Section 85. Determining compliance with individual regulatory requirements  


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  • A. During the audit process, the department shall determine whether the program or facility is compliant with each regulatory requirement. To be found in compliance, the following shall be shown:

    1. The program or facility shall:

    a. For critical regulatory requirements, demonstrate 100% compliance;

    b. For noncritical regulatory requirements with multiple elements, the certification audit team will make a determination of compliance as provided in department procedures that shall require (i) an acceptable percentage of compliance with the entire regulatory requirement or (ii) any single element; or

    c. For all noncritical regulatory requirements, demonstrate an acceptable percentage compliance as provided in department procedures.

    2. The program or facility shall not have:

    a. Any circumstance or condition constituting a pattern of action that presents a concern for the health, welfare, or safety of the residents, program participants, or staff; or

    b. Any circumstance or condition that presents an immediate threat to the health, welfare, or safety of the residents, program participants, or staff.

    B. The determination of noncompliance shall be a decision made by the entire certification team.

    C. For purposes of calculating percentage of compliance, the determination of what constitutes individual regulatory requirements (e.g., section, subsection, subdivision, or element in a list in the regulatory chapter) will be specified as provided in department procedures.

Historical Notes

Derived from Volume 29, Issue 26, eff. September 25, 2013.

Statutory Authority

§§ 16.1-233 and 66-10 of the Code of Virginia.