the remainder of the cost report year.

2. The provider shall notify DMAS and the Virginia Department of Health (VDH), Division of Long Term Care Services, Office of Licensure and Certification in advance and present a renovation plan including a reasonable timetable for when the beds will be placed back into service.

3. The provider shall keep the appropriate documentation of available beds and days during the renovation period, which will provide the evidence of the beds and days taken out of service for renovation purposes. This supporting documentation, along with a copy of the provider's notification letter to the VDH Division of Long Term Care Services, Office of Licensure and Certification shall be submitted with the filing of the provider's cost report, as applicable. The provider's notification letter shall account for the number of beds not in use for the defined period of time.

G. A new NFs interim rate for the first cost reporting period shall be determined based upon the lower of its anticipated allowable cost determined from a detailed budget (or pro forma cost report) prepared by the provider and accepted by DMAS, or the appropriate operating ceilings or charges.

H. Effective July 1, 2001, on the first day of its second cost reporting period, a new nursing facility's interim plant or capital, as appropriate, rate shall be converted to a per diem amount by dividing its allowable plant/capital costs for its first cost reporting period by 90% of the potential number of patient days for all licensed beds during the first cost reporting period.

I. During its first semiannual period of operation, a newly constructed or newly enrolled NF shall have an assigned CMI based upon its peer group's normalized average Medicaid CMI for direct patient care. An expanded NF receiving new NF treatment shall receive the CMI calculated for its last semiannual period prior to obtaining new NF status.

Group Ceiling	Hospital's Allowable Cost Per Day	$	Difference % or Ceiling	$	Sliding Scale Incentive % of Difference
$230.00	$230.00	-0-	-0-	-0-	-0-
230.00	207.00	23.00	10%	2.30	10%
230.00	172.00	57.50	25%	14.38	25%
230.00	143.00	76.00	33%	19.00	25%

F. There will be special consideration for exception to the median operating cost limits in those instances where extensive neonatal care is provided.

G. F. Disproportionate share hospitals defined.

The following criteria shall be met before a hospital is determined to be eligible for a disproportionate share payment adjustment.

1. Criteria.

a. A Medicaid inpatient utilization rate in excess of 8% for hospitals receiving Medicaid payments in the Commonwealth, or a low-income patient utilization rate exceeding 25% (as defined in the Omnibus Budget Reconciliation Act of 1987 and as amended by the Medicare Catastrophic Coverage Act of 1988); and

b. At least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to such services under a State Medicaid plan. In the case of a hospital located in a rural area (that is, an area outside of a Metropolitan Statistical Area, as defined by the Executive Office of Management and Budget), the term "obstetrician" includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.

c. Subdivision 1 b of this subsection does not apply to a hospital:

(1) At which the inpatients are predominantly individuals under 18 years of age; or

(2) Which does not offer nonemergency obstetric services as of December 21, 1987.

2. Payment adjustment.

a. Hospitals which have a disproportionately higher level of Medicaid patients shall be allowed a disproportionate share payment adjustment based on the type of hospital and on the individual hospital's Medicaid utilization. There shall be two types of hospitals: (i) Type One, consisting of state-owned teaching hospitals, and (ii) Type Two, consisting of all other hospitals. The Medicaid utilization shall be determined by dividing the number of utilization Medicaid inpatient days by the total

number of inpatient days. Each hospital with a Medicaid utilization of over 8.0% shall receive a disproportionate share payment adjustment.

b. For Type One hospitals, the disproportionate share payment adjustment shall be equal to the product of (i) the hospital's Medicaid utilization in excess of 8.0% times 11, times (ii) the lower of the prospective operating cost rate or ceiling. For Type Two hospitals, the disproportionate share payment adjustment shall be equal to the product of (i) the hospital's Medicaid utilization in excess of 8.0% times (ii) the lower of the prospective operating cost rate or ceiling.

c. No payments made under subdivision 1 or 2 of this subsection shall exceed any applicable limitations upon such payments established by federal law or regulations.

H. G. Outlier adjustments.

1. DMAS shall pay to all enrolled hospitals an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after July 1, 1991, involving exceptionally high costs for individuals under one year of age.

2. DMAS shall pay to disproportionate share hospitals (as defined in paragraph G above) subsection F of this section) an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after July 1, 1991, involving exceptionally high costs for individuals under six years of age.

3. The outlier adjustment calculation.

a. Each eligible hospital which desires to be considered for the adjustment shall submit a log which contains the information necessary to compute the mean of its Medicaid per diem operating cost of treating individuals identified in subdivision H 1 or 2 above of this subsection. This log shall contain all Medicaid claims for such individuals, including, but not limited to: (i) the patient's name and Medicaid identification number; (ii) dates of service; (iii) the remittance date paid; (iv) the number of covered days; and (v) total charges for the length of stay. Each hospital shall then calculate the per diem operating cost (which excludes capital and education) of treating such patients by multiplying the charge for each patient by the Medicaid operating cost-to-charge ratio determined from its annual cost report.

b. Each eligible hospital shall calculate the mean of its Medicaid per diem operating cost of treating individuals identified in subdivision H 1 or 2 above of this subsection. Any hospital which qualifies for the extensive neonatal care provision (as governed by paragraph F, above) shall calculate a separate mean for the cost of providing extensive neonatal care to individuals identified in subdivision H 1 or 2 above.

c. Each eligible hospital shall calculate its threshold for payment of the adjustment, at a level equal to two and one-half standard deviations above the mean or means calculated in subdivision H 3 a (ii) above of this subsection.

d. DMAS shall pay as an outlier adjustment to each eligible hospital all per diem operating costs which exceed the applicable threshold or thresholds for that hospital.

4. Pursuant to 12VAC30-50-100, there is no limit on length of time for medically necessary stays for individuals under six years of age. This section provides that consistent with 42 CFR 441.57, payment of medical assistance services shall be made on behalf of individuals under 21 years of age, who are Medicaid eligible, for medically necessary stays in acute care facilities in excess of 21 days per admission when such services are rendered for the purpose of diagnosis and treatment of health conditions identified through a physical examination. Medical documentation justifying admission and the continued length of stay must be attached to or written on the invoice for review by medical staff to determine medical necessity. Medically unjustified days in such admissions will be denied.

Part V
Inpatient Hospital Payment System

Article 1
Application of Payment Methodologies

12VAC30-70-201. Application of payment methodologies.

A. The state agency will pay for inpatient hospital services in general acute care hospitals, rehabilitation hospitals, and freestanding psychiatric facilities licensed as hospitals under a prospective payment methodology. This methodology uses both per case and per diem payment methods. Article 2 (12VAC30-70-221 et seq.) describes the prospective payment methodology, including both the per case and the per diem methods.

B. Article 3 (12VAC30-70-400 et seq.) describes a per diem methodology that applied to a portion of payment to general acute care hospitals during state fiscal years 1997 and 1998, and that will continue to apply to patient stays with admission dates prior to July 1, 1996. Inpatient hospital services that are provided in long stay hospitals and state-owned rehabilitation hospitals shall be subject to the provisions of Supplement 3 (12VAC30-70-10 through 12VAC30-70-130).

C. Inpatient hospital facilities operated by the Department of Behavioral Health and Developmental Services (DBHDS) shall be reimbursed costs. Facilities may also receive disproportionate share hospital (DSH) payments. The criteria for DSH eligibility and the payment amount shall be based on subsection F of 12VAC30-70-50. If the DSH limit is exceeded by any facility, the excess DSH payments shall be distributed to all other qualifying DBHDS facilities in proportion to the amount of DSH they otherwise receive.

C. D. Transplant services shall not be subject to the provisions of this part. Reimbursement for covered liver, heart, and bone marrow/stem cell transplant services and any other medically necessary transplantation procedures that are determined to not be experimental or investigational shall be a fee based upon the greater of a prospectively determined, procedure-specific flat fee determined by the agency or a prospectively determined, procedure-specific percentage of usual and customary charges. The flat fee reimbursement will cover procurement costs; all hospital costs from admission to discharge for the transplant procedure; and total physician costs for all physicians providing services during the hospital stay, including radiologists, pathologists, oncologists, surgeons, etc. The flat fee reimbursement does not include pre- and post-hospitalization for the transplant procedure or pretransplant evaluation. If the actual charges are lower than the fee, the agency shall reimburse the actual charges. Reimbursement for approved transplant procedures that are performed out of state will be made in the same manner as reimbursement for transplant procedures performed in the Commonwealth. Reimbursement for covered kidney and cornea transplants is at the allowed Medicaid rate. Standards for coverage of organ transplant services are in 12VAC30-50-540 through 12VAC30-50-580.

D. E. Reduction of payments methodology.

1. For state fiscal years 2003 and 2004, the Department of Medical Assistance Services (DMAS) shall reduce payments to hospitals participating in the Virginia Medicaid Program by $8,935,825 total funds, and $9,227,815 total funds respectively. For purposes of distribution, each hospital's share of the total reduction amount shall be determined as provided in this subsection.

2. Determine base for revenue forecast.

a. DMAS shall use, as a base for determining the payment reduction distribution for hospitals Type I and Type II, net Medicaid inpatient operating reimbursement and outpatient reimbursed cost, as recorded by DMAS for state fiscal year 1999 from each individual hospital settled cost reports. This figure is further reduced by 18.73%, which represents the estimated statewide HMO average percentage of Medicaid business for those hospitals engaged in HMO contracts, to arrive at net baseline proportion of non-HMO hospital Medicaid business.

b. For freestanding psychiatric hospitals, DMAS shall use estimated Medicaid revenues for the six-month period (January 1, 2001, through June 30, 2001), times two, and adjusted for inflation by 4.3% for state fiscal year 2002, 3.1% for state fiscal year 2003, and 3.7% for state fiscal year 2004, as reported by DRI-WEFA, Inc.'s, hospital input price level percentage moving average.

3. Determine forecast revenue.

a. Each Type I hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 a of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type I hospitals.

b. Each Type II, including freestanding psychiatric, hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type II hospitals.

4. Each hospital's total yearly reduction amount is equal to their respective state fiscal year 2003 and 2004 forecast reimbursement as described in subdivision 3 of this subsection, times 3.235857% for state fiscal year 2003, and 3.235857%, for the first two quarters of state fiscal year 2004 and 2.88572% for the last two quarters of state fiscal year 2004, not to be reduced by more than $500,000 per year.

5. Reductions shall occur quarterly in four amounts as offsets to remittances. Each hospital's payment reduction shall not exceed that calculated in subdivision 4 of this subsection. Payment reduction offsets not covered by claims remittance by May 15, 2003, and 2004, will be billed by invoice to each provider with the remaining balances payable by check to the Department of Medical Assistance Services before June 30, 2003, or 2004, as applicable.

12VAC30-70-351. Updating rates for inflation.

A. Each July, the Virginia moving average values as compiled and published by Global Insight (or its successor), under contract with the department shall be used to update the base year standardized operating costs per case, as determined in 12VAC30-70-361, and the base year standardized operating costs per day, as determined in 12VAC30-70-371, to the midpoint of the upcoming state fiscal year. The most current table available prior to the effective date of the new rates shall be used to inflate base year amounts to the upcoming rate year. Thus, corrections made by Global Insight (or its successor), in the moving averages that were used to update rates for previous state fiscal years shall be automatically incorporated into the moving averages that are being used to update rates for the upcoming state fiscal year.

B. The inflation adjustment for hospital operating rates, disproportionate share hospitals (DSH) payments, and graduate medical education payments shall be eliminated zero percent for fiscal year (FY) 2010, with the exception of long stay hospitals. The elimination of the inflation adjustments shall not be applicable to re-basing in FY 2011.

C. In FY 2011, hospital operating rates shall be rebased; however the 2008 base year costs shall only be increased 2.58% for inflation. For FY 2011 there shall be no inflation adjustment for graduate medical education (GME) or freestanding psychiatric facility rates. The inflation adjustment shall be eliminated for hospital operating rates, GME payments, and freestanding psychiatric facility rates for FY 2012.

12VAC30-80-20. Services that are reimbursed on a cost basis.

A. Payments for services listed below shall be on the basis of reasonable cost following the standards and principles applicable to the Title XVIII Program with the exception provided for in subdivision D 2 1 d. The upper limit for reimbursement shall be no higher than payments for Medicare patients on a facility by facility basis in accordance with 42 CFR 447.321 and 42 CFR 447.325. In no instance, however, shall charges for beneficiaries of the program be in excess of charges for private patients receiving services from the provider. The professional component for emergency room physicians shall continue to be uncovered as a component of the payment to the facility.

B. Reasonable costs will be determined from the filing of a uniform cost report by participating providers. The cost reports are due not later than 90 150 days after the provider's fiscal year end. If a complete cost report is not received within 90 150 days after the end of the provider's fiscal year, the Program shall take action in accordance with its policies to assure that an overpayment is not being made. The cost report will be judged complete when DMAS has all of the following:

1. Completed cost reporting form(s) provided by DMAS, with signed certification(s);

2. The provider's trial balance showing adjusting journal entries;

3. The provider's financial statements including, but not limited to, a balance sheet, a statement of income and expenses, a statement of retained earnings (or fund balance), and a statement of changes in financial position;

4. Schedules that reconcile financial statements and trial balance to expenses claimed in the cost report;

5. Depreciation schedule or summary;

6. Home office cost report, if applicable; and

7. Such other analytical information or supporting documents requested by DMAS when the cost reporting forms are sent to the provider.

C. Item 398 D of the 1987 Appropriation Act (as amended), effective April 8, 1987, eliminated reimbursement of return on equity capital to proprietary providers.

D. The services that are cost reimbursed are:

1. Inpatient hospital services to persons over 65 years of age in tuberculosis and mental disease hospitals.

2. 1. Outpatient hospital services including rehabilitation hospital outpatient services and excluding laboratory.

a. Definitions. The following words and terms when used in this regulation shall have the following meanings when applied to emergency services unless the context clearly indicates otherwise:

"All-inclusive" means all emergency department and ancillary service charges claimed in association with the emergency room visit, with the exception of laboratory services.

"DMAS" means the Department of Medical Assistance Services consistent with Chapter 10 (§et seq.) (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.

"Emergency hospital services" means services that are necessary to prevent the death or serious impairment of the health of the recipient. The threat to the life or health of the recipient necessitates the use of the most accessible hospital available that is equipped to furnish the services.

"Recent injury" means an injury that has occurred less than 72 hours prior to the emergency department visit.

b. Scope. DMAS shall differentiate, as determined by the attending physician's diagnosis, the kinds of care routinely rendered in emergency departments and reimburse for nonemergency care rendered in emergency departments at a reduced rate.

(1) With the exception of laboratory services, DMAS shall reimburse at a reduced and all-inclusive reimbursement rate for all services, including those obstetric and pediatric procedures contained in 12VAC30-80-160, rendered in emergency departments that DMAS determines were nonemergency care.

(2) Services determined by the attending physician to be emergencies shall be reimbursed under the existing methodologies and at the existing rates.

(3) Services performed by the attending physician that may be emergencies shall be manually reviewed. If such services meet certain criteria, they shall be paid under the methodology for subdivision 2 1 b (2) of this subsection. Services not meeting certain criteria shall be paid under the methodology of subdivision 2 1 b (1) of this subsection. Such criteria shall include, but not be limited to:

(a) The initial treatment following a recent obvious injury.

(b) Treatment related to an injury sustained more than 72 hours prior to the visit with the deterioration of the symptoms to the point of requiring medical treatment for stabilization.

(c) The initial treatment for medical emergencies including indications of severe chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness, status epilepticus, or other conditions considered life threatening.

(d) A visit in which the recipient's condition requires immediate hospital admission or the transfer to another facility for further treatment or a visit in which the recipient dies.

(e) Services provided for acute vital sign changes as specified in the provider manual.

(f) Services provided for severe pain when combined with one or more of the other guidelines.

(4) Payment shall be determined based on ICD-9-CM diagnosis codes and necessary supporting documentation.

(5) DMAS shall review on an ongoing basis the effectiveness of this program in achieving its objectives and for its effect on recipients, physicians, and hospitals. Program components may be revised subject to achieving program intent, the accuracy and effectiveness of the ICD-9-CM code designations, and the impact on recipients and providers.

c. Limitation to 80% of allowable cost. Effective for services on and after July 1, 2003, reimbursement of Type Two hospitals for outpatient services shall be at 80% of allowable cost, with cost to be determined as provided in subsections A, B, and C of this section. For hospitals with fiscal years that do not begin on July 1, 2003, outpatient costs, both operating and capital, for the fiscal year in progress on that date shall be apportioned between the time period before and the time period after that date, based on the number of calendar months in the cost reporting period, falling before and after that date. Operating costs apportioned before that date shall be settled according to the principles in effect before that date, and those after at 80% of allowable cost. Capital costs apportioned before that date shall be settled according to the principles in effect before that date, and those after at 80% of allowable cost. Operating and capital costs of Type One hospitals shall continue to be reimbursed at 94.2% and 90% of cost respectively.

d. Outpatient reimbursement methodology prior to July 1, 2003. DMAS shall continue to reimburse for outpatient hospital services, with the exception of direct graduate medical education for interns and residents, at 100% of reasonable costs less a 10% reduction for allowable capital costs and a 5.8% reduction for allowable operating costs. This methodology shall continue to be in effect after July 1, 2003, for Type One hospitals.

e. Payment for direct medical education costs of nursing schools, paramedical programs and graduate medical education for interns and residents.

(1) Direct medical education costs of nursing schools and paramedical programs shall continue to be paid on an allowable cost basis.

(2) Effective with cost reporting periods beginning on or after July 1, 2002, direct graduate medical education (GME) costs for interns and residents shall be reimbursed on a per-resident prospective basis. See 12VAC30-70-281 for prospective payment methodology for graduate medical education for interns and residents.

3. 2. Rehabilitation agencies operated by community services boards. For reimbursement methodology applicable to other rehabilitation agencies, see 12VAC30-80-200. Reimbursement for physical therapy, occupational therapy, and speech-language therapy services shall not be provided for any sums that the rehabilitation provider collects, or is entitled to collect, from the NF or any other available source, and provided further, that this amendment shall in no way diminish any obligation of the NF to DMAS to provide its residents such services, as set forth in any applicable provider agreement.

4. Rehabilitation hospital outpatient services.

Part I
Methods and Standards for Establishing Payment Rates for Long-Term Care

12VAC30-90-10. Methods and standards for establishing payment rates for long-term care.

The policy and the method to be used in establishing payment rates for nursing facilities listed in § 1905(a) of the Social Security Act and included in this State Plan for Medical Assistance are described in the following paragraphs.

1. Reimbursement and payment criteria will be established which are designed to enlist participation of a sufficient number of providers of services in the Program so that eligible persons can receive the medical care and services included in the Plan to the extent these are available to the general population.

2. Participation in the Program will be limited to providers of services who accept, as payment in full, the amounts so paid.

3. Payment for care of service will not exceed the amounts indicated to be reimbursed in accord with the policy and the methods described in the Plan and payments will not be made in excess of the upper limits described in 42 CFR 447.253(b)(2). The state agency has continuing access to data identifying the maximum charges allowed. Such data will be made available to the Secretary of Health and Human Services upon request.

4. Payments for services to nursing facilities shall be on the basis of reasonable cost in accordance with the standards and principles set forth in 42 CFR 447.252 as follows:

a. A uniform annual cost report which itemizes allowable cost will be required to be filed within 150 days of each provider's fiscal year end.

b. The determination of allowable costs will be in accordance with Medicare principles as established in the Provider Reimbursement Manual (PRM-15) except where otherwise noted in this Plan.

c. Field audits will be conducted on the cost data submitted by the provider to verify the accuracy and reasonableness of such data. Audits will be conducted for each facility on a periodic basis as determined from internal desk audits and more often as required. Audit procedures are in conformance with SSA standards set forth in PRM-13-2. Internal desk audits are conducted annually within six months of receipt of a completed cost report from the provider.

d. Reports of field audits are retained by the state agency for at least three years following submission of the report.

e. Facilities are paid on a cost-related basis in accordance with the methodology described in the Plan.

f. Modifications to the Plan for reimbursement will be submitted as Plan amendments.

g. Covered cost will include such items as:

(1) Cost of meeting certification standards.

(2) Routine services, which include items expense providers normally incur in the provision of services.

(3) The cost of such services provided by related organizations except as modified in the payment system at Part II (12VAC30-90-20 et seq.) of this chapter.

h. Bad debts, charity and courtesy allowances shall be excluded from allowable cost.

i. Effective for facility cost reporting periods beginning on or after October 1, 1978, the reimbursable amount will be determined prospectively on a facility by facility basis, except that mental institutions and mental retardation facilities shall continue to be reimbursed retrospectively operated by the Department of Behavioral Health and Developmental Services and effective July 1, 2002, the Virginia Veterans Care Center nursing facility by the Department of Veterans Services shall be reimbursed retrospectively. The prospective rate will be based on the prior period's actual cost (as determined by an annual cost report and verified by audit as set forth in subdivision 4 c of this section) plus an inflation factor. Payments will be made to facilities no less than monthly.

j. The payment level calculated by the prospective rate will be adequate to reimburse in full such actual allowable costs that an economically and efficiently operated facility must incur. In addition, an incentive plan will be established as described in the payment system at 12VAC30-90-20 et seq 12VAC30-90.

k. Upper limits for payment within the prospective payment system shall be as follow:

(1) Allowable cost shall be determined in accordance with Medicare principles as defined in PRM-15, except as may be modified in this plan.

(2) Reimbursement for operating costs will be limited to regional ceilings.

(3) Reimbursement, in no instance, will exceed the charges for private patients receiving the same services. In accordance with § 1903(a)(2)(B) of the Social Security Act, nursing facility costs incurred in relation to training and competency evaluation of nurse aides will be considered as State administrative expenses and, as such, shall be exempted from this provision.

l. In accordance with 42 CFR 447.205, an opportunity for public comment was permitted before final implementation of rate setting processes.

m. A detailed description of the prospective reimbursement formula is attached for supporting detail.

n. Item 398D of the 1987 Appropriation Act (as amended), effective April 8, 1987, eliminated reimbursement of return on equity capital to proprietary providers.

5. Reimbursement of nonenrolled long term care facilities.

a. Nonenrolled providers of institutional long term care services shall be reimbursed based upon the average per diem cost, updated annually, reimbursed to enrolled nursing facility providers.

b. Prior approval must be received from the DMAS for recipients to receive institutional services from nonenrolled long-term care facilities. Prior approval can only be granted:

(1) When the nonenrolled long-term care facility with an available bed is closer to the recipient's Virginia residence than the closest facility located in Virginia with an available bed;

(2) When long-term care special services, such as intensive rehabilitation services, are not available in Virginia; or

(3) If there are no available beds in Virginia facilities.

6. Specialized care services. The payment methodology for specialized care services is contained in Part XVII (12VAC30-90-350 et seq.) of the Nursing Home Payment System.

12VAC30-90-20. Nursing home payment system; generally.

A. Effective July 1, 2001, the payment methodology for nursing facility (NF) reimbursement by the Virginia Department of Medical Assistance Services (DMAS) is set forth in this part.

B. Three separate cost components are used: plant or capital, as appropriate, cost; operating cost; and nurse aide training and competency evaluation program and competency evaluation program (NATCEPs) costs. The rates, which are determined on a facility-by-facility basis, shall be based on annual cost reports filed by each provider.

C. Effective July 1, 2001, in determining the ceiling limitations, there shall be direct patient care medians established for nursing facilities in the Virginia portion of the Washington DC-MD-VA Metropolitan Statistical Area (MSA), the Richmond-Petersburg Metropolitan Statistical Area (MSA), and in the rest of the state. There shall be indirect patient care medians established for nursing facilities in the Virginia portion of the Washington DC-MD-VA MSA, for NFs with less than 61 beds in the rest of the state, and for NFs with more than 60 beds in the rest of the state. The Washington DC-MD-VA MSA and the Richmond-Petersburg MSA shall include those cities and counties as listed and changed from time to time by the Health Care Financing Administration (HCFA) Centers for Medicare and Medicaid Services (CMS). A nursing facility located in a jurisdiction which HCFA CMS adds to or removes from the Washington DC-MD-VA MSA or the Richmond-Petersburg MSA shall be placed in its new peer group, for purposes of reimbursement, at the beginning of its next fiscal year following the effective date of HCFA's final rule.

D. Institutions for mental diseases providing nursing services for individuals age 65 and older Nursing facilities operated by the Department of Behavioral Health and Developmental Services and the Department of Veterans Services shall be exempt from the prospective payment system as defined in Articles 1 (12VAC30-90-29), 3 (12VAC39-90-35 et seq.) (12VAC30-90-35 et seq.), 4 (12VAC39-90-40 et seq.) (12VAC30-90-40 et seq.), 6 (12VAC30-90-60 et seq.), and 8 (12VAC30-90-80 et seq.) of this subpart, as are mental retardation facilities and effective July 1, 2002, as is the Virginia Veterans Care Center nursing facility. All other sections of this payment system relating to reimbursable cost limitations shall apply. These facilities shall continue to be reimbursed retrospectively on the basis of reasonable costs in accordance with Medicare principles of reimbursement and Medicaid principles of reimbursement in effect on June 30, 2000, except that those that are defined as skilled nursing facilities (SNFs) and are operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services shall not be subject to the routine cost limits that are normally required and applicable under Medicare principles of reimbursement. Reimbursement to Intermediate Care Facilities for the Mentally Retarded (ICF/MR) shall be reimbursed retrospectively on the basis of reasonable costs in accordance with Medicare principles of reimbursement but limited to the highest rate paid to a state ICF/MR institution, approved each July 1 by DMAS.

E. Except as specifically modified herein, Medicare principles of reimbursement, as amended from time to time, shall be used to establish the allowable costs in the rate calculations. Allowable costs must be classified in accordance with the DMAS uniform chart of accounts (see 12VAC30-90-270 through 12VAC30-90-276) and must be identifiable and verifiable by contemporaneous documentation.

All matters of reimbursement which are part of the DMAS reimbursement system shall supersede Medicare principles of reimbursement. Wherever the DMAS reimbursement system conflicts with Medicare principles of reimbursement, the DMAS reimbursement system shall take precedence. Appendices are a part of the DMAS reimbursement system.

Article 6
New Nursing Facilities

12VAC30-90-60. Interim rate.

A. A new facility shall be defined as follows:

1. A facility that is newly enrolled and new construction has taken place through the COPN process; or

2. A facility that is newly enrolled which was previously denied payments for new admissions and was subsequently terminated from the program.

B. Upon a showing of good cause, and approval of DMAS, an existing NF that expands its bed capacity by 50% or more shall have the option of retaining its prospective rate or being treated as a new NF.

C. A replacement facility or one that has changed location may not be considered a new facility if it serves the same inpatient population. An exception may be granted by DMAS if the provider can demonstrate that the occupancy substantially changed as a result of the facility being replaced or changing location. A decline in the replacement facility's total occupancy of 20 percentage points, in the replacement facility's first cost reporting period, shall be considered to indicate a substantial change when compared to the lower of the old facility's previous two prior cost reporting periods. The replacement facility shall receive the previous operator's operating rates if it does not qualify to be considered a new facility.

D. A change in either ownership or adverse financial conditions (e.g., bankruptcy), or both, of a provider does not change a nursing facility's status to be considered a new facility.

E. Effective July 1, 2001, for all new NFs the 90% occupancy requirement for indirect and capital costs shall be waived for establishing the first cost reporting period interim rate. This first cost reporting period shall not exceed 13 months from the date of the NFs certification.

F. The 90% occupancy requirement for indirect and capital costs shall be applied to the first and subsequent cost reporting periods' actual indirect and capital costs for establishing such NFs second and future cost reporting periods' prospective reimbursement rates. The 90% occupancy requirement shall be considered as having been satisfied if the new NF achieved a 90% occupancy at any point in time during the first cost reporting period.

1. The department may grant an exception to the minimum occupancy requirement for reimbursement purposes for beds taken out of service for the purpose of renovation. In this case, the occupancy requirement shall be calculated as 90% of available bed days for the period of the exception plus 90% of licensed bed days for the remainder of the cost report year.

2. The provider shall notify DMAS and the Virginia Department of Health (VDH), Division of Long Term Care Services, Office of Licensure and Certification in advance and present a renovation plan including a reasonable timetable for when the beds will be placed back into service.

3. The provider shall keep the appropriate documentation of available beds and days during the renovation period, which will provide the evidence of the beds and days taken out of service for renovation purposes. This supporting documentation, along with a copy of the provider's notification letter to the VDH Division of Long Term Care Services, Office of Licensure and Certification shall be submitted with the filing of the provider's cost report, as applicable. The provider's notification letter shall account for the number of beds not in use for the defined period of time.

G. A new NFs interim rate for the first cost reporting period shall be determined based upon the lower of its anticipated allowable cost determined from a detailed budget (or pro forma cost report) prepared by the provider and accepted by DMAS, or the appropriate operating ceilings or charges.

H. Effective July 1, 2001, on the first day of its second cost reporting period, a new nursing facility's interim plant or capital, as appropriate, rate shall be converted to a per diem amount by dividing its allowable plant/capital costs for its first cost reporting period by 90% of the potential number of patient days for all licensed beds during the first cost reporting period.

I. During its first semiannual period of operation, a newly constructed or newly enrolled NF shall have an assigned CMI based upon its peer group's normalized average Medicaid CMI for direct patient care. An expanded NF receiving new NF treatment shall receive the CMI calculated for its last semiannual period prior to obtaining new NF status.

Table 1. Minimum approach distances from energized conductors for qualified line-clearance arborists and qualified line-clearance arborist trainees.
Nominal voltage in kilovolts (kV) phase to phase	Includes 1910.269 elevation factor, sea level to 5,000 ft*		Includes 1910.269 elevation factor, 5,000–10,000 ft*		Includes 1910.269 elevation factor, 10,001–14,000 ft*
	ft-in	m	ft-in	m	ft-in	m
0.051 to 0.3	Avoid contact		Avoid contact		Avoid contact
0.301 to 0.75	1-01	0.33	1-03	0.38	1-04	0.41
0.751 to 15.0	2-05	0.7	2-09	0.81	3-00	0.88
15.1 to 36.0	3-00	0.91	3-05	1.04	3-09	1
36.1 to 46.0	3-04	1.01	3-10	1.16	4-02	1.09
46.1 to 72.5	4-02	1.26	4-09	1.44	5-02	1.3
72.6 to 121.0	4-06	1.36	5-02	1.55	5-07	1.68
138.0 to 145.0	5-02	1.58	5-11	1.8	6-05	1.96
161.0 to 169.0	6-00	1.8	6-10	2.06	7-05	2.23
230.0 to 242.0	7-11	2.39	9-00	2.73	9-09	2.95
345.0 to 362.0	13-02	3.99	15-00	4.56	16-03	4.94
500.0 to 550.0	19-00	5.78	21-09	6.6	23-07	7.16
765.0 to 800.0	27-04	8.31	31-03	9.5	33-10	10.29
*Exceeds phase to ground; elevation factor per 29 CFR 1910.269.
Note: At time of publication, the minimum approach distances in this table for voltages between 301 and 1,000 volts exceed those specified by 29 CFR 1910.269. ]

Table [ 2 1 ]. Minimum approach distances to energized conductors for persons other than qualified line-clearance arborists and qualified line-clearance arborist trainees
Nominal voltage in kilovolts (kV) phase to phase*	Distance
	ft-in	M
0.0 to 1.0	10-00	3.05
1.1 to 15.0	10-00	3.05
15.1 to 36.0	10-00	3.05
36.1 to 50.0	10-00	3.05
50.1 to 72.5	10-09	3.28
72.6 to 121.0	12-04	3.76
138.0 to 145.0	13-02	4
161.0 to 169.0	14-00	4.24
230.0 to 242.0	16-05	4.97
345.0 to 362.0	20-05	6.17
500.0 to 550.0	26-08	8.05
785.0 to 800.0	35-00	10.55
*Exceeds phase to ground per 29 CFR 1910.333.

[ 5. Qualified line-clearance arborists and line-clearance arborist trainees shall maintain minimum approach distances from energized electrical conductors in accordance with Table 1.

6. 4. ] All other arborists and other workers shall maintain a minimum approach distance from energized electrical conductors in accordance with Table [ 2 1 ].

[ 5. Branches hanging on an energized electrical conductor shall be removed using nonconductive equipment.

8. 6. ] The tie-in position shall be above the work area and located in such a way that a slip would swing the arborist away from any energized electrical conductor or other identified hazard.

[ 9. 7. ] While climbing, the arborist shall climb on the side of the tree that is away from energized electrical conductors while maintaining the required distances shown in Table 1 [ or 2, as applicable ].

[ 10. 8. ] Footwear, including lineman's overshoes or those with electrical-resistant soles, shall not be considered as providing any measure of safety from electrical hazards.

[ 11. 9. ] Rubber gloves, with or without leather or other protective covering, shall not be considered as providing any measure of safety from electrical hazards.

[ 12. 10. ] A rope that is wet, that is contaminated to the extent that its insulating capacity is impaired, or that is otherwise not to be considered insulated for the voltage involved shall not be used near exposed energy lines.

[ 13. 11. ] Ladders, platforms, and aerial devices, including insulated aerial devices, shall be subject to minimum approach distances in accordance with Table 1 [ or 2, as applicable ].

[ 14. 12. ] Aerial devices with attached equipment (such as chippers) brought into contact with energized electrical conductors shall be considered energized. Contact by people and/or equipment shall be avoided.

[ 15. 13. ] Emergency response to an electric contact shall be performed in accordance with 16VAC25-73-40 C.

[ C. Storm work and emergency conditions: line clearance.

1. The items contained in subsection A of this section shall always be included in the review of this section.

2. Line clearance shall not be performed during adverse weather conditions such as thunderstorms, high winds, and snow and ice storms.

3. Qualified line-clearance arborists and qualified line-clearance arborist trainees performing line clearance after a storm or under similar conditions shall be trained in the special hazards associated with this type of work.

4. Line-clearance operations shall be suspended when adverse weather conditions or emergency conditions develop involving energized electrical conductors. Electrical system owners/operators shall be notified immediately. ]

16VAC25-73-60. Safe use of vehicles and mobile equipment used in arboriculture.

A. General.

1. Prior to daily use of any vehicles and mobile equipment (units), visual walk-around inspections and operational checks shall be made in accordance with manufacturers' and owners' instructions (see 16VAC25-60-120) and applicable federal, state, and local requirements.

2. Units shall be equipped and maintained with manufacturers' safety devices, instructions, warnings, and safeguards. Arborists and other workers shall follow instructions provided by manufacturers.

3. Manufacturers' preventive maintenance inspections and parts replacement procedures shall be followed.

4. Manufacturers' instructions shall be followed in detecting hydraulic leaks. No part of the body shall be used to locate or stop hydraulic leaks.

5. Units shall be operated or maintained only by authorized and qualified personnel in accordance with company policies and federal, state, or local laws.

6. Material and equipment carried on vehicles shall be properly stored and secured in compliance with the design of the unit in order to prevent the movement of material or equipment.

7. [ Step If previously installed by the manufacturer, step ] surfaces and platforms on mobile equipment shall be [ skid resistant properly maintained ].

8. Safety seat belts, when provided by the manufacturer, shall be worn while a unit is being operated.

9. Riding or working outside or on top of units shall not be permitted unless the units are designed for that purpose or the operator is performing maintenance or inspection. Fall protection shall be provided for employees performing maintenance or inspection on top of units six feet or more above a lower level. [ Fall protection is not required when performing inspections on top of units six feet or more above a lower level. ]

10. Hoisting or lifting equipment on vehicles shall be used within rated capacities as stated by the manufacturers' specifications.

11. Units with obscured rear vision, particularly those with towed equipment, shall be backed up in accordance with 16VAC25-97.

12. When units are left unattended, keys shall be removed from ignition, the wheels chocked, and, if applicable, the parking brake applied.

13. Units shall be turned off, keys removed from the ignition, and rotating parts at rest prior to making repairs or adjustments, except where manufacturers' procedures require otherwise. Defects or malfunctions affecting the safe operation of equipment shall be corrected before such units are placed into use.

14. Personal protective equipment (for example, eye, head, hand, and ear protection) shall be worn in accordance with 16VAC25-73-40 D.

15. When towing, safety chains shall be crossed under the tongue of the unit being towed and connected to the towing vehicle.

16. The unit's exhaust system shall not present a fire hazard.

17. Towed units that detach from another unit (for example, a motorized vehicle) shall be chocked or otherwise secured in place.

18. Units operated off-road shall be operated in the proper gear and at the proper speed relative to the operating environment and the manufacturers' instructions and guidelines.

B. Aerial devices.

1. The items contained in subsection A of this section shall always be included in the review of this section. 16VAC25-90-1910.67 is hereby incorporated by reference. Damaged aerial devices and vehicles shall be removed from service and tagged until repaired or discarded.

2. Aerial devices shall be provided with an approved point of attachment on which to secure a full-body harness with an energy-absorbing lanyard, which shall be worn when aloft.

3. Booms, buckets, or any other part of the aerial device shall not be allowed to make contact or violate minimum approach distances with energized electrical conductors, poles, or similar conductive objects. See Table [ 2 1 ] of 16VAC25-73-50 or §§ 59.1-406 through 59.1-414 of the Code of Virginia (Overhead High Voltage Line Safety Act), as applicable.

4. Aerial devices or aerial ladders shall not be used as cranes or hoists to lift or lower materials or tree parts, unless they were specifically designed by the manufacturer to do so (see 16VAC25-60-120).

5. Wheel chocks shall be set before using an aerial device unless the device has no wheels on the ground or is designed for use without chocks.

6. Units equipped with outriggers or a stabilizing system shall be operated in a manner consistent with manufacturers' requirements.

7. The operator shall ensure adequate clearance exists and give warning to all employees in the work area prior to lowering outriggers. Pads shall be placed under outrigger feet when they are needed to ensure stable footing.

8. When operating aerial devices, the operator shall look in the direction the bucket is traveling and be aware of the location of the booms in relation to all other objects and hazards.

9. Clearances from passing vehicles shall be maintained, or traffic control shall be provided when booms or buckets are operated over roads in accordance with VDOT's Virginia Work Area Protection Manual.

10. One-person buckets shall not have more than one person in them during operations.

11. Hydraulic/pneumatic tools shall be disconnected when they are being serviced or adjusted, except where manufacturers' procedures require otherwise.

12. To avoid flying particles or whipping hydraulic/pneumatic hoses, pressure shall be released before connections are broken, except where quick-acting connectors are used. Hydraulic/pneumatic hoses shall never be kinked in order to cut off pressure.

13. No part of the body shall be used to locate or stop hydraulic leaks.

14. Hoses affecting dielectric characteristics of equipment shall meet manufacturers' requirements.

15. The flash point of hydraulic fluid shall meet the minimum set by the manufacturer.

16. Combined loads shall not exceed rated lift capacities. Load ratings shall be conspicuously and permanently posted on aerial devices in accordance with ANSI A92.2.

17. Electric cables/cords used with electric saws or lights, or other conductive material shall not be run from the vehicle to the bucket when arborists are working in proximity to energized electrical conductors.

18. Aerial devices shall not be moved with an arborist on an elevated platform (for example, a bucket) except when equipment is specifically designed for such operation.

19. Holes shall not be drilled in buckets or liners.

20. During aerial device operations, arborists and other workers who are not qualified line-clearance arborists shall maintain a minimum approach distance from energized electrical conductors in accordance with Table [ 2 1 ] of 16VAC25-73-50. Only qualified line-clearance arborists or qualified line-clearance arborist trainees using an insulated aerial device may operate in accordance with minimum approach distances provided in Table 1.

21. Arborists and other workers shall be instructed that insulated aerial buckets do not protect them from other electric paths to the ground, such as paths through trees, guy wires, or from one phase wire to the second phase wire, any one of which can be fatal.

22. All underground hazards shall be located prior to operating aerial lift devices off-road. These hazards could include natural gas tanks, underground oil tanks, and septic systems.

C. Brush chippers.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged brush chippers shall be removed from service and tagged until repaired or discarded.

2. Access panels (for example, guards) for maintenance and adjustment, including discharge chute and cutter housing, shall be closed and secured prior to starting the engine of brush chippers. These access panels shall not be opened or unsecured until the engine and all moving parts have come to a complete stop (see 16VAC25-73-110, Appendix B, General Safety Procedures that Apply to All Tree Work).

3. Rotary drum or disc brush chippers not equipped with a mechanical infeed system shall be equipped with an infeed hopper not less than 85 inches (2.15 m) measured from the blades or knives to ground level over the center line of the hopper. Side members of the infeed hopper shall have sufficient height so as to prevent workers from contacting the blades or knives during operations.

4. Rotary drum or disc brush chippers not equipped with a mechanical infeed system shall have a flexible anti-kickback device installed in the infeed hopper to reduce the risk of injury from flying chips and debris.

5. Chippers equipped with a mechanical infeed system shall have a quick-stop and reversing device on the infeed system. The activating mechanism for the quick-stop and reversing device shall be located across the top, along each side, and close to the feed end of the infeed hopper within easy reach of the worker.

6. Vision, hearing, and other appropriate personal protective equipment shall be worn when in the immediate area of a brush chipper in accordance with 16VAC25-73-40 D.

7. Arborists, mechanics, and other workers shall not, under any circumstances, reach into the infeed hopper when the cutter disc, rotary drum, or feed rollers are moving.

8. When trailer chippers are detached from the vehicles, they shall be chocked or otherwise secured in place.

9. When in a towing position, chipper safety chains shall be crossed under the tongue of the chipper and properly affixed to the towing vehicle.

10. See 16VAC25-73-90 F [ , ] for additional requirements.

D. Sprayers and related equipment.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged sprayers and related equipment shall be removed from service and tagged until repaired or discarded.

2. Walking and working surfaces of all sprayers and related equipment shall be covered with skid-resistant material.

3. Equipment on which the applicator/operator stands while the vehicle is in motion shall be equipped with guardrails around the working area. Guardrails shall be constructed in accordance with 16VAC25-90-1910.23.

4. The applicator/operator shall make a visual inspection of hoses, fittings, exposed plumbing, tanks, covers, and related equipment prior to its use each workday.

5. The applicator/operator shall not allow hoses or other parts of the equipment to create a tripping hazard for coworkers or the public.

6. The applicator/operator shall have a firm grip on the spray gun/excavation tool when pulling the trigger.

7. The operator of high-pressure excavation equipment shall wear a face shield in addition to eye protection.

8. Related equipment:

a. The applicator/operator shall be aware of underground utility locations when drilling holes in the ground for fertilizer or pesticide applications.

b. The equipment shall have splash guards, and the applicator shall wear eye protection when injecting liquid fertilizer or pesticides into the ground.

c. The applicator shall wear eye protection and follow label instructions when injecting liquids into trees.

E. Stump cutters.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged stump cutters shall be removed from service and tagged until repaired or discarded.

2. Stump cutters shall be equipped with enclosures or guards that reduce the risk of injury during operation. Enclosures or guards shall be kept in place when stump cutters are operative.

3. Arborists and other workers in the immediate stump-cutting work zone shall wear vision, hearing, and other personal protective equipment in accordance with 16VAC25-73-40 D.

4. When in a towing position, stump-cutter safety chains shall be crossed under the tongue of the stump cutter and properly affixed to the towing vehicle.

5. Towable stump cutters or stump-cutter trailers, when detached from the vehicle, shall be chocked or otherwise secured in place.

6. The operator shall be aware of underground utility locations prior to performing work.

F. Vehicles.

1. The items contained in subsection A of this section shall always be included in the review of this section. (See 16VAC25-60-120.) Damaged vehicles shall be removed from service and tagged until repaired or discarded.

2. A steel bulkhead or equivalent protective devices shall be provided to protect workers from load shifts in vehicles carrying logs or other material.

3. Load-securing procedures shall be followed to prevent accidental shifting or discharge of logs or other materials from the vehicle during transport.

4. Logs or other material shall not overhang the sides; obscure taillights, brake lights, or vision; or exceed height limits per state and local requirements for bridges, overpasses, utility lines, or other overhead hazards.

5. To avoid the hazard of spontaneous combustion or the generation of undesirable odors, wood chips shall not be left in vehicles for extended periods.

G. Log loaders, knucklebooms, cranes, and related hoists

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged log loaders, knuckle booms, cranes and related hoists shall be removed from service and tagged until repaired or discarded.

2. Log loaders, cranes, and related hoisting equipment shall be inspected in accordance with applicable regulations as well as manufacturers' instructions and guidelines. Chokers, slings, and other means of lifting, lowering, or rigging equipment shall be inspected before each use. An inspection procedure checklist shall be available to the crew.

3. Operators of hoisting equipment shall be trained and shall maintain a minimum approach distance from energized conductors in accordance with Table 1 [ or 2 ] of 16VAC25-73-50, or §§ 59.1-406 through 59.1-414, Overhead High Voltage Line Safety Act, as applicable. A spotter shall be used when work is being performed in proximity to electrical conductors. Personnel assigned to work in proximity to the tree removal shall be trained and follow guidelines for electrical hazards (see 16VAC25-73-50).

4. The crane operator shall be familiar with the potential hazards encountered and operational techniques used in tree work.

5. Cranes with telescoping booms shall be equipped with an anti-two block device. A boom angle indicator and a device to indicate the boom's extended length shall be clearly visible to the operator at all times. A load rating chart with clearly legible letters and figures shall be provided with each crane and securely fixed at a location easily visible to the operator.

6. Operators of hoisting equipment shall remain at the controls while a load is lifted, suspended, or lowered.

7. Tree sections shall be rigged to minimize load shifting. Controlled load lowering shall be employed. Shock-loading shall be avoided, and free fall is prohibited. A green log weight chart (see 16VAC25-73-130, Appendix D) [ , ] shall be available to the crew. All workers shall be kept clear of loads about to be lifted and of suspended loads.

8. Riding the load line of a crane while it is under load tension shall be prohibited.

9. The use of a crane to hoist a qualified arborist into position is prohibited, except when the use of conventional means of reaching the work area, such as, but not limited to, an aerial lift, would be more hazardous or is not physically possible because of worksite conditions. If the above exception applies, a qualified arborist may be hoisted into position utilizing a crane if the crane manufacturer's specifications and limitations do not prohibit such use, and any fall protection requirements of the crane manufacturer are complied with, and the arborist is tied in with an arborist climbing line and arborist saddle and secured to a designated anchor point on the boom line or crane. The following procedures shall be followed when an arborist is to be lifted by a crane:

a. The qualified crane operator, the signal person, the person responsible for the work to be performed and the arborist to be lifted shall meet prior to the work to review the procedures to be followed. A job briefing shall be done before any work begins, in accordance with 16VAC25-73-40 A 4.

b. The arborist climbing line shall be secured to the crane in such a way that it does not interfere with the function of any damage-prevention or warning device on the crane and so that no part of the crane compromises the climbing line or any component of the climbing system.

c. The crane operator shall test the adequacy of footing prior to any lifting, and shall conduct a trial lift immediately before lifting the arborist into position. The crane operator shall determine that all systems, controls and safety devices are activated and functioning properly; that no interferences exist; and that all configurations necessary to reach the intended work location will allow the operator to remain under the 50% limit of the hoist's rated capacity. The crane shall be uniformly level and located on firm footing. If necessary, blocking shall be used so that the support system does not exceed its load-bearing capabilities. Cranes equipped with outriggers shall have them all fully extended and properly set, as applicable, before lifting and lowering operations begin and/or before the qualified arborist is lifted.

d. Lifting and supporting shall be done under controlled conditions and under the direction of a qualified arborist or an appointed signal person. Lifting and supporting operations shall not be performed during adverse weather conditions such as thunderstorms, high winds, and snow and ice storms.

e. The load-line hoist drum shall have a system or other device on the power train, other than the load hoist brake, that regulates the lowering speed of the hoist mechanism. Load lines shall be capable of supporting, without failure, at least seven times the maximum intended load, except that where rotation resistant rope is used, the lines shall be capable of supporting without failure, at least 10 times the maximum intended load. The required design factor is achieved by taking the current safety factor of 3.5 and applying 50% de-rating of the crane capacity.

f. Communication between the crane operator and the arborist being lifted shall be maintained either directly or through the appointed signal person. This communication shall either be visual, using the accepted hand signals, or audible, using voice or radio. Radio communication shall be used to control blind picks. The crew members shall know and follow hand signals for standard crane operations (see 16VAC25-73-150, Appendix F).

g. The crane operator shall remain at the controls when the qualified arborist is attached to the crane and during lifting and lowering operations.

h. The crane boom and load line shall be moved in a slow, controlled, cautious manner when the arborist is attached. Lifting or lowering speed shall not exceed 100 feet/minute (0.5 m/sec), and any sudden movements shall be avoided. The crane shall be operated so that lowering is power controlled.

i. The crane carrier shall not travel at any time while the qualified arborist is attached. An accurate determination of the load radius to be used during lifting shall be made before the qualified arborist is hoisted.

j. The qualified arborist shall be detached from the crane any time it comes under load tension.

H. Specialized units.

1. The items contained in subsection A of this section shall always be included in the review of this section.

2. Off-road and tracked vehicles shall be operated at the proper speed and in the proper gear relative to the operating environment and the manufacturer's instructions and guidelines.

3. Deadman controls on towing equipment for brush hogs and similar implements shall be used and maintained in good working condition. If the deadman control is malfunctioning or not operational, the equipment shall be removed from service and tagged until it has been repaired or discarded. When deadman controls were not provided by the manufacturer, the worker shall disengage the power source to the rotary or cutter head before dismounting.

I. Equipment-mounted winches.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged equipment mounted winches shall be removed from service and tagged until repaired or discarded.

2. Operators shall wear the appropriate personal protective equipment during winch operations, including eye and head protection.

3. The winch cable/synthetic line shall be inspected daily for broken or worn strands, bird caging, major kinks, and other defects. Damaged cables shall be removed from service and tagged until repaired or discarded.

4. Cable hooks and attachment points shall be inspected for damage. Damaged hooks or attachment assemblies shall be removed from service and tagged until repaired or discarded.

5. All mounting bolts and hardware shall be inspected for loose or missing components. The winch shall not be used until complete repairs are made to damaged or missing bolts and hardware.

6. Operators shall be aware of the dangers of load or cable breakage and ensure that all personnel remain clear of the recoil area in the event of load or cable breakage.

7. All winch operators shall be properly trained and be aware of the inherent dangers associated with winch operations.

8. Operators shall be aware of the winch cable at all times during extension and ensure that it does not become a hazard to personnel or machinery.

9. Winch systems and cables shall be used only as intended and instructed by the manufacturer.

10. The winch shall never be used with personnel, including the operator, within the span of the winch cable and the winch.

11. Pinch point hazards develop during winching operations; therefore, all operators involved in the winching operation shall constantly be aware of such hazards and stand clear of these areas.

12. All loads shall be pulled in such a manner as to avoid angles that may result in tipping, cause the vehicle to become unstable, or result in unintended movement of the vehicle.

13. Pulling loads from the side requires special equipment and techniques. Therefore, loads shall be pulled in line with the winch unless the winch is properly equipped with a fair lead and the operator is trained to pull loads at an angle.

14. The operator shall ensure that the vehicle supporting the winch is secured to avoid unintended movement.

15. The operator shall ensure that all rigging points comply with 16VAC25-73-90 D.

16. To ensure precise communication, an effective means of communication shall be established and used with all workers involved in the winching operations (see 16VAC25-73-90 D 14).

16VAC25-73-70. Portable power hand tools.

A. General.

1. The purpose of this section is to provide guidelines for arborists and other workers pertaining to the safe use and care of portable power hand tools. Damaged portable power tools shall be removed from service and tagged until repaired or discarded.

2. Manufacturers' operating and safety instructions shall be followed (see 16VAC25-60-120).

3. Before starting or otherwise using any portable power tools, a communication system shall be established in accordance with the requirements of 16VAC25-73-90 B 1.

B. Portable electric power tools.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged portable electric power tools shall be removed from service and tagged until repaired or discarded.

2. Corded electric power tools shall not be used in trees or aerial devices near energized electrical conductors where there is a possibility of power tools or supply cords contacting the conductor.

3. All corded portable electric power tools shall be:

a. Equipped with three-wire cords having the ground wire permanently connected to the tool frame and a means for grounding the other end;

b. Double insulated and permanently labeled as "double insulated"; or

c. Connected to power supplies by means of an isolating transformer or other isolated power supply.

4. Extension cords shall be maintained in safe condition. Exposed metal sockets shall not be used. Worn or frayed extension cords shall be removed from service and tagged until repaired or discarded.

5. Arborists and other workers shall:

a. Prevent cords from becoming entangled, damaged, or cut by blades and bits;

b. Not lay extension cords in water; and

c. Support electric power tools and supply cords by a tool lanyard or separate line, when used aloft.

C. Chain saws.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged chain saws shall be removed from service and tagged until repaired or discarded.

2. Chain saws shall not be operated unless the manufacturer's safety devices are in proper working order. Chain-saw safety devices shall not be removed or modified.

3. When an arborist or other worker is working in a tree other than from an aerial device, chain saws weighing more than 15 pounds (6.8 kg) service weight shall be made safe against falling (i.e., supported by a separate line or tool lanyard).

4. Secure footing shall be maintained when starting the chain saw.

5. When starting a chain saw, the operator shall hold the saw firmly in place on the ground or otherwise support the saw in a manner that minimizes movement of the saw when pulling the starter handle. The chain saw shall be started with the chain brake engaged, on saws so equipped. Drop-starting a chain saw is prohibited.

6. Chain-saw engines shall be started and operated only when other arborists and workers are clear of the swing radius of the chain saw.

7. When operating a chain saw, the arborist or other worker shall hold the saw firmly with both hands, keeping the thumb and fingers wrapped around the handle.

8. Arborists shall use a second point of attachment (for example, lanyard or doublecrotched climbing line) when operating a chain saw in a tree, unless the employer demonstrates that a greater hazard is posed by using a second point of attachment while operating a chain saw in that particular situation. Using both ends of a two-in-one lanyard shall not be considered two points of attachment when using a chain saw.

9. Chain-saw mufflers and spark arresters (if the latter are provided) shall be maintained in good condition.

10. The chain brake shall be engaged, or the engine shut off, before setting a chain saw down.

11. When a chain saw is being carried more than two steps, the chain brake shall be engaged or the engine shut off. The chain saw shall be carried in a manner that will prevent operator contact with the cutting chain and the muffler.

12. The chain-saw operator shall be certain of footing before starting to cut. The chain saw shall not be used in a position or at a distance that could cause the operator to become off-balance, have insecure footing, or relinquish a firm grip on the saw.

D. Powered pole tools and backpack power units.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged powered pole tools and backpack power units shall be removed from service and tagged until repaired or discarded.

2. Only workers operating the equipment shall be within 10 feet (3.05 m) of the cutting head of a brush saw during operations.

3. Power units shall be equipped with a readily accessible, quick shutoff switch.

4. Operators shall observe the position of all other workers in the vicinity while the equipment is running.

5. Engines shall be stopped for all cleaning, refueling, adjustments, and repairs to the saw or engine, except where manufacturers' procedures require otherwise.

6. Powered pole tools with poles made of metal or other conductive material shall not be used in operations where electrical hazards exist.

16VAC25-73-80. Hand tools and ladders.

A. General.

1. Correct hand tools and equipment shall be selected for the job.

2. Hand tools and equipment that have been made unsafe by damage or defect, including tools with loose or cracked heads or cracked, splintered, or weakened handles, shall be removed from service and tagged until repaired or discarded.

3. Workers shall maintain a safe working distance from other workers when using hand tools and equipment.

4. When climbing into a tree, arborists shall not carry hand tools and equipment in their hands unless the tools are used to assist them in climbing. Tools other than ropes or throwlines shall not be thrown into a tree or between workers aloft.

5. Arborist climbing lines or handlines shall be used for raising and lowering hand tools and equipment. Arborists shall raise or lower hand tools and equipment in a manner such that the cutting edge will not contact the arborist climbing line or handline.

6. Hand tools and equipment shall be properly stored or placed in plain sight out of the immediate work area when not in use.

B. Cant hooks, cant dogs, peaveys, and tongs.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged cant hooks, cant dogs, peaveys and tongs shall be removed from service and tagged until repaired or discarded.

2. Cant hooks shall be firmly set before applying force.

3. Points of hooks shall be at least two inches (5 cm) long and kept sharp.

4. Arborists and other workers shall always stand uphill from rolling logs, and all workers shall be warned and in the clear before logs are moved.

C. Wedges, chisels, and gouges.

1. The items contained in subsection A of this section shall always be included in the review of this section.

2. Wedges, chisels, and gouges shall be inspected for cracks and flaws before use. Tools with damaged heads shall be removed from service and tagged until repaired or discarded.

3. Wedges and chisels shall be properly pointed and tempered.

4. Eye protection shall be used during impact operations.

5. Only wood, plastic, or soft-metal wedges shall be used while operating chain saws.

6. Wood-handled chisels shall be protected with a ferrule on the striking end.

7. Wood, rubber, or high-impact plastic mauls, sledges, or hammers shall be used when striking wood-handled chisels or gouges.

D. Chopping tools.

1. The items contained in subsection A of this section shall always be included in the review of this section. Damaged chopping tools shall be removed from service and tagged until repaired or discarded.

2. Chopping tools shall not be used while working aloft.

3. Chopping tools shall not be used as wedges or used to drive metal wedges.

4. Chopping tools shall be swung away from the feet, legs, and body, using the minimum force practical for function and control.

5. When swinging tools such as grub hoes, mattocks, and axes, a secure grip, firm footing, and clearance of workers and overhead hazards shall be maintained.

E. Ladders.

1. The items contained in subsection A of this section shall always be included in the review of this section.

2. Ladders made of metal or other conductive material shall not be used where electrical hazards exist. Only wooden ladders or nonconductive ladders made of synthetic material equal to or exceeding the strength of wooden ladders shall be used. Portable wooden ladders shall be used in accordance with 16VAC25-90-1910.25.

3. Metal ladders used where no electrical hazard exists shall be used in accordance with 16VAC25-90-1910.26.

4. All ladders shall be inspected before use and removed from service if found defective, and tagged until repaired or discarded.

5. Cleats, metal points, skid-resistant feet, lashing, or other effective means of securing the ladder shall be used.

6. Ladders shall not be used as bridges or inclined planes to load or handle logs or other material.

7. Ladders shall be supported while in storage to prevent sagging. Except when on mobile equipment, ladders shall be stored under suitable cover, protected from the weather, and kept in a dry location away from excessive heat.

8. The third, or hinged, leg of a tripod/orchard ladder shall be braced or fastened when on hard or slick surfaces.

9. All ladders shall be used in accordance to the manufacturers' specifications and limitations and shall not be altered in a way that contradicts those specifications and limitations.

16VAC25-73-90. Work procedures.

A. Ropes and arborist climbing equipment.

1. A visual hazard assessment, including a root collar inspection, shall be performed prior to climbing, entering, or performing any work in a tree, and an ongoing hazard assessment shall be conducted as operations progress while the arborist is in the tree. If the hazard assessment reveals a serious hazard to the climber or ground personnel, work shall immediately stop and personnel shall be removed from the hazardous area until a work plan is developed to safety remove the hazard/tree. The following items, at a minimum [ , ] shall be inspected:

a. Trunk and root hazards including, but not limited to, cracks, cavities, wood decay/rot, cut roots, mushrooms;

b. Lower stem hazards including, but not limited to, loose bark, open cavities, cracks, mushrooms, conks, and depressions or swelling in the stem;

c. Limb hazards including, but not limited to, watersprouts, hangers, cankers, dead branches, lightning damage, and weak crotches; and

d. Storm damage hazards including, but not limited to, cracked stems and crotches, broken limbs supported by cables, points of pressure, and tension on limbs or small trees underneath larger fallen trees.

2. A second arborist or other worker trained in emergency procedures shall be within visual or voice communication during arboricultural operations above 12 feet (3.65 m) that are not subject to the requirements of 16VAC25-73-50 B 4.

3. Climbing lines used in a split-tail system and split-tails shall be terminated with an eye splice or a knot that interfaces appropriately with the connecting link that it is attached to. The termination knot selected shall remain secure under normal loading and unloading. When using a carabiner without a captive eye, the knot or eye splice shall cinch in place to prevent accidental opening and/or side-loading of the carabiner.

4. Arborists shall inspect climbing lines, worklines, lanyards, and other climbing equipment for damage, cuts, abrasion, and/or deterioration before each use and shall remove them from service if signs of excessive wear or damage are found. The items removed from service shall be tagged until repaired or discarded.

5. Arborist saddles and lanyards used for work positioning shall be identified by the manufacturer as suitable for tree climbing.

6. Arborist saddles and lanyards used for work positioning shall not be altered in a manner that would compromise the integrity of the equipment.

7. Hardware used in the manufacture of arborist saddles shall meet the hardware material, strength, and testing requirements outlined in ANSI 359.1.

8. Arborist climbing lines shall have a minimum diameter of 7/16 (11 mm) and be constructed from a synthetic fiber, with a minimum breaking strength of 5,400 pounds (24.02 kilonewtons (kN)) when new. Maximum working elongation shall not exceed 7.0% at a load of 540 pounds (2.402 kN). Arborist climbing lines shall be identified by the manufacturer as suitable for tree climbing.

9. [ All components of a climbing system (e.g., ropes, pulleys, etc.) shall meet the manufacturer's design, specifications, and limitations. Components from different climbing systems shall not be combined without prior approval of the manufacturers. The qualified arborist shall assure that each component of the climbing system is approved by the manufacturer for its intended use as well as its compatibility with other components of the climbing system. ]

10. Prusik loops, split-tails, and work-positioning lanyards used in a climbing system shall meet the minimum strength standards for arborist climbing lines.

11. Snap hooks (rope snaps) used in climbing shall be self-closing and self-locking, with a minimum tensile strength of 5,000 pounds (22.24 kN).

12. Carabiners used in climbing shall be self-closing and self-locking, with a minimum tensile strength of 5,000 pounds (22.24 kN). Carabiners shall be designed to release the load by requiring at least two consecutive, deliberate actions to prepare the gate for opening.

13. Splicing shall be done in accordance with cordage manufacturers' specifications.

14. All load-bearing components of the climbing system shall meet the minimum standards for arborist climbing equipment.

15. Equipment used to secure an arborist in the tree or from an aerial lift shall not be used for anything other than its intended purpose. The arborist climbing line may be used to raise and lower tools.

16. Rope ends shall be finished in a manner to prevent raveling.

17. Ropes and climbing equipment shall be stored and transported in such a manner to prevent damage through contact with sharp tools, cutting edges, gas, oil, or chemicals.

18. Arborist climbing lines shall never be left in trees unattended.

19. Arborists shall have available a climbing line and at least one other means of being secured while working aloft; for example, an arborist climbing line and a work-positioning lanyard.

20. The arborist shall be secured while ascending the tree. The arborist shall be tied in once the work begins and shall be tied in until the work is completed and he has returned to the ground. The arborist shall be secured when repositioning the climbing line.

21. While ascending a ladder to gain access to a tree, the arborist shall not work from or leave the ladder until he is tied in or otherwise secured.

22. A false crotch and/or false crotch redirect may be used at the discretion of the arborist in lieu of a natural crotch.

23. The tie-in position shall be such that the arborist will not be subjected to an uncontrolled pendulum swing in the event of a slip.

24. When a climber is working at heights greater than one-half the length of the arborist climbing line, a figure-8 knot shall be tied in the end of the arborist climbing line to prevent pulling the rope through the climbing hitch.

B. Pruning and trimming.

1. Voice communications among arborists aloft and among arborists and other workers on the ground shall be established before cutting and dropping limbs. The communication method shall be clearly understood and used by all workers during all operations. The command "stand clear" from aloft and the response "all clear," "Underneath," or "No" from the ground are terms that may be used for this purpose. Prearranged, two-way hand signals may also be used when verbal communication is not possible because of distance or surrounding noise levels. Arborists and other workers returning to the work area shall be acknowledged by arborists aloft.

2. Pole pruners and pole saws, when hung, shall be securely positioned to prevent dislodgment. Pole pruners or pole saws shall not be hung on electrical conductors or left in a tree unattended. Pole saws and pole pruners shall be hung so that sharp edges are away from the arborist and shall be removed when the arborist leaves the tree.

3. Scabbards or sheaths shall be used to carry handsaws when not in use. Folding saws, when not in use, shall be closed and hooked to the arborist saddle.

4. Pole tools used in line-clearance operations shall be constructed with fiberglass reinforced plastic (FRP) or wooden poles meeting the requirements of 16VAC25-90-1910.269.

5. A separate workline shall be attached to limbs that cannot be dropped safely or controlled by hand. Arborist climbing lines and worklines shall not be secured to the same crotch.

6. Dry conditions and dead palm fronds present an extreme fire hazard. When dry conditions exist, arborists and other workers shall not smoke while working in or near dead palm fronds. All chain saws used under such conditions shall have mufflers and spark arresters in good working condition.

7. Palm frond skirts that have three years or more of growth shall be removed from the top down. Arborists performing this work shall be supported by an arborist climbing line and a false crotch. Arborists shall never attempt to remove skirts of three years or more by positioning themselves below work areas while being supported by a lanyard.

8. Cut branches shall not be left in trees upon completion of work.

C. Cabling.

1. Arborists and other workers on the ground shall not stand under the work area of a tree when a cabling system is being installed.

2. Tools used for cabling, bark tracing, and cavity work shall be carried in a bag, on a belt designed to hold such tools, or attached to a tool lanyard.

3. Arborists installing cabling systems in trees shall be positioned off to one side in order to avoid injury in case of cable system failure that could occur when a block and tackle or a hand winch is released.

4. When removing a cable from a tree, a block and tackle or come-along system shall be installed before removing the existing cable.

5. When installing a replacement cable, the replacement cable shall be fully installed before removing the outdated cable.

D. Rigging.

1. Arborists performing rigging operations shall inspect trees for their integrity to determine whether the trees have any visible defect that could affect the operation. If it is determined that the tree poses a risk of failure due to the forces and strains that will be created by the design of the rigging operation, an alternate plan shall be used that does not expose workers to the hazards of a failure.

2. The number of connecting links used for connecting components of a rigging system shall be minimized when possible. Connecting links shall interface properly and be in compliance with manufacturers' specifications and limitations (reference 16VAC26-60-120).

3. The qualified arborist shall ensure that load ratings shown on the rigging equipment or provided by the manufacturer for all ropes, connecting links, and rigging equipment are observed in all rigging operations. Rigging equipment shall be chosen for the specific task based on working-load limits and design specifications.

4. All equipment used for rigging operations shall be in good working condition. Equipment that has been damaged or overloaded shall be removed from service. Items removed from service shall be tagged until repaired or discarded.

5. To avoid confusion between rigging equipment and climbing equipment, the equipment shall be clearly marked to indicate their different purposes.

6. Rigging points shall be assessed for their structural integrity by a qualified arborist. The rigging plan and the tree shall be considered relative to the forces being applied to any part of the tree, including branch attachments and anchoring roots, before a rigging point is chosen and established.

7. Climbers shall choose tie-in points that will provide proper protection while allowing for a separation between the rigging system and the climbing system. Running rigging lines shall not be allowed to come into contact with any part of the climbing system.

8. Arborists performing rigging operations shall be educated to understand and trained to estimate the potential forces at any point in the rigging system being used. The system components shall comply with working-load limits relative to the operation and the maximum potential forces.

9. Careful consideration shall be given to the potential forces resulting from the specific influences of rope angles as well as the number of lines and/or line parts that will act on any rigging point.

10. Prior to the start of removal/rigging operations, a communication system shall be established in accordance with the requirements in subdivision B 1 of this section.

11. A work zone shall be established prior to the start of rigging operations. Workers not directly involved in the rigging operation shall stay out of the pre-established work zone until it has been communicated by a qualified arborist or qualified arborist trainee directly involved in the rigging operation that it is safe to enter the work zone. Workers shall be positioned and their duties organized so that the actions of one worker will not create a hazard for any other worker.

12. Only qualified arborists or qualified arborist trainees directly involved in the operation shall be permitted in the work zone when a load is being suspended by the rigging system. All workers shall be kept clear of suspended loads.

13. Taglines or other means may be used to help control and handle suspended loads.

14. Arborists working aloft shall position themselves so as to be above or to the side of the piece being rigged and out of the path of movement of the piece when it has been cut. Climbers and their climbing systems shall be positioned outside of the rigging system itself when a cut is being made or a load is being moved or lowered. Climbers shall have an escape plan prepared.

15. The spars, limbs, or leaders being worked on and the spars being used for tie-in and/or rigging points shall be assessed for structural integrity and potential reaction forces that could cause a spar to split when it is cut.

16. Steps shall be taken to prevent spars from splitting or tearing during the rigging operation, and climbers shall take steps to avoid trapping, pinning, or entangling themselves in the system should the tree split or the rigging fail. Load binders are one possible means of preventing splitting.

E. Tree removal.

1. Before beginning any tree removal operation, the chain-saw operator and/or crew leader shall carefully consider all relevant factors pertaining to the tree and site and shall take appropriate actions to ensure a safe removal operation. The following factors shall be considered:

a. The area surrounding the tree to be removed, including nearby trees;

b. Species and shape of the tree;

c. Lean of the tree;

d. Loose limbs, chunks, or other overhead material;

e. Wind force and direction;

f. Decayed or weak spots throughout the tree (be aware of additional hazards if these conditions exist in the hinge area);

g. Location and means to protect other persons, property, and electrical conductors;

h. Size and terrain characteristics or limitations of the work area; and

i. Evidence of bees or wildlife habitation in the tree.

2. Work plans for removal operations shall be communicated to all workers in a job briefing before commencing work.

3. Workers not directly involved in the removal operation shall be clear of the work area, beyond the length of the tree, unless a team of workers is necessary to remove a particular tree.

4. A planned escape route for all workers shall be prepared before cutting any standing tree or trunk. The preferred escape route is 45 degrees on either side of a line drawn opposite the intended direction of the fall. Obstructions shall be cleared along the escape path. The chain-saw operator shall use this path for egress once the cut has been completed.

5. When it is necessary to shorten or remove branches before removing the tree, the arborist shall determine whether the tree can withstand the strain of the lowering procedures. If not, other means of removing the tree shall be considered and used.

6. The crew leader shall determine the number of workers necessary for tree removal operations.

7. The crew leader shall develop a work plan so that operations do not conflict with each other, thereby creating a hazard.

8. Climbing spurs shall have gaffs of a type and length compatible for the tree being climbed.

9. Wedges, block and tackle, rope, wire cable (except where an electrical hazard exists), or other appropriate devices shall be used when there is a danger that the tree or trees being removed may fall in the wrong direction or damage property. All limbs shall be removed to a height and width sufficient to allow the tree to fall clear of any wires and other objects in the vicinity.

10. Tackle blocks and pulleys and their connecting links shall be inspected immediately before use and removed from service if they are found to be defective.

11. Workers returning to the work area shall not enter until the chain-saw operator has acknowledged that it is safe to do so.

12. When a pull line is being used, workers involved in removing a tree or trunk shall be clear by a minimum of one tree length.

13. All workers other than the individual engaged in manual land-clearing operations shall be at least two tree lengths away from the tree or trunk being removed. This requirement does not apply in the presence of site restrictions, such as waterways or cliffs. Other arborists and workers shall be beyond the trees' striking range and at a distance as close to twice the tree's height as possible.

NOTE: This regulation does not apply to tree removal activities where the primary objective is land clearing in preparation for construction, real estate development, or other related activities, unless directly supervised by a certified arborist. Such activities are covered by 16VAC25-90-1910.266.

14. Notches shall be used on all trees and trunks greater than five inches (12.7 cm) in diameter at breast height.

15. Notches and back cuts shall be made at a height that enables the chain-saw operator to safely begin the cut, control the tree or trunk, and have freedom of movement for escape:

a. The notch cut used shall be a conventional notch, an open-face notch, or a Humboldt notch.

b. Notches shall be 45 degrees or greater and large enough to guide the fall of the tree or trunk to prevent splitting.

c. Notch depth shall not exceed one-third the diameter of the tree.

d. The back cut shall not penetrate into the predetermined hinge area.

16. With a conventional notch or Humboldt notch, the back cut shall be one to two inches (2.5 to 5 cm) above the apex of the notch to provide an adequate platform to prevent kickback of the tree or trunk. With an open-face notch (greater than 70 degrees), the back cut shall be at the same level as the apex of the notch.

17. The two cuts that form the notch shall not cross at the point where they meet.

18. Before making the back cut, there shall be a command such as "stand clear" from the arborist operating the chain saw and a response such as "all clear" from the workers supporting the removal operation. Pre-arranged, two-way hand signals may also be used in accordance with subdivision B 1 of this section. Only designated persons shall give such signals. All workers in the vicinity shall be out of range when the tree or trunk falls. Visual contact shall be maintained with the tree or trunk until it is on the ground.

19. When the back cut has been completed, the chain-saw operator shall immediately move a safe distance away from the tree or trunk using the planned escape route.

20. Workers shall not approach mechanical tree removal or mechanical re-clearing operations, such as with a rotary or flail mower, until the operator has acknowledged that it is safe to do so.

F. Brush removal and chipping.

1. Traffic control around the jobsite shall be established prior to the start of chipping operations along roads and highways (see 16VAC25-73-40 B).

2. Brush and logs shall not be allowed to create hazards in the work areas.

3. To prevent an entanglement hazard, loose clothing, climbing equipment, body belts, harnesses, lanyards, or gauntlet-type gloves (for example, long-cuffed lineman's or welder's gloves) shall not be worn while operating chippers.

4. Personal protective equipment shall be worn when in the immediate area of chipping operations in accordance with 16VAC25-73-40 D.

5. Training shall be provided in the proper operation, feeding, starting, and shutdown procedures for the chipper being used.

6. Maintenance shall be performed only by those persons authorized by the employer and trained to perform such operations.

7. Brush and logs shall be fed into chippers, butt or cut end first, from the side of the feed table center line, and the operator shall immediately turn away from the feed table when the brush is taken into the rotor or feed rollers. Chippers shall be fed in accordance with the manufacturer's instructions.

8. The brush chipper discharge chute or cutter housing cover shall not be raised or removed while any part of the chipper is turning or moving. Chippers shall not be used unless a discharge chute of sufficient length or design is provided that prevents personal contact with the blades (see 16VAC25-73-110, Appendix B, General Safety Procedures that Apply to All Tree Work).

9. Foreign material, such as stones, nails, sweepings, and rakings, shall not be fed into chippers.

10. Small branches shall be fed into chippers with longer branches or by being pushed with a long stick.

11. Hands or other parts of the body shall not be placed into the infeed hopper. Leaning into or pushing material into infeed hoppers with feet is prohibited.

12. While material is being fed into the chipper infeed hopper chute, pinch points continually develop within the material being chipped and between the material and machine. The operator shall be aware of this situation and respond accordingly.

13. When feeding a chipper during roadside operations, the operator shall do so in a manner that prevents him from stepping into traffic or being pushed into traffic by the material that is being fed into the chipper.

14. When using a winch in chipper operations, the operator shall ensure that the winch cable is properly stored before initiating chipper operations.

15. Refer to 16VAC25-73-60 C, for additional information.

G. Limbing and bucking.

1. Work plans for limbing and bucking operations shall be communicated to all workers in a job briefing before work begins.

2. When more than one worker is limbing or bucking a tree, each shall be positioned and their duties organized so that the actions of one worker will not create a hazard for any other worker.

3. Chain saws shall be operated away from the vicinity of the legs and feet. Natural barriers, such as limbs between the saw and the body, shall be employed where possible, while ensuring proper balance. While operating a chain saw, the preferred working position is on the uphill side of the work.

4. The worker shall make sure of firm footing before and during limbing and bucking. The worker shall not stand on loose chunks or logs that will roll when the log being bucked is sawed off.

5. Trees, limbs, or saplings under tension shall be considered hazardous. Appropriate cutting techniques and precautions shall be followed.

6. Wedges shall be used as necessary to prevent binding of the guide bar or chain when bucking trunks of trees.

7. Cant hooks or peaveys shall be used as an aid in rolling large or irregular logs to complete bucking.

8. If mechanized equipment is to be used, the equipment operator shall establish an effective means of communication with other workers (see subdivisions B 1 and D 10 of this section).

9. Workers shall not approach mechanized equipment operations until the equipment operator has acknowledged that it is safe to do so.

H. Pesticide application.

1. The applicator shall follow label instructions in regard to pesticide applications.

2. The applicator shall follow pesticide label instructions in regard to laundering his clothing.

3. The applicator shall comply with the manufacturer's instructions with regard to showering or bathing at the end of each workday.

4. The employer shall provide a clean water source at the worksite, which can be used for emergency personal decontamination. Precautions shall be taken to prevent contamination of the clean water source. Drinking water and decontamination water shall be kept in separate containers.

5. The applicator shall not direct a solid spray column into contact with electrical conductors.

16VAC25-73-100. Appendix A (Informative): Recommended Guidelines for Standard Performance and Safety Training for Qualified Line-Clearance Arborists/Qualified Line-Clearance Arborist Trainees and Qualified Arborists/Qualified Arborist Trainees.

NOTE: The content of this training outline is generic and may be customized to achieve equivalent levels of safe practice by substituting or, where deemed appropriate to the circumstances, omitting portions of this outline. Use or nonuse of training aids that may be available shall not be evidence of noncompliance with this regulation.

A. General requirements. Specific training in the area of individual expertise and work required of a qualified line-clearance arborist or qualified arborist shall be provided by the employer and documentation of training retained on file for the duration of employment.

1. Introduction and employer/employee responsibilities.

2. Employee orientation, to include:

a. Job description appropriate to job assignment (qualified line-clearance arborist or qualified arborist).

b. Introduction to immediate supervisor and crew members.

c. Familiarization with appropriate personal protective clothing and equipment and its proper use and maintenance.

d. Familiarization with equipment.

e. Introduction to company policies, procedures, and safe work practices.

f. Safe work practices as related to job assignments.

g. Written acknowledgment by employee that he has participated in such training.

3. Line-clearance or tree care pruning techniques appropriate to job assignments, as follows:

a. Provide education and training in accordance with prevailing national standards for utility pruning. Refer to recommended resources in 16VAC25-73-120 (Appendix C) for further information.

b. Provide education and training in accordance with prevailing local, state, or regional standards for utility pruning, as well as those specified by utility contracts.

c. Provide tree knowledge for line-clearance or tree care techniques appropriate to job assignments.

d. Provide education and training relative to predominant tree species within geographic area, such as identification, growth habits, structure, and wood strength.

e. Provide education and training for recognition and evaluation of potentially hazardous conditions related to tree structure. Refer to recommended resources in 16VAC25-73-120 (Appendix C).

B. General safety.

1. VOSH regulations. Familiarize employees with the requirements of VOSH regulations as applicable to employee job assignments. Refer to recommended resources in 16VAC25-73-120 (Appendix C).

2. American national standards. Familiarize employees with the requirements in ANSI A300 as applicable to employee job assignments. Refer to additional recommended standards in 16VAC25-73-120 (Appendix C).

3. Public safety and traffic control. Provide education and training in the use of public safety and traffic control devices as applicable under federal, state, or local regulations.

4. Electrical hazards. Provide education and training in the recognition and avoidance of electrical hazards applicable to employee job assignments (line clearance or tree care).

5. Emergency conditions. Provide education and training in the proper procedures for safely performing work in emergency conditions applicable to employee job assignments.

6. Jobsite briefings. Provide education and training in jobsite-specific hazards associated with the job, work procedures, and practices involved. Instruct employees about special precautions, personal protective clothing, and equipment requirements as applicable to employee job assignments.

C. Personal safety.

1. Personal protective equipment. Provide personal protective equipment as required for applicable job assignments, and instruct employees in its proper use, fit, life, and maintenance.

2. Emergency response procedures. Furnish employees with appropriate information and training necessary to expedite a response to a worksite emergency, such as first aid, CPR, and aerial rescue (see 16VAC25-73-150, Appendix E, Aerial Rescue Flowchart).

3. Prevention of back and other injuries. Provide education and training in the techniques required to avoid back and other injuries applicable to job assignments.

4. Identification and avoidance of animals and poison plants. Provide education and training in the identification of and the need to avoid contact with poison plants and instructions for treating insect stings/bites and snake bites.

D. Equipment safety.

1. Mobile equipment and aerial lifts. Provide education and training in the inspection, operation, and maintenance of all vehicles and equipment, such as aerial lifts, brush chippers, stump grinders, log loaders, tree cranes, mowing equipment, and pesticide application equipment. All equipment shall comply with applicable federal and state regulations, local ordinances, and manufacturers' operating instructions (see 16VAC25-60-120). Such training shall be appropriate to employee job assignments.

2. Aerial equipment and electrical hazards. Provide education and training so that affected employees understand the required and recommended procedures for operating aerial devices in proximity to electrical hazards. Such training shall be appropriate to employee job assignments.

3. Chain saw, power tool, and hand tool use and safety. Provide education and training in the safe use of chain saws, power tools, and hand tools in accordance with manufacturers' instructions. Such training shall be appropriate to employee job assignments.

4. Climbing equipment use and safety. Provide education and training in the inspection, maintenance, and storage of climbing equipment such as ropes, saddles, personal lanyards, rope snaps, carabiners, and related equipment. Such training shall be appropriate to employee job assignments.

E. Operational safety.

1. Climbing techniques. Provide education and training in climbing techniques as appropriate to employee job assignments.

2. Rigging and tree removal:

a. Provide education and training appropriate to employee job assignments, such as knots and ropes, rigging techniques, tree strength and weight characteristics, and potential electrical hazards.

b. Provide education and training in the identification and removal of hazard trees. Such training shall be appropriate to employee job assignments.

3. Hazard communications. Provide education and training necessary to comply with federal and state regulations appropriate to employee job assignments.

4. Pesticide use. Provide education and training necessary to comply with federal and state regulations appropriate to employee job assignments.

16VAC25-73-110. Appendix B (Informative): General Safety Procedures that Apply to All Tree Work.

A. Lifting. Before lifting any weight, workers shall:

1. Be sure there is a clear path available if the weight is to be carried from one place to another;

2. Decide exactly how the object should be grasped to avoid sharp edges, slivers, splinters, or other factors that might cause injury;

3. Make a preliminary lift to be sure the load can be safely handled;

4. Place feet solidly on the walking surface;

5. Crouch as close to the load as possible, with legs bent at an angle of about 90 degrees;

6. Lift with the legs, not the back, keeping the weight as close to the body as possible; and

7. Use additional workers or material-handling equipment when necessary.

B. Control of hazardous energy. When a worker, hereafter referred to as the "authorized person," is doing mechanical work, precautions must taken to prevent injury caused by moving or elevated parts, or the release of stored energy, such as hydraulic pressure. Failure to do so could result in a serious, potentially maiming, or fatal injury. The authorized person performing maintenance/repair shall comply with the employer's procedures. The specific Control of Hazardous Energy requirements established by VOSH may be obtained by consulting 16VAC25-90-1910.147.

1. The following is a sample procedure.

Sequence for Securing Equipment (Sample):

a. The authorized person shall notify the crew and/or affected employees that maintenance or repair is to be done and that such equipment must be shut down and secured.

b. The authorized person shall refer to the manufacturer's manual for proper procedures (as needed).

c. If equipment is in an operational mode, it shall be shut down by normal procedures.

d. Rotating parts, such as chipper blades, shall be stopped before maintenance or repair. Keyed ignition systems must be in working order.

e. Keys shall be removed and pocketed by the foreman or mechanic. When there is no keyed ignition system, the battery cables or spark plug wires shall be disconnected.

f. The power takeoff shall be disengaged before beginning service or repair tasks, such as hose replacement. All hydraulic tools shall be disconnected before equipment is adjusted or serviced.

g. An employee shall never attempt to stop a hydraulic leak with his body.

h. Materials or parts that must be raised or disconnected and suspended shall be properly secured, such as with an appropriate sling or jackstand. Flywheels, such as chipper cutter heads, are to be blocked to prevent pinch points.

i. Before proceeding with maintenance or repair, the authorized person shall ensure that equipment is isolated and will not operate.

j. Any piece of equipment being serviced or repaired shall not be started, energized, or used by any other worker not under the direction of the authorized person.

k. When the engine must be running for tuning or adjustment, special care must be given to moving parts.

2. Restoring equipment to service (sample). When maintenance or repair is complete and equipment is ready to return to normal operation, the following steps shall be taken by the authorized person to restore the equipment to service:

a. To prevent accidental contact with moving or electrical components when the equipment is engaged, check for loose parts or tools that may have been left in the immediate area.

b. Ensure that all guards are in place and employees are in the clear.

c. Confirm that controls are in neutral.

d. Reconnect key, cable, or plug wires.

e. Notify affected employees that equipment is ready to return to service.

16VAC25-73-120. Appendix C (Informative): Additional Resources.

A. Applicable American National Standards:

Fall protection systems for construction and demolition operations (A10.32-2004)

Personal fall arrest systems, subsystems, and components (Z359.1-1992 [R1999])

Protective headgear for industrial workers (Z89.1-2003)

Tree care operations—tree, shrub, and other woody plant maintenance (A300, Parts 1 through 7)

Vehicle-mounted elevating and rotating aerial devices (A92.2-2001)

B. Cordage Institute Rope Standards

The Cordage Institute, www.ropecord.com

C. Applicable VOSH and U.S. Department of Labor/Federal Labor/Federal Motor Carrier Safety Administration Regulations

Electric Power Generation, Transmission, and Distribution, 16VAC25-90-1910.269

General Industry, 16VAC25-90-1910

Hazard Communication, 16VAC25-90-1910.1200

[ Medical Services and First Aid, 16VAC25-95 [PROPOSED REGULATION] ]

Occupational Noise Exposure, 16VAC25-90-1910.95

Personal Protective Equipment, 16VAC25-90-1910.132 to 16VAC25-90-1910.136

Electrical - Safety-Related Work Practices, 16VAC25-90-1910.331 to 16VAC25-90-1910.335

Telecommunication, 16VAC25-90-1910.268

Transportation (49 CFR, Subchapter B, Federal Motor Carrier Safety Regulations)

16VAC25-73-130. Appendix D (Informative): Weight of Green Logs.

Species	Weight, lb per ft	Weight of 1-ft section, based on average diameter
		10"	12"	14"	16"	18"	20"	22"	24"
Alder, red	46	25	36	49	64	81	100	121	144
Ash, green	47	25	37	50	66	83	102	124	148
Ash, Oregon	48	26	38	51	67	85	104	126	150
Ash, white	48	26	38	51	67	85	104	126	150
Aspen, quaking	43	23	34	46	60	76	94	114	135
Baldcypress	51	28	40	54	71	90	111	135	160
Basswood	42	23	33	45	59	74	92	111	132
Beech	54	29	42	58	75	95	118	142	169
Birch, paper	50	27	39	53	70	88	109	132	157
Cedar, incense	45	25	35	48	63	79	98	119	141
Cedar, western red	28	15	22	30	39	49	61	74	88
Cherry, black	45	25	35	48	63	79	98	119	141
Chinaberry	50	27	39	53	70	88	109	132	157
Cottonwood	49	27	38	52	68	86	107	129	154
Elm, American	54	29	42	58	75	95	118	142	169
Fir, Douglas	39	21	30	41	55	69	85	103	122
Fir, noble	29	16	23	31	41	51	63	77	91
Fir, white	47	25	37	50	66	83	102	124	148
Gum, black	45	25	35	48	63	79	98	119	141
Gum, red (Eucalyptus)	50	27	39	53	70	88	109	132	157
Hackberry	50	27	39	53	70	88	109	132	157
Hemlock, eastern	49	27	38	52	68	86	107	129	154
Hemlock, western	41	22	32	43	57	72	89	108	129
Hickory, shagbark	64	35	50	68	89	113	140	169	201
Horsechestnut	41	22	32	43	57	72	89	108	129
Larch	51	28	40	54	71	90	111	135	160
Locust, black	58	32	45	62	81	102	126	153	182
Locust, honey	61	33	48	65	85	108	133	161	192
Maple, red	50	27	39	53	70	88	109	132	157
Maple, silver	45	25	35	48	63	79	98	119	141
Maple, sugar	56	31	44	60	78	99	122	148	176
Oak, California black	66	36	51	70	92	116	144	174	207
Oak, English	52	28	41	55	72	92	113	137	163
Oak, live	76	41	60	81	106	134	166	200	238
Oak, pin	64	35	50	68	89	113	140	169	201
Oak, post	63	34	49	67	88	111	137	166	198
Oak, red	63	34	49	67	88	111	137	166	198
Oak, scarlet	64	35	50	68	89	113	140	169	201
Oak, white	62	34	48	66	86	109	135	163	194
Pecan	61	33	48	65	85	108	133	161	192
Persimmon	63	34	49	67	88	111	137	166	198
Pine, eastern white	36	20	28	38	50	64	78	95	113
Pine, loblolly	53	29	41	56	74	93	116	140	166
Pine, lodgepole	39	21	30	41	55	69	85	103	122
Pine, longleaf	55	30	43	58	77	97	120	145	173
Pine, ponderosa	46	25	36	49	64	81	100	121	144
Pine, slash	58	32	45	62	81	102	126	153	182
Pine, sugar	52	28	41	55	72	92	113	137	163
Pine, western white	36	20	28	38	50	64	78	95	113
Poplar, yellow	38	21	30	40	53	67	83	99	119
Redwood, coast	50	27	39	53	70	88	109	132	157
Spruce, red	34	19	27	36	47	60	74	90	106
Spruce, Sitka	32	17	25	34	45	56	70	84	100
Sweetgum	55	30	43	58	77	97	120	145	173
Sycamore	52	28	41	55	72	92	113	137	163
Walnut, black	58	32	45	62	81	102	126	153	182
Willow	32	17	25	34	45	56	70	84	100

16VAC25-73-140. Appendix E (Informative): Aerial Rescue Flowchart.

16VAC25-73-150. Appendix F (Informative): Hand Signal Chart for Crane Operations.

DOCUMENTS INCORPORATED BY REFERENCE (16VAC25-73)

American National Standards Institute (ANSI), 11 West 42nd Street, New York, NY 10036:

ANSI/ASSE A10.32-2004, Fall Protection Systems for Construction and Demolition Operations.

ANSI Z359.1-1992 (R-1999), Personal Fall Arrest Systems, Subsystems, and Components.

ANSI Z89.1-2003, Protective Headgear for Industrial Workers.

ANSI A300, Tree Care Operations—Tree, Shrub, and Other Woody Plant Maintenance—Standard Practices:

Part 1-2001, Pruning, revised 2008.

Part 2-1998, Fertilization, revised 2004.

Part 3-2000, Supplemental Support Systems, revised 2006.

Part 4-2002, Lightning Protection Systems.

Part 5-2005, Management of Trees and Shrubs During Site Planning, Site Development, and Construction.

Part 6-2005, Transplanting.

Part 7-2006, Integrated Vegetation Management, Electric Utility Rights-of-Way.

ANSI/SIA A92.2-2001, Vehicle-Mounted Elevating and Rotating Aerial Devices.

Virginia Work Area Protection Manual, Standards and Guidelines for Temporary Traffic Control, Virginia Department of Transportation, May 2005.