Compliance Analysis Overview

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-90.05 Principles for Establishment of Fees This document provides guidance to health regulatory boards when establishing fees mandated by Virginia Code §§ 54.1-113 and 54.1-2400(5).

Boards will promptly adjust fees to avoid the collection of unnecessary revenue or a sharp increase in fees. Fee adjustments will rely on official estimates of revenues and expenditures provided by the agency’s Chief Financial Officer as well as a board’s cash balances.

Renewal fees should cover the board’s cost of discipline, inspections, the Health Practitioners' Monitoring Program, enforcement of continued competency requirements, policy development and general overhead.

Initial licensure fees should cover:

• Credential review (possibly at several levels);
• Initial fees should generally cover costs up to the first renewal of the license;
• Cost of preparation and delivery of any hardcopy materials or wall certificates; and
• Other activities directly associated with initial licensure issuance.

Duplicate license fees, wall certificate fees, and other miscellaneous fees should be based on cost estimates provided by the Chief Financial Officer.

Unless there is clear evidence that indicates a reason to establish fees otherwise, renewal fees for all occupations should be consistent across occupational categories within a health regulatory board. Reasons that may lead to alternative renewals may include differences in rates of discipline, requirements for inspections, document review, re-qualification as well as reasons related to fairness and equity.

Inactive license renewal fees should typically be 50% of active license renewal fees. Costs associated with investigating allegations of misconduct, operation of the Health Practitioner Monitoring Program, and enforcement of continued competence requirements are excluded from the cost estimate for inactive licenses. Costs such as board overhead, processing of applications, and general board operations may be included in the cost estimate for an inactive license. The fee for reactivation of an inactive license will generally be the difference between an inactive and active renewal fee.

Fees for services that represent small costs (such as a license verification online, which may cost less than $5.00) should be avoided. Total expenses for many such activities are an component of the number of applicants, licensees, examinees, etc. Therefore, small cost items may be appropriately incorporated in the determining component items when setting renewal and application fees.

The reissuance of a license after it has expired should require the payment of a penalty that acts as an incentive to renew promptly and remain in compliance with applicable laws. An 1 Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-90.05 expired license may be renewed upon payment of a penalty fee for the single renewal period following expiration.

After the passage of the renewal period, reinstatement of the license (now lapsed) may be required, which may result in a review of credentials, re-examination or other substantive qualification requirements. In the case of reinstatement of a lapsed license that involves review of continued education hours or other evidence of competency to practice, the fee may include the renewal fee, a late fee, and a credential review fee.

References Va. Code § 54.1-113 Va. Code § 54.1-2400 2

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-90.05 Principles for Establishment of Fees This document guides health regulatory boards in establishing fees mandated by Virginia Code §§ 54.1-113 and 54.1-2400(5).

Boards will promptly adjust fees to prevent unnecessary revenue collection or sharp increases, relying on official estimates from the CFO and the board’s cash balances.

Renewal fees should cover the board’s cost of discipline, inspections, the Health Practitioners' Monitoring Program, enforcement of continued competency requirements, policy development and general overhead.

Initial licensure fees should cover:

• Credential review (possibly at several levels);
• Initial fees should cover costs through the first renewal;
• Cost of preparing and delivering hardcopy materials or wall certificates;
• Other activities related to initial licensure.

Duplicate license, wall certificate, and other miscellaneous fees should be based on cost estimates from the CFO.

Unless justified, renewal fees should be consistent across occupations within a board, with exceptions for discipline rates, inspections, review, re-qualification, fairness, or equity.

Inactive license renewal fees should typically be 50% of active fees. Costs for misconduct investigations, the Monitoring Program, and enforcement are excluded; overhead and processing may be included. Reactivation fee is usually the difference between inactive and active renewal fees.

Fees for low-cost services (e.g., online verification under $5) should be avoided; such costs are included in overall fee components when setting renewal and application fees.

Reissuance after expiration requires a penalty to incentivize prompt renewal and compliance. Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-90.05 expired license may be renewed by paying a penalty fee for the next renewal period.

After the renewal period, reinstatement of a lapsed license may require credential review, re-examination, or other qualifications, with fees including renewal, late, and review fees.

References: Va. Code § 54.1-113, § 54.1-2400

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-90.03 Foreign Applicants and Social Security Numbers The purpose of this policy is to provide guidance on the processing of applications from foreign applicants who do not possess a permanent social security number or a control number issued by the Virginia Department of Motor Vehicles.

Certain foreign applicants for licensure, certification, or registration by the health regulatory boards may encounter obstacles in the effort to obtain work visas, social security numbers, and the authorization required to pursue their professions in Virginia. An applicant reportedly cannot obtain a work authorization from the Immigration and Naturalization Service (“INS”) unless the applicant has a license, registration or certification to practice his or her profession.

Virginia Code § 54.1-116 requires an applicant for license, registration or certification by a health regulatory board to provide a social security number or a control number issued by the Department of Motor Vehicles (“DMV”) on the application. Even a statutory exemption which allows certain Canadian nurses to be licensed as Registered Nurses by endorsement requires a “proper application” to the Board. See Va. Code § 54.1-3001(A)(4). Because Virginia Code § 54.1-116 requires “all” applications to include a social security number or a control number issued by the DMV, the exemption for certain Canadian nurses also requires a social security number or control number issued by the DMV.

The Social Security Administration, however, requires that a foreign applicant for a social security number have a work permit before it will issue a social security number.

To address this circular dilemma, Virginia Code § 54.1-116 was amended to allow a health regulatory board to issue a temporary license or authorization to practice, effective for not longer than 90 days, to an otherwise qualified applicant for a license, certificate, or registration who is a foreign national and cannot provide a social security number or control number at the time of application. See Va. Code § 54.1-116(B). The Board may grant additional temporary licenses for an applicant whose 90 days have expired, provided the reason given for the extension is outside of the applicant’s control.

Procedure for Board staff

If an application is received by a board without a social security number or DMV control number, and all other requirements in board regulation are met, the board may issue a temporary license. The temporary license will expire 90 days from issuance.

If a board issues a temporary license, it will be recorded as temporary, with a 90-day expiration date, in the DHP License Lookup system and in any other applicable licensing database systems reported to by a board.

Any temporary licenses issued by a board will be flagged with a hold/alert pending provision of a social security number or DMV control number. The hold/alert may be released when all requirements in for licensure are met. 1 Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-90.03 If all requirements in board regulations are met and a social security number or DMV control number is verified, an application is deemed complete and a permanent license may be issued.

References Va. Code § 54.1-116 2

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-90.03 Foreign Applicants and Social Security Numbers This policy guides processing applications from foreign applicants lacking a permanent social security or DMV control number.

Foreign applicants for licensure, certification, or registration may face obstacles obtaining work visas, social security numbers, and authorization in Virginia. INS work authorization requires a license, registration, or certification.

Virginia Code § 54.1-116 requires applicants for licensure, registration, or certification to provide a social security or DMV control number. The Canadian nurse exemption also requires this, per Va. Code § 54.1-3001(A)(4).

The Social Security Administration requires a foreign applicant to have a work permit before issuing a social security number.

Virginia Code § 54.1-116 was amended to allow boards to issue temporary licenses (up to 90 days) to qualified foreign applicants lacking a social security or control number. Extensions may be granted for reasons beyond the applicant’s control.

Procedure for Board staff

If an application lacks a social security or DMV control number but meets other requirements, the board may issue a temporary license valid for 90 days.

Temporary licenses will be recorded as such, with a 90-day expiration, in the DHP License Lookup and other licensing systems.

Temporary licenses will be flagged with a hold/alert pending social security or DMV control number; released when requirements are met.

Revised: April 16, 2025

Guidance Document: 76-90.03 When all requirements are met and a social security or DMV control number is verified, the application is complete, and a permanent license may be issued.

References Va. Code § 54.1-116 2

Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

Virginia Board of Audiology and Speech-Language Pathology

Guidance for the Use and Supervision of Speech-Language Pathology Assistants (SLPAs)

The Board of Audiology and Speech-Language Pathology often receives questions regarding the use of Speech-Language Pathology Assistants. The most frequently asked questions are the following:

1) Question: What is the scope of practice for an SLPA? 2) Question: Are all individuals that assist an SLP an SLPA? 3) Question: How many assistants may an SLP supervise? 4) Question: Can an SLPA implement treatment services? 5) Question: How often must the SLP observe and evaluate the SLPA implementing the treatment services? 6) Question: Is the SLP required to observe and evaluate at least two client sessions every 30 days for each client for which an SLPA is implementing treatment services? 7) Question: May an SLP provide onsite supervision of an SLPA via tele-supervision? 8) Question: Must the SLP who provides direct treatment and provides treatment plans to the SLPA also provide the supervisory observations of the SLPA? 9) Question: How often is the SLP required to provide services to a client that utilizes SLPAs?

Guidance

1) Question: What is the scope of practice for an SLPA?

Response: The Regulations Governing the Practice of Audiology and Speech-Language Pathology define the scope of practice for an SLPA to be the following:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

C. Scope of practice of a speech-language pathologist assistant. After demonstration and documentation of competency for the duties to be assigned, an assistant shall only engage in those duties planned, designed, and supervised by a licensed speech-language pathologist, to include the following:

1. Assist with speech, language, and hearing screenings without clinical interpretation of results.
2. Assist during assessment of a client exclusive of administration or interpretation.
3. Perform activities for each session that are routine and do not require professional judgment, in accordance with a plan developed and directed by the speech-language pathologist who retains the professional responsibility for the client.

Page 1 of 4Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

1. Document a client's performance and report information to the supervising speech-language pathologist.
2. Assist with programming augmentative and alternative communication devices and assist the client in repetitive use of such devices.
3. Sign or initial informal treatment notes and, upon request, co-sign formal documents with the supervising speech-language pathologist.
4. Engage in the following activities: a. Preparing materials; b. Scheduling appointments and activities; c. Preparing charts, records, or graphs and performing other clerical duties; d. Performing checks and maintenance of equipment; and e. Assisting a client with transitioning to and from therapy sessions.
5. Perform duties not otherwise restricted to the practice of speech-language pathology.

2) Question: Are all individuals that assist an SLP an SLPA?

Response: Not all individuals that assist an SLP are SLPAs. An assistant that performs any of the duties defined in the scope of practice for an SLPA found in 18VAC30-21-140(1-6) and (8) is an SLPA. Individuals that only assist by performing functions listed in 18VAC30-21-140(7) do not need to be an SLPA.

3) Question: How many assistants may an SLP supervise?

Response: An SLP may supervise the equivalent of two full-time speech-language pathology assistants.

The Regulations Governing the practice of Audiology and Speech-Language Pathology state the following:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

E. Supervision of an assistant in speech-language pathology.

1. … A speech-language pathologist shall only supervise the equivalent of two full-time assistants.

4) Question: Can an SLPA implement treatment services?

Response: An SLPA may implement treatment services planned and developed by their supervising SLP.

5) Question: How often must an SLP observe and evaluate an SLPA implementing the treatment services?

Page 2 of 4Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

Response: The supervising SLP must provide documented onsite supervision of at least two client sessions for each SLPA every 30 days. This is to directly observe and evaluate the performance of the SLPA. The onsite supervision requirement is distinctly different from the requirement for the SLP to provide services to all clients provided in Question 9.

The Regulations Governing the Practice of Audiology and Speech-Language Pathology state the following:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

E. Supervision of an assistant in speech-language pathology.

1. The speech-language pathologist shall provide the level of supervision to the speech-language pathologist assistant necessary to ensure quality of care to include onsite supervision of at least two client sessions for each assistant being supervised every 30 days to directly observe and evaluate the performance of the assistant. The speech-language pathologist shall document such onsite observation and evaluation in the client record for each session.

6) Question: Is the SLP required to observe and evaluate at least two client sessions every 30 days for each client for which an SLPA is implementing treatment services?

Response: No, the SLP is required to provide onsite supervision of a minimum of least two client sessions per SLPA every 30 days as provided in the response to Question 5.

7) Question: May an SLP provide onsite supervision of an SLPA via tele-supervision?

Response: Onsite supervision may occur in-person, face-to-face; or via a real-time, audio and visual electronic communication method that is synchronous, (real-time) in which the SLP, SLPA and client may visually see and verbally communicate with one another.

Recordings of SLPAs working with clients are not “real-time” and do not satisfy this requirement.

8) Question: Must the SLP who provides direct treatment and provides treatment plans to the SLPA also provide the supervisory observations of the SLPA?

Response: The SLP providing treatment to a client and planning treatment for the SLPA to implement to the client is required to conduct the supervisory observations. In the event the SLPA works for multiple SLPs, each SLP must observe and supervise 2x/month to ensure standard of care for the clients under their treatment.

9) Question: How often is the SLP required to provide services to a client that utilizes SLPAs?

Page 3 of 4Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

Response: The treating SLP must meet with each client receiving services from the SLPA at least once every 30 days to provide treatment and to aid in their planning and development of treatment to be implemented by the SLPA.

The Regulations Governing the Practice of Audiology and Speech-Language Pathology state the following:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

A. Responsibility of a licensee.

1. A licensed speech-language pathologist who supervises unlicensed assistants shall document such supervision, shall be held fully responsible for their performance and activities, and shall ensure that they perform only those activities that do not constitute the practice of speech-language pathology and that are commensurate with their level of training.

b. The frequency in which the speech-language pathologist personally delivers treatment or services to a client who is receiving some services from an assistant shall be up to the professional judgment of the speech-language pathologist and shall be determined by the treatment needs of the client, the type of services being provided, and the setting in which the client is being served, but shall occur at least every 30 days.

Page 4 of 4

Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

Virginia Board of Audiology and Speech-Language Pathology

Guidance for the Use and Supervision of Speech-Language Pathology Assistants (SLPAs)

The Board often receives questions about Speech-Language Pathology Assistants; the most common are:

1) Question: What is the scope of practice for an SLPA? 2) Are all individuals assisting an SLP SLPAs? 3) Question: How many assistants may an SLP supervise? 4) Can an SLPA implement treatment? 5) Question: How often must the SLP observe and evaluate the SLPA implementing the treatment services? 6) Must the SLP observe two client sessions per 30 days for each client with an SLPA? 7) Can onsite supervision be via tele-supervision? 8) Must the SLP providing treatment and plans also supervise? 9) How often must the SLP provide services to clients using SLPAs?

Guidance

1) Question: What is the scope of practice for an SLPA?

Response: The Regulations define the SLPA scope of practice as follows:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

C. Scope of a speech-language pathologist assistant. Once competent, an assistant shall only perform duties planned, designed, and supervised by a licensed SLP, including:

1. Assist with speech, language, and hearing screenings without interpreting results.
2. Assist during client assessment excluding administration or interpretation.
3. Perform routine activities per a plan by the SLP, who retains professional responsibility.

Page 1 of 4Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

1. Document client performance and report to the supervising SLP.
2. Assist with programming and client use of augmentative and alternative communication devices.
3. Sign informal notes and co-sign formal documents upon request with the supervising SLP.
4. Perform activities: a. preparing materials; b. scheduling; c. preparing charts/records; d. equipment checks; e. assisting client transitions.
5. Perform duties not restricted to speech-language pathology.

2) Question: Are all individuals that assist an SLP an SLPA?

Response: Not all assistants are SLPAs. Those performing duties in 18VAC30-21-140(1-6,8) are SLPAs; those only assisting with functions in (7) are not.

3) Question: How many assistants may an SLP supervise?

Response: An SLP may supervise the equivalent of two full-time SLPAs.

The Regulations state:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

E. Supervision of an assistant in speech-language pathology.

1. A speech-language pathologist shall supervise only two full-time assistants.

4) Question: Can an SLPA implement treatment services?

Response: An SLPA may implement treatment services planned and developed by their supervising SLP.

5) How often must an SLP observe and evaluate an SLPA?

Page 2 of 4Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

Response: The SLP must supervise onsite at least two client sessions per SLPA every 30 days to observe and evaluate performance. This differs from the service provision requirement in Question 9.

The Regulations state:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

E. Supervision of an assistant in speech-language pathology.

1. The SLP shall provide necessary supervision, including onsite observation of at least two client sessions per assistant every 30 days, and document each in the client record.

6) Question: Is the SLP required to observe and evaluate at least two client sessions every 30 days for each client for which an SLPA is implementing treatment services?

Response: No; the SLP must supervise at least two client sessions per SLPA every 30 days, per Question 5.

7) Question: May an SLP provide onsite supervision of an SLPA via tele-supervision?

Response: Supervision can be in-person or via real-time, audio-visual electronic communication where SLP, SLPA, and client see and communicate in real-time.

Recordings of SLPAs do not meet this requirement.

8) Question: Must the SLP who provides direct treatment and provides treatment plans to the SLPA also provide the supervisory observations of the SLPA?

Response: The SLP providing treatment and planning for the SLPA must conduct supervisory observations. If working for multiple SLPs, each must observe and supervise twice monthly to ensure care standards.

9) Question: How often is the SLP required to provide services to a client that utilizes SLPAs?

Page 3 of 4Guidance Document: 30-4 Adopted: March 8, 2022 Effective: April 28, 2022

The treating SLP must meet each client receiving SLPA services at least every 30 days to provide treatment and assist in planning and developing treatment for the SLPA.

The Regulations Governing the Practice of Audiology and Speech-Language Pathology state the following:

18VAC30-21-140. Supervisory responsibilities; supervision of unlicensed assistants.

A. Licensee responsibility.

1. A licensed SLP supervising unlicensed assistants must document supervision, be responsible for their performance, and ensure they perform only activities within their training and not practicing speech-language pathology.

b. The SLP's personal treatment frequency, based on client needs, service type, and setting, shall be at least every 30 days, per professional judgment.

Page 4 of 4

Guidance Document: 30-6 Reaffirmed: February 9, 2021 Effective: April 1, 2021

Virginia Board of Audiology and Speech-Language Pathology

Policy on Active Practice

Applicable Regulations

18VAC30-21-10. Definitions.

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

"Active practice" means a minimum of 160 hours of professional practice as an audiologist or speech-language pathologist for each 12-month period immediately preceding application for licensure. Active practice may include supervisory, administrative, educational, research, or consultative activities or responsibilities for the delivery of such services.

Guidance

Question: What activities constitute “active practice” in the profession of Audiology or Speech-Language Pathology?

Response: The Board considers the following activities as active practice:

• Employment by a company or organization
• Self-employment
• Supervision of clinical practice
• Teaching in an academic institution
• Clinical fellowship
• Research activities
• Volunteer activities

Question: What documents must be submitted to demonstrate that active practice has occurred?

Response: The following documents may be submitted to demonstrate active practice:

Employment by a company or organization; teaching in an academic institution; clinical fellowship; and volunteer activities

• Verification from employer, supervisor, or program director on the organization’s letterhead that includes information on the title of the position or assignment, a description of job duties or responsibilities, the city and state (country if outside of the U.S.) where activities occurred, and the dates activities were performed; or
• Verification on board form found at http://www.dhp.virginia.gov/aud/aud_forms.htm .

Page 1 of 2Guidance Document: 30-6 Reaffirmed: February 9, 2021 Effective: April 1, 2021

Self-employment

• Letters from clients served to include who received the services, the services provided, dates of service and the city and state where services were provided; or
• Tax returns that reflect occupation information.

Supervision of clinical practice and research activities

• If employed, teaching or participating in a volunteer organization provide verification from employer, supervisor, or program director on the organization’s letterhead that includes information on the description of job duties or responsibilities, the city and state (country if outside of the U.S.) where activities occurred, and the dates activities were performed; or
• If self-employed, a statement attesting to the provision of supervision to include the name of person supervised, a description of job duties or responsibilities, the city and state (country if outside of the U.S.), and the dates activities were performed.

Page 2 of 2

Guidance Document: 30-6 Reaffirmed: February 9, 2021 Effective: April 1, 2021

Virginia Board of Audiology and Speech-Language Pathology

Policy on Active Practice

Applicable Regulations

18VAC30-21-10. Definitions.

B. The following words and terms in this chapter shall have these meanings unless the context indicates otherwise:

"Active practice" means at least 160 hours of professional work as an audiologist or speech-language pathologist in the 12 months before licensure, including supervisory, administrative, educational, research, or consultative activities.

Guidance

Question: What activities constitute "active practice" in Audiology or Speech-Language Pathology?

Response: The Board considers the following activities as active practice:

• Employment by a company or organization
• Self-employment
• Supervision of clinical practice
• Teaching in an academic institution
• Clinical fellowship
• Research activities
• Volunteer activities

Question: What documents must demonstrate active practice?

Response: The following documents may demonstrate active practice:

Employment by a company or organization; teaching; clinical fellowship; volunteer activities

• Verification from employer, supervisor, or program director on letterhead with position title, job duties, location, and dates; or
• Verification on board form at http://www.dhp.virginia.gov/aud/aud_forms.htm.

Page 1 of 2Guidance Document: 30-6 Reaffirmed: February 9, 2021 Effective: April 1, 2021

Self-employment

• Letters from clients including recipient, services, dates, and location; or
• Tax returns that reflect occupation information.

Supervision of clinical practice and research activities

• If employed, teaching, or volunteering, provide verification on letterhead with duties, location, and dates;
• If self-employed, provide a statement attesting to supervision, including supervisee name, duties, location, and dates.

Page 2 of 2

Department of Health Professions

Revised: April 17, 2025

Guidance Document: 76-40.02 Unlicensed Activity This guidance document establishes procedures for the Department of Health Professions regarding allegations of unlicensed activity.

It is the policy of the Department to review all allegations of unlicensed practice and report findings of investigations with evidence of unlicensed activity to the Attorney for the Commonwealth for possible prosecution. This policy applies to the handling of information alleging that an unlicensed person or entity offered or is offering services or engaged in practice for which a health regulatory license is required. This includes possible violations of Virginia Code §§ 54.1-111, 54.1-2409.1 and 54.1-3008 or any other applicable provision of law. It does not apply to regulatory board decisions regarding consideration of applications for issuance or reinstatement of a license.

Procedures

All case information for unlicensed case allegations will be entered into the Department’s complaint and licensure system.

The case intake analyst will review all allegations of unlawful conduct and consult with the Director of Enforcement or designee and Board staff to make a determination regarding whether the allegation indicated unlicensed practice or acts, including any violation of law that requires licensure.

Cases with no evidence of harm or expired statutes of limitation If the case involves no evidence of harm or injury (physical, mental, financial, etc.) to a patient or the public and there are no other previous allegations or convictions of unlawful practice by the unlicensed person, correspondence may be sent to the unlicensed person by the Director of Enforcement or designee informing him of the law which requires a license.

A response may be solicited from the unlicensed person but will not be required. Any responses from the unlicensed person will be reviewed and evaluated by the Director of Enforcement. Counsel may be sought from the Office of the Attorney General if there are concerns regarding the response. In the absence of evidence of injury and where there are no prior complaints or convictions, the Director of Enforcement will close the case undetermined, and closure letters will be sent to the unlicensed person and the source.

Cases involving harm or repeated occurrence1

• If upon review by the case intake analyst and consultation with the Director of Enforcement or his designee, it is determined that there is evidence of either a repeated unlicensed practice or injury to a patient, client, or the public; or, if requested by a 1 These procedures will be used where there is evidence of harm, ongoing unlawful practice, or a violation of Virginia Code §§ 54.1-111, 54.1-2409.1, or 54.1-3008. 1 Department of Health Professions

Revised: April 17, 2025

Guidance Document: 76-40.02 Commonwealth’s Attorney or law enforcement, the complaint will be sent to an investigator or to a Commonwealth’s Attorney for investigation.

• The investigator will conduct an investigation to thoroughly address the alleged unlicensed practice in order to gather sufficient evidence to warrant criminal prosecution or closure.
• The case will be referred by the Investigator or Director of Enforcement to the appropriate Commonwealth's Attorney for possible prosecution. The original file will be provided to the Commonwealth’s Attorney as evidence for prosecution upon request.
• The investigator will advise the Director of Enforcement in writing of the response from the Commonwealth’s Attorney.
• If the Commonwealth’s Attorney declines prosecution, the case may be closed by the Director of Enforcement or referred to the Office of the Attorney General for review and possible injunction or criminal prosecution.

Cases involving issuance of a summons Investigators with actual knowledge of unlicensed activity may issue a summons in accordance with Virginia Code § 54.l-2506(C) or obtain a warrant. Investigators with summons authority must use a summons approved by the Department and must have knowledge of available court dates for the applicable Commonwealth’s Attorney.

Nothing in this guidance document may be construed to limit, impede, or prohibit cooperation with law enforcement agencies or the judiciary, to include referrals of suspected criminal activity to law enforcement agencies having jurisdiction over the suspected violation.

The Director for Enforcement or designee will provide the Office of the Attorney General any information that may be needed to enjoin any person, partnership, or corporation and who is in violation of Virginia Code § 54.1-111.

References Va. Code § 54.1-111 Va. Code § 54.1-2409.1 Va. Code § 54.1-2506 Va. Code § 54.1-3008 2

Department of Health Professions

Revised: April 17, 2025

Guidance Document: 76-40.02 Unlicensed Activity outlines procedures for handling unlicensed activity allegations.

The Department reviews all unlicensed practice allegations and reports findings with evidence to the Attorney for possible prosecution. This policy covers unlicensed persons offering services requiring a license, including violations of Virginia Code §§ 54.1-111, 54.1-2409.1, 54.1-3008, excluding licensing application or reinstatement decisions.

Procedures

All unlicensed case information will be entered into the Department’s complaint and licensure system.

The intake analyst reviews allegations and consults with the Director of Enforcement or designee and Board staff to determine if unlicensed practice or violations requiring licensure are indicated.

For cases with no harm evidence or expired statutes, and no prior allegations or convictions, the Director of Enforcement may send a letter informing the unlicensed person of licensing law.

Responses from the unlicensed person may be solicited but are not required; reviewed by the Director. Without injury evidence or prior complaints, the case is closed undetermined, and closure letters sent.

Cases involving harm or repeated occurrence1

• If review shows repeated unlicensed practice, injury, or per request, procedures for harm, ongoing practice, or violations of Virginia Code §§ 54.1-111, 54.1-2409.1, 54.1-3008 apply.

Revised: April 17, 2025

The complaint will be sent to an investigator or Commonwealth’s Attorney for investigation.

• The investigator will investigate to gather sufficient evidence for prosecution or closure.
• The case will be referred to the Commonwealth’s Attorney for prosecution, with the original file provided upon request.
• The investigator will notify the Director of Enforcement of the Commonwealth’s Attorney’s response in writing.
• If prosecution is declined, the case may be closed or referred to the Attorney General for review and possible action.

Investigators with knowledge of unlicensed activity may issue a summons per Virginia Code § 54.1-2506(C) or obtain a warrant, using approved summons and court date info.

This guidance does not limit cooperation or referrals of suspected criminal activity to law enforcement or judiciary.

The Director of Enforcement or designee will provide the Attorney General with info needed to enjoin violators of Virginia Code § 54.1-111.

References: Virginia Code §§ 54.1-111, 54.1-2409.1, 54.1-2506, 54.1-3008.

Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35 Virginia Freedom of Information Act Requests The Virginia Freedom of Information Act, Va. Code § 2.2-3700 et seq. (“FOIA”), provides citizens of the Commonwealth and representatives of the media access to public records held by public bodies, public officials, and public employees.

A public record is any writing or recording – regardless of whether it is a paper record, an electronic file, an audio or video recording, or any other format – that is prepared or owned by, or in the possession of, a public body or its officers, employees or agents in the transaction of public business. All public records are presumed to be open and may only be withheld if a specific statutory exemption applies. Va. Code § 2.2-3701.

The purpose of FOIA is to promote an increased awareness by all persons of governmental activities. Thus, FOIA requires that the law be interpreted liberally in favor of access, and that any exemption allowing public records to be withheld be interpreted narrowly. Va. Code § 2.2-3700.

Your FOIA Rights

• Citizens of the Commonwealth, representatives of newspapers and magazines with circulation in the Commonwealth, and representatives of radio and television stations broadcasting into the Commonwealth have the right to request to inspect or receive copies of public records, or both. Va. Code § 2.2-3704(A).
• Requesters have the right to ask that any charges for the requested records be estimated in advance.

Easiest Way to Get Information

Information you seek may already be available online. Most information that is available for disclosure to the public can be found on the following websites:

• Department of Health Professions main website: www.dhp.virginia.gov. This website contains copies of laws,1 copies of regulations,2 information about how to file a complaint, newsletters, policies, guidance documents, case decisions, and links to other boards, divisions, and programs at DHP.

• License Lookup: https://dhp.virginiainteractive.org/Lookup/Index. This site allows any user to look up current licensure information. It also provides access to purchase larger lists of licensees. Any public orders or information related to a licensee can be located using this site.

• Physician Profiles: https://www.vahealthprovider.com/index.asp. This site contains extensive self-reported information about currently licensed doctors of medicine, 1 These are provided as a courtesy and should not be considered an official record of effective statutes in the Commonwealth. Official statutory text must be obtained from the Legislative Information System at https://law.lis.virginia.gov/. 2 These are provided as a courtesy and should not be considered an official record of effective regulations in the Commonwealth. Official regulatory text must be obtained from the Legislative Information System at https://law.lis.virginia.gov/. 1 Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35 osteopathic medicine, and podiatry. The information includes: practice location; hospital affiliations; education; residencies; board certifications; honors and awards; appointments and publications; proceedings, actions, and convictions; and paid malpractice claims.

• Profiles for Oral and Maxillofacial Surgeons licensed by the Board of Dentistry: https://www.dhp.virginia.gov/dentistry/profile/public/index.asp.

This site contains information similar to physician profiles.

• Commonwealth Calendar: https://commonwealthcalendar.virginia.gov/. This site includes the following information about Board and Committee meetings: name of entity meeting; date and time of meeting; location of meeting; links to agendas when available; links to minutes; staff contacts, accessibility information.
• Virginia Regulatory Town Hall: https://townhall.virginia.gov/. This site includes information on regulatory actions, including: notices of intent to amend regulations; proposed regulations; newly adopted regulations; public comment forums on proposed actions; comment forums on guidance document changes; information about meetings, including minutes and agendas; and instructions on how to file a petition for rulemaking with an agency.

Making a request for records from the Department of Health Professions

• An individual may request records by U.S. Mail, fax, email, in person, or over the phone.

FOIA does not require that your request be in writing, nor do you need to specifically state that you are requesting records under FOIA.

• It may be helpful to both you and the person receiving your request to put your request in writing. This allows you to create a record of your request. It also gives the Department a clear statement of the records you are requesting so that there is no misunderstanding over a verbal request. However, verbal FOIA requests will be responded to if you elect not to put your request in writing.

• Your request must identify the records you are seeking with “reasonable specificity.” Va.

Code § 2.2-3704(B). The phrase “reasonable specificity” does not refer to the volume or number of records you are requesting. Instead, it requires that you be specific enough that the Department can identify and locate the records that you are seeking.

• Your request must ask for existing records or documents. FOIA gives you a right to inspect or copy records; it does not apply to a situation where you are asking general questions about the work of the Department or a specific board within the Department, nor does it require the Department or a board to create a record that does not already exist. Va. Code

§ 2.2-3704(D).

• You may choose to receive electronic records in any format used by the Department in the regular course of business. For example, if you are requesting records maintained in an Excel database, you may elect to receive those records electronically or to receive a printed copy of those records.
• If Department or board staff have questions about your request, please cooperate with efforts to clarify the type of records that you are seeking, or to attempt to reach a reasonable agreement about a response to a large request. FOIA requests are not adversarial, but we may need to discuss your request with you to ensure that we understand what records you are seeking. 2 Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

The following individuals within the Department are designated as the FOIA officers and are responsible to respond to FOIA requests as noted below:

Audiology & Speech-Language Pathology FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

Counseling FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Jaime jaime.hoyle@dhp.virginia.gov Jennifer Lang Jennifer.Lang@dhp.virginia.gov Hoyle

Dentistry FOIA Officer FOIA Officer Email Backup Backup FOIA Officer Email Name FOIA Officer Name Jamie C. jamie.sacksteder@dhp.virginia.gov Erin erin.weaver@dhp.virginia.gov Sacksteder Weaver

Department of Health Professions FOIA Officer Name FOIA Officer Email Erin Barrett

Leslie Knachel foia@dhp.virginia.gov

Kelly Smith

Enforcement

3Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Sarah Sarah.Rogers@dhp.virginia.gov Pamela Pam.Twombly@dhp.virginia.gov Rogers Twombly

Funeral Directors & Embalmers FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Corie corie.wolf@dhp.virginia.gov Annette Kelley annette.kelley@dhp.virginia.gov Tilman Wolf

Health Practitioners’ Monitoring Program FOIA FOIA Officer Email Backup Backup FOIA Officer Email Officer FOIA Name Officer Name Julia K. julia.bennett@dhp.virginia.gov James L. james.banning@dhp.virginia.gov Bennett Banning

Health Professions (Board of) FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

Healthcare Workforce Data Center FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Yetty yetty.shobo@dhp.virginia.gov Barbara barbara.Hodgdon@dhp.virginia.gov Shobo Hodgdon

Long-Term Care Administrators

4Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Corie corie.wolf@dhp.virginia.gov Annette Kelley annette.kelley@dhp.virginia.gov Tilman Wolf

Medicine FOIA FOIA Officer Email Backup Backup FOIA Officer Email Officer FOIA Name Officer Name Jennifer jennifer.deschenes@dhp.virginia.gov William william.harp@dhp.virginia.gov Deschenes Harp

Nursing FOIA FOIA Officer Email Backup Backup FOIA Officer Email Officer FOIA Name Officer Name Claire Claire.morris@dhp.virginia.gov Stephanie Stephanie.willinger@dhp.virginia.gov Morris Willinger

Optometry FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

Pharmacy FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Caroline caroline.juran@dhp.virginia.gov Beth O'Halloran pharmbd@dhp.virginia.gov Juran

Physical Therapy

5Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Corie corie.wolf@dhp.virginia.gov Annette Kelley annette.kelley@dhp.virginia.gov Tilman Wolf

Prescription Monitoring Program FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Ashley ashley.carter@dhp.virginia.gov Nicole Barron nicole.barron@dhp.virginia.gov Carter

Psychology FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Jaime jaime.hoyle@dhp.virginia.gov Jennifer Lang Jennifer.Lang@dhp.virginia.gov Hoyle

Social Work FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Jaime jaime.hoyle@dhp.virginia.gov Jennifer Lang Jennifer.Lang@dhp.virginia.gov Hoyle

Veterinary Medicine FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

All of the individuals referenced above may be contacted at our main address:

6Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35 9960 Mayland Drive Suite 300 Henrico, Virginia 23233-1463

All of the individuals referenced above may also be reached via the FOIA inbox, foia@dhp.virginia.gov.

The Department’s Responsibilities in Responding to Your Request

• The Department must respond to your request within five working days of receiving it. Day one is the day after your request is received. The five-day period does not include weekends or holidays.

• You are not required to state the reason behind your request for public records or the reason why you want the records before the agency responds to your request. FOIA does, however, allow the Department to ask you to provide your name and legal address.

• FOIA requires that the Department make one of the following responses to your request within the five-day time period (Va. Code § 2.2-3704(B)): 1) We provide you with the records that you have requested in their entirety.

2) We withhold all of the records that you have requested because all of the records are subject to a specific statutory exemption. If all of the records are being withheld, we must send you a response in writing. That writing must identify a specific section of the Code of Virginia that allows us to withhold the records.

3) We provide some of the records that you have requested, but withhold other records.

We cannot withhold an entire record if only a portion of it is subject to an exemption. In that instance, we may redact the portion of the record that may be withheld, and must provide you with the remainder of the record. We must provide you with a written response stating the specific section of the Code of Virginia that allows portions of the requested records to be withheld. 4) We inform you in writing that the requested records cannot be found or do not exist.

However, if we know that another public body has the requested records, we must include contact information for the other public body in our response to you.

5) If it is practically impossible for the Department to respond to your request within the five-day period, we must state this in writing, explaining the conditions that make the response impossible. This will allow us seven additional working days to respond to your request, giving us a total of 12 working days to respond to your request.

• If you make a request for a very large number of records and we feel that we cannot provide the records to you within 12 days without disrupting our other organizational responsibilities, we may petition the court for additional time to respond to your request. However, FOIA 7 Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35 requires that we make a reasonable effort to reach an agreement with you concerning the production of the records before we go to court to ask for more time.

Costs

You may have to pay for the records that you request from the Department. FOIA allows the Department to charge for the actual costs of responding to FOIA requests. See Va. Code § 2.2-3704(F). Actual costs may include staff time spent searching for and reviewing the requested records, copying costs, or any other costs directly related to supplying the requested records. Actual costs cannot include general overhead costs.

You may request a cost estimate for supplying the records you request in advance. This will allow you to know about any costs upfront and give you an opportunity to modify your request in an attempt to lower the estimated costs if your wish.

If the Department estimates that it will cost more than $200 to respond to your request, the Department may require you to pay a deposit before proceeding with the request. The five days that we have to respond to your request does not include the time between when we ask for a deposit and when you respond. Va. Code § 2.2-3704(H). Additionally, if the Department receives no response from you for 30 days following a cost estimate, the FOIA request is considered withdrawn. Va. Code § 2.2-3704(F).

If you owe the Department money from a previous FOIA request that has remained unpaid for more than 30 days, the Department may require payment of the past-due bill before it responds to your new FOIA request. Va. Code § 2.2-3704(I).

Commonly used exemptions

Certain statutory provisions, both within FOIA and within the Department’s basic laws, allow the Department to withhold certain records from public disclosure.

Virginia Code § 54.1-2400.2 strictly prohibits the release of “any reports, information or records received and maintained by the Department of Health Professions or any health regulatory board in connection with possible disciplinary proceedings, including any material received or developed by a board during an investigation or proceeding.” FOIA requests regularly include requests for information which the Department cannot release pursuant to this statute.

Exemptions contained within FOIA which the Department commonly uses include:

• Personnel records (Va. Code § 2.2-3705.1(1));

• Records subject to attorney-client privilege (Va. Code § 2.2-3705.1(2)) or attorney work product (Va. Code § 2.2-3705.1(3));

• Vendor proprietary information (Va. Code § 2.2-3705.1(6));
• Personal information as defined in Virginia Code § 2.2-3801, which includes electronic mail addresses, furnished to a public body for the purpose of receiving electronic mail from the public body where the recipient has requested that the public body not disclose the personal information (Va. Code § 2.2-3705.1(10); 8 Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35

• Records related to the negotiation and award of a contract prior to a contract being awarded (Va. Code § 2.2-3705.1(12));

• Records of active investigation being conducted (Va. Code § 2.2-3705.3(2));
• Any tests or examinations used to license or certify individuals (Va. Code § 2.2-3705.1(4));
• Information required to be provided to the Department by certain licensees pursuant to Virginia Code § 54.1-2506.1 (Va. Code § 2.2-3705.5(2)); and
• Applications for examination or licensure, except when requested by the applicant (Va. Code § 2.2-3705.5(2)).

Additionally, basic laws of the Department exempt records of the Health Practitioners’ Monitoring Program and the Virginia Prescription Monitoring Program from disclosure pursuant to FOIA requests. See Va. Code §§ 54.1-2517(B), 54.1-2523(A).

FOIA Council The Freedom of Information Advisory Council is available to answer any questions you may have about FOIA. The Council may be contacted by email at foiacouncil@dls.virginia.gov, or by phone at (804) 698-1810 or toll free at 1-866-448-4100. Information about FOIA may be found at: http://foiacouncil.dls.virginia.gov/. 9

Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35 Virginia FOIA Requests. The Virginia FOIA, Va. Code § 2.2-3700 et seq., grants citizens and media access to public records held by public bodies, officials, and employees.

A public record is any writing or recording—paper, electronic, audio, video, or other—that is prepared, owned, or possessed by a public body or its agents in public business. Records are presumed open unless a statutory exemption applies. Va. Code § 2.2-3701.

FOIA aims to increase public awareness of government activities. It must be interpreted liberally for access and exemptions narrowly. Va. Code § 2.2-3700.

Your FOIA Rights

• Citizens, newspaper/magazine reps, and radio/TV stations broadcasting into Virginia can request inspection or copies of public records. Va. Code § 2.2-3704(a).
• Requesters may ask for advance estimates of charges for records.

Easiest Way to Get Information

Information may already be online. Most public info is on these websites:

• DHP website: www.dhp.virginia.gov, with laws, regulations, complaint info, newsletters, policies, guidance, case decisions, and links.

• License Lookup: https://dhp.virginiainteractive.org/Lookup/Index. This site allows any user to look up current licensure information. It also provides access to purchase larger lists of licensees. Any public orders or information related to a licensee can be located using this site.

• Physician Profiles: https://www.vahealthprovider.com/index.asp. This site contains extensive self-reported information about currently licensed doctors of medicine, 1 These are provided as a courtesy and should not be considered an official record of effective statutes in the Commonwealth. Official statutory text must be obtained from the Legislative Information System at https://law.lis.virginia.gov/. 2 These are provided as a courtesy and should not be considered an official record of effective regulations in the Commonwealth. Official regulatory text must be obtained from the Legislative Information System at https://law.lis.virginia.gov/. 1 Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35 osteopathic medicine and podiatry. Info includes practice location, hospital affiliations, education, residencies, certifications, honors, appointments, publications, proceedings, actions, convictions, and malpractice claims.

• Oral and Maxillofacial Surgeons profiles: https://www.dhp.virginia.gov/dentistry/profile/public/index.asp.

This site contains information similar to physician profiles.

• Commonwealth Calendar: https://commonwealthcalendar.virginia.gov/ with meeting names, dates, times, locations, agendas, minutes, contacts, and accessibility info.
• Virginia Regulatory Town Hall: https://townhall.virginia.gov/ with notices, proposed and adopted regs, comment forums, meeting info, and petition instructions.

Making a request for records from the Department of Health Professions

• Records can be requested via U.S. Mail, fax, email, in person, or phone.

FOIA requests need not be in writing or specify FOIA.

• Writing requests helps create a record and clarifies the records requested. Verbal requests are also responded to if you choose.

• Requests must specify records with reasonable clarity. Va.

Code § 2.2-3704(B). “Reasonable specificity” means enough detail for the Department to identify and locate records, not volume or number.

• Requests must seek existing records; FOIA does not cover general questions or require creation of new records. Va. Code

§ 2.2-3704(D).

• You can choose electronic records in any Department-used format, e.g., Excel, or printed copies.
• If Department or board staff have questions about your request, please cooperate with efforts to clarify the type of records that you are seeking, or to attempt to reach a reasonable agreement about a response to a large request. FOIA requests are not adversarial, but we may need to discuss your request with you to ensure that we understand what records you are seeking. 2 Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

The Department's designated FOIA officers respond to requests below:

Audiology & Speech-Language Pathology FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

Counseling FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Jaime jaime.hoyle@dhp.virginia.gov Jennifer Lang Jennifer.Lang@dhp.virginia.gov Hoyle

Dentistry FOIA Officer FOIA Officer Email Backup Backup FOIA Officer Email Name FOIA Officer Name Jamie C. jamie.sacksteder@dhp.virginia.gov Erin erin.weaver@dhp.virginia.gov Sacksteder Weaver

Department of Health Professions FOIA Officer Name FOIA Officer Email Erin Barrett

Leslie Knachel foia@dhp.virginia.gov

Kelly Smith

Enforcement

3Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Sarah Sarah.Rogers@dhp.virginia.gov Pamela Pam.Twombly@dhp.virginia.gov Rogers Twombly

Funeral Directors & Embalmers FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Corie corie.wolf@dhp.virginia.gov Annette Kelley annette.kelley@dhp.virginia.gov Tilman Wolf

Health Practitioners’ Monitoring Program FOIA FOIA Officer Email Backup Backup FOIA Officer Email Officer FOIA Name Officer Name Julia K. julia.bennett@dhp.virginia.gov James L. james.banning@dhp.virginia.gov Bennett Banning

Health Professions (Board of) FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

Healthcare Workforce Data Center FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Yetty yetty.shobo@dhp.virginia.gov Barbara barbara.Hodgdon@dhp.virginia.gov Shobo Hodgdon

Long-Term Care Administrators

4Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Corie corie.wolf@dhp.virginia.gov Annette Kelley annette.kelley@dhp.virginia.gov Tilman Wolf

Medicine FOIA FOIA Officer Email Backup Backup FOIA Officer Email Officer FOIA Name Officer Name Jennifer jennifer.deschenes@dhp.virginia.gov William william.harp@dhp.virginia.gov Deschenes Harp

Nursing FOIA FOIA Officer Email Backup Backup FOIA Officer Email Officer FOIA Name Officer Name Claire Claire.morris@dhp.virginia.gov Stephanie Stephanie.willinger@dhp.virginia.gov Morris Willinger

Optometry FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

Pharmacy FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Caroline caroline.juran@dhp.virginia.gov Beth O'Halloran pharmbd@dhp.virginia.gov Juran

Physical Therapy

5Department of Health Professions Revised: April 1, 2025 Guidance Document: 76-35

FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Corie corie.wolf@dhp.virginia.gov Annette Kelley annette.kelley@dhp.virginia.gov Tilman Wolf

Prescription Monitoring Program FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Ashley ashley.carter@dhp.virginia.gov Nicole Barron nicole.barron@dhp.virginia.gov Carter

Psychology FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Jaime jaime.hoyle@dhp.virginia.gov Jennifer Lang Jennifer.Lang@dhp.virginia.gov Hoyle

Social Work FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Jaime jaime.hoyle@dhp.virginia.gov Jennifer Lang Jennifer.Lang@dhp.virginia.gov Hoyle

Veterinary Medicine FOIA FOIA Officer Email Backup FOIA Backup FOIA Officer Email Officer Officer Name Name Kelli Moss kelli.moss@dhp.virginia.gov Claire Foley claire.foley@dhp.virginia.gov

All referenced individuals may be contacted at our main address:

6Department of Health Professions

Revised: April 1, 2025

Guidance Document: 76-35 9960 Mayland Drive Suite 300 Henrico, Virginia 23233-1463

All individuals above may also be reached via FOIA inbox, foia@dhp.virginia.gov.

The Department’s Responsibilities in Responding to Your Request

• Department must respond within 5 working days, starting the day after receipt; weekends/holidays excluded.

• You need not state reasons for requests; Department may ask for your name and address. FOIA.

• Within 5 days, Department must respond by providing records in full, as per Va. Code § 2.2-3704(b).

2) We withhold all requested records if subject to a specific statutory exemption. If all are withheld, we must respond in writing, citing the specific Code of Virginia section.

3) We provide some requested records but withhold others.

Records cannot be fully withheld if only part is exempt; we may redact the exempt part and provide the rest, citing the relevant Virginia Code section. We also notify if records are unavailable.

If another public body holds the records, we must include their contact info in our response.

If response within five days is impossible, we must explain in writing, allowing seven extra days, for a total of 12 working days.

• For large requests, if response exceeds 12 days, the Department may petition the court for extra time. FOIA.

Revised: April 1, 2025

Guidance Document: 76-35 requires reasonable effort to reach record production agreement before court extension.

Costs

You may be charged for actual costs of responding, including staff time, copying, or related expenses, but not overhead, per Va. Code § 2.2-3704(F).

You may request an advance cost estimate to understand and possibly reduce your request costs.

If costs exceed $200, a deposit may be required; response time excludes deposit wait. No response within 30 days after estimate results in withdrawal, per Va. Code § 2.2-3704.

Outstanding unpaid FOIA bills over 30 days may be required before responding to new requests, per Va. Code § 2.2-3704(I).

Commonly used exemptions

Statutory provisions within FOIA and Department laws permit withholding certain records.

Virginia Code § 54.1-2400.2 prohibits releasing records related to disciplinary proceedings; FOIA requests for such info are barred.

Common FOIA exemptions used by the Department include:

• Personnel records (Va. Code § 2.2-3705.1(1));

• Attorney-client privileged or work product records: Va. Code § 2.2-3705.1(2)-(3);

• Vendor proprietary information (Va. Code § 2.2-3705.1(6));
• Personal info per Va. Code § 2.2-3801, including email addresses provided for contact, not to be disclosed if requested. Va. Code § 2.2-3705.1(10).

Revised: April 1, 2025

Guidance Document: 76-35

• Pre-contract negotiation and award records: Va. Code § 2.2-3705.1(12);

• Active investigation records: Va. Code § 2.2-3705.3(2);
• Licensing/certification tests: Va. Code § 2.2-3705.1(4);
• Licensee info per Va. Code § 54.1-2506.1 and § 2.2-3705.5(2).
• Applications for examination or licensure, except when requested by the applicant (Va. Code § 2.2-3705.5(2)).

Records of the Health Practitioners’ Monitoring and Prescription Monitoring Programs are exempt from FOIA disclosure per Va. Code §§ 54.1-2517(B), 54.1-2523(A).

FOIA Council The FOIA Advisory Council answers questions about FOIA. Contact via email at foiacouncil@dls.virginia.gov, phone at (804) 698-1810 or toll free 1-866-448-4100. Info at: http://foiacouncil.dls.virginia.gov/.

anCtIOnIng RefeRenCe POIntS S instruction manual Board of Audiology & Speech-Language Pathology Prepared for Virginia Department of Health Professions Perimeter Center 9960 Mayland Drive, Suite 300 Henrico, Virginia 23233 (t) 804.367.4400 Prepared by VisualResearch, Inc.

Post Office Box 1025 Midlothian, Virginia 23113 (t) 804.794.3144 www.vis-res.com Adopted June 3, 2010 Revised November 3, 2011 Guidance Document 30-1 Table of Contents General Instructions Overview ................................................................................................................... 5 Background ............................................................................................................... 6 Goals ......................................................................................................................... 6 Methodology ............................................................................................................. 6

Qualitative ..................................................................................................... 7

Quantitative .................................................................................................. 7 Wide Sanctioning Ranges .......................................................................................... 8 The Sanctioning Factors ............................................................................................. 8 Three Sanctioning Thresholds .................................................................................... 9 Voluntary Nature ...................................................................................................... 9 Worksheet Not Used in Certain Cases ..................................................................... 10 Case Selection When Multiple Cases Exist .............................................................. 11

Sanctioning Reference Points Case Type Table .......................................... 11 Completing the Coversheet and Worksheet ............................................................. 12 Scoring Factor Instructions ...................................................................................... 12 Coversheet ................................................................................................................. 12 Determining a Specific Sanction ............................................................................ 14

Sanctioning Reference Points Threshold Table ........................................... 14 Sanctioning Reference Points Forms Coversheet ................................................................................................................. 15 Instructions .............................................................................................................. 16 Worksheet ................................................................................................................. 17 ............................................................................................................................................................................... 5 General Instructions Overview The Virginia Board of Health Professions (BHP) has spent the last 7 years studying sanctioning in disciplinary cases. The study is examining all 13 health regulatory boards, with the greatest focus most recently on the Board of Audiology Speech-Language Pathology. The Board of Audiology Speech-Language Pathology is now in a position to implement the results of the research by using a set of voluntary Sanctioning Reference Points. This manual contains some background on the project, the goals and purposes of the system, and the offense-based sanction worksheet that will be used to help Board members determine how a similarly situated respondent has been treated in the past. This sanctioning system is based on a specific sample of cases, and thus only applies to those persons sanctioned by the Virginia Board of Audiology Speech-Language Pathology. Moreover, the worksheet has not been tested or validated on any other groups of persons. Therefore, they should not be used at this point to sanction respondents coming before other health regulatory boards, other states, or other disciplinary bodies.

The Sanctioning Reference system is comprised of a single worksheet which scores case type and offense and respondent factors that were identified using data analyses from both this Board and from previously implemented Boards. Sanctioning thresholds found on the worksheet recommend a range of sanctions from which the Board may select in a particular case.

In addition to this instruction booklet, separate coversheets and worksheets are available to record case specific information, the recommended sanction, the actual sanction, and any reasons for departure (if applicable). The completed coversheets and worksheets will be evaluated as part of an on-going effort to monitor and refine the SRPs. These instructions and the use of the SRP system fall within current Department of Health Professions and Board of Audiology Speech-Language Pathology policies and procedures. Furthermore, all sanctioning recommendations are those currently available to the Board and are specified within existing Virginia statutes. 6 ................................................................................................................................................................................

Background In April of 2001, BHP approved a work plan to conduct an analysis of health regulatory board sanctioning and to consider the appropriateness of developing historically-based SRPs for health regulatory boards, including the Board of Audiology Speech-Language Pathology. BHP and project staff recognize the complexity and difficulty in sanction decision-making and have indicated that for any sanction reference system to be successful, it must be “developed with complete Board oversight, be value-neutral, be grounded in sound data analysis, and be totally voluntary”—that is, the system is viewed strictly as a Board decision tool.

Goals BHP and the Board of Audiology Speech-Language Pathology cite the following purposes and goals for establishing SRPs:

• Making sanctioning decisions more predictable
• Providing an education tool for new Board members
• Adding an empirical element to a process/system that is

inherently subjective

• Providing a resource for the Board and those involved in

proceedings.

• “Neutralizing” sanctioning inconsistencies
• Validating Board member or staff recall of past cases
• Constraining the influence of undesirable factors—e.g., Board

member ID, overall Board makeup, race or ethnic origin, etc.

• Helping predict future caseloads and need for probation

services and terms Methodology The fundamental question when developing a sanctioning reference system is deciding whether the supporting analysis should be grounded in historical data (a descriptive approach) or whether it should be developed normatively (a prescriptive approach). A normative approach reflects what policymakers feel sanction recommendations should be, as opposed to what they have been. SRPs can also be developed using historical data analysis with normative adjustments to follow.

This approach combines information from past practice with policy adjustments, in order to achieve some desired outcome. The Board of Audiology Speech-Language Pathology chose a descriptive approach with normative adjustments. The normative adjustments were largely based on data gathered through the ongoing monitoring of previously ............................................................................................................................................................................... 7 Methodology, continued implemented Boards. It was necessary, in part, to consider the experience of previous boards due to the relatively small Audiology Speech-Language Pathology disciplinary caseload.

Qualitative Analysis Researchers conducted personal interviews with select Board members, staff, and representatives from the Attorney General’s office. The interview results were used to build consensus regarding the purpose and utility of SRPs and to further frame the analysis. Additionally, interviews helped ensure the factors considered when sanctioning were included during the quantitative phase of the study. A literature review of sanctioning practice across the United States was also conducted earlier.

Quantitative Analysis Researchers analyzed detailed information on Audiology Speech-Language Pathology disciplinary cases ending in a violation between 1999 and 2010; approximately 9 sanctioning “events.” Over 50 different factors were collected on each case in order to describe the case attributes Board members identified as potentially impacting sanction decisions. Researchers used data available through the DHP case management system combined with primary data collected from hard copy files. The hard copy files contained investigative reports, Board notices, Board orders, and all other documentation that is made available to Board members when deciding a case sanction.

A database was created to analyze the offense and respondent factors which were identified as potentially influencing sanctioning decisions.

The Board reviewed these factors and those considered important by other Boards in order to determine which factors would ultimately be used in the SRP development process. Weights (point values) were assigned to the selected factors based on their relative influence in the sanctioning process. Totaling the points on a worksheet resulted in a score that was translated into three sanctioning thresholds with recommended sanctions. These scoring factors and thresholds are the basis of the SRPs. 8 ................................................................................................................................................................................

Methodology, continued Offense factors such as financial gain and case severity (priority level) were analyzed as well as prior history factors such as substance abuse, and previous Board orders. Some collected factors were deemed inappropriate for use in a structured sanctioning reference system.

Though many factors, both “legal” and “extra-legal” can help explain sanction variation, only those “legal” factors the Board felt should consistently play a role in a sanction decision were included in the final product. By using this method, the hope is to achieve more neutrality in sanctioning, by making sure the Board considers the same set of “legal” factors in every case.

Wide Sanctioning The SRPs consider and weigh the circumstances of an offense and the relevant characteristics of the respondent. The SRPs attempt to provide sanctioning guidance on typical Board cases. Acknowledging that aggravating and mitigating factors play a legitimate role in sanctioning, researchers anticipate certain cases will receive a sanction not within the range recommended by the worksheet. The wide sanctioning ranges recognize that the Board will sometimes reasonably disagree on a particular sanction outcome, so a broad selection of sanctions fall within the recommended range.

Ranges Any sanction recommendation the Board derives from the SRP worksheets must fall within Virginia law and regulations. If a Sanctioning Reference Point worksheet recommendation is more or less severe than a Virginia statute or DHP regulation, the existing laws or policies supercede any worksheet recommendation.

The Sanctioning The Board indicated early in the study that sanctioning is influenced by a variety of circumstances. The analysis supported the notion that not only do case types affect sanctioning outcomes, but certain offense, respondent and prior record factors do as well. To this end, the Audiology Speech-Language Pathology SRP system scores two groups of factors in order to arrive at a sanctioning recommendation. The first set of factors relates to the case type. The second group relates to elements of the offense, the respondent, and his or her prior record.

Factors ............................................................................................................................................................................... 9 Therefore, a respondent before the Board for a standard of care case will receive points for the type of case and can potentially receive points for act of commission, multiple patient involvement, and/or for having a history of disciplinary violations.

Three Sanctioning The SRP worksheet uses three thresholds for recommending a sanction.

Once all factors are scored, the corresponding points are then added for a total worksheet score. The total is used to locate the sanctioning threshold recommendation found at the bottom of the worksheet. For instance, a respondent having a total worksheet score of 40 would be recommended for a Reprimand/CE/Monetary Penalty.

Thresholds Voluntary Nature The SRP system is a tool to be utilized by the Board of Audiology and Speech-Language Pathology. Compliance with the SRPs is voluntary.

The Board will use the system as a reference tool and may choose to sanction outside the recommendation. The Board maintains complete discretion in determining the sanction handed down. However, a structured sanctioning system is of little value if the Board is not provided with the appropriate coversheet and worksheet in every case eligible for scoring. A coversheet and worksheet should be completed in cases resolved by Informal Conferences and Pre-Hearing Consent Orders. The coversheet and worksheet will be referenced by Board members during Closed Session. 10 ................................................................................................................................................................................

Worksheets Not Used The SRPs will not be applied in any of the following circumstances: in Certain Cases

• Formal Hearings — SRPs will not be used in cases that reach a Formal Hearing level.
• Mandatory suspensions – Virginia law requires that under certain circumstances (conviction of a felony, declaration of legal incompetence or incapacitation, license revocation in another jurisdiction) the licensee must be suspended. The sanction is defined by law and is therefore excluded from the SRPs system.
• Compliance/reinstatements – The SRPs should be applied to new cases only.
• Action by another Board – When a case which has already been adjudicated by a Board from another state appears before the Virginia Board of Audiology and Speech-Language Pathology, the Board often attempts to mirror the sanction handed down by the other Board. The Virginia Board of Audiology and Speech-Language Pathology usually requires that all conditions set by the other Board are completed or complied with in Virginia. The SRPs do not apply as the case has already been heard and adjudicated by another Board.
• Confidential Consent Agreements (CCA) - SRPs will not be used in cases settled by CCA. ............................................................................................................................................................................... 11

Case Selection When When multiple cases have been combined into one “event” (one order) Multiple Cases Exist for disposition by the Board, only one coversheet and worksheet should be completed and it should encompass the entire event. If a case (or set of cases) has more than one offense type, one case type is selected for scoring according to the offense group that appears highest on the following table and receives the highest point value. For example, a respondent found in violation for Fraud and Inability to Safely Practice would receive forty points, since Inability to Safely Practice is above Standard of Care/Fraud on the list and receives the most points. If an offense type is not listed, find the most analogous offense type and use the appropriate score.

Sanctioning Reference Points Case Type Table

Case Type Included Case Categories Applicable Points

Inability to Safely • Impairment due to use of alcohol, Practice illegal substances, or prescription drugs 40

• Incapacitation due to mental, physical or medical conditions

Standard of Care • Instances in which the diagnosis/treatment was / Fraud improper, delayed, or unsatisfactory. Also includes failure to diagnose/treat & other diagnosis/treatment issues. 30 • Performing unwarranted/unjust services

• Falsification/alteration of patient records
• Improper patient billing
• Falsification of licensing/renewal documents

Unlicensed Activity • Practicing a profession or occupation without more than 2 years holding a valid license as required by statute 30 or regulation to include: practicing on a revoked, 2 years or less 20 suspended, lapsed, or expired license, as well as aiding and abetting the practice of unlicensed activity

Continuing • Failure to obtain or document CE requirements 10 Education12 ................................................................................................................................................................................

Completing the Coversheet Ultimately, it is the responsibility of the Board to complete the SRP coversheet and worksheet in all applicable cases. & Worksheet The information relied upon to complete a coversheet and worksheet is derived from the case packet provided to the Board and respondent. It is also possible that information discovered at the time of the informal conference may impact worksheet scoring. The SRP coversheet and worksheet, once completed, are confidential under the Code of Virginia. However, copies of the SRP Manual, including blank coversheets and worksheets, can be found on the Department of Health Professions web site: www.dhp.virginia.gov (paper copy also available on request).

Scoring Factor To ensure accurate scoring, instructions are provided for scoring each factor on the SRP worksheet. When scoring a worksheet, the numeric values assigned to a factor on the worksheet cannot be adjusted. The scoring weights can only be applied as ‘yes or no’- with all or none of the points applied. In instances where a scoring factor is difficult to interpret, the Board has final say in how a case is scored.

Instructions Coversheet The coversheet is completed to ensure a uniform record of each case and to facilitate recordation of other pertinent information critical for system monitoring and evaluation.

If the Board feels the sanctioning threshold does not recommend an appropriate sanction, the Board is encouraged to depart either high or low when handing down a sanction. If the Board disagrees with the sanction recommendation and imposes a sanction greater or less than the recommended sanction, a short explanation should be recorded on the coversheet to explain the factors or reasons for departure. This process will ensure worksheets are revised appropriately to reflect current Board practice. If a particular reason is continually cited, the Board can examine the issue more closely to determine if the worksheets should be modified to better reflect Board practice. ............................................................................................................................................................................... 13 Aggravating and mitigating circumstances that may influence Board decisions can include, but should not be limited to, such things as:

• Prior record
• Dishonesty/Obstruction
• Motivation
• Remorse
• Restitution/Self-corrective action
• Multiple offenses/Isolated incident A space is provided on the coversheet to record the reason(s) for departure. Due to the uniqueness of each case, the reason(s) for departure may be wide-ranging. Sample scenarios are provided below: Departure Example #1 Sanction Threshold Recommendation: Probation /Recommend Formal Hearing Imposed Sanction: CE Reason(s) for Departure: Respondent displayed a lack of knowledge that could be corrected with further education Departure Example #2 Sanction Threshold Recommendation: Reprimand / CE /Monetary Penalty Imposed Sanction: Probation with Terms Reason(s) for Departure: Respondent has multiple prior violations for the same case type. 14 ................................................................................................................................................................................

Determining the Sanction The bottom of the SRP worksheet lists three sanction thresholds Recommendations that encompass a variety of specific sanction types. The table below lists the sanctions most often used by the Board that fall under each threshold. After considering the sanction recommendation, the Board should fashion a more detailed sanction(s) based on the individual case circumstances.

Sanctioning Reference Points Threshold Table

Worksheet Score Available Sanctions Monetary Penalty Ranges

Reprimand 0-50 Continuing Education (CE) Up to $1500 Monetary Penalty

Continuing Education (CE) Monetary Penalty Probation Terms:

• CE audit 51-100 • Inform employer of probation and $500 to $2500 provide him/her with a copy of order
• Quarterly self reports
• On site visits
• Written statement to the Board reflecting documentation practices
• Submit annual performance evaluation

Probation Terms: 101 or more $2500 or more • CE audit

• Inform employer of probation and provide him/her with a copy of order
• Quarterly self reports
• On site visits
• Written statement to the Board reflecting documentation practices
• Submit annual performance evaluation Suspension Revocation Surrender Recommend Formal............................................................................................................................................................................... 15

Audiology and Speech-Language Pathology SRP - Coversheet

• Complete Case Type section.
• Complete the Offense and Respondent Factors section
• Determine the Sanctioning Recommendation using the scoring results and the Sanction Thresholds.
• Complete this coversheet.

Case Number(s)

Respondent Name Last First

License Number

Case Category … … Inability to Safely Practice Standard of Care /Fraud Unlicensed Activity Continuing Education

Sanction Threshold Result … … 0-50 51-100 101 or more

Imposed Sanction … … Reprimand Monetary Penalty $_______ Probation ___________ months CE _______ hours CE Audit Suspension Revocation Surrender Recommend Formal Other sanction _____________________________________________ ______________________________________________________________ Terms ____________________________________________________ ______________________________________________________________

Reasons for Departure from _____________________________________________________________ Sanction Threshold Result _____________________________________________________________ _____________________________________________________________

Worksheet Preparer(name) _______________________________ Date completed: ______________

Confidential pursuant to § 54.1-2400.2 of the Code of Virginia.16 ................................................................................................................................................................................

Audiology and Speech-Language Pathology SRP - Worksheet Instructions

Step 1: Case Type (score only one) Enter “30” if the patient is especially vulnerable. Patients in this Select the case type from the list and score accordingly. category fulfill at least one of the following descriptions: under age 18, over age 65, or mentally/physically handicapped.

When multiple cases have been combined into one “event” (one order) for disposition by the Board, only one case type can be selected. If a Enter “25” if the offense involves multiple patients. Patient case (or set of cases) has more than one offense type, one case type is involvement does not require direct contact with a patient (i.e. selected for scoring based on the offense group that receives the highest fraudulently billing multiple patients). point value.

Enter “25” if there was financial or material motivation by the respondent. Inability to Safely Practice – 40 Points

• Impairment due to use of alcohol, illegal substances, Enter “20” if the respondent has had any past difficulties in the or prescription drugs following areas: drugs, alcohol, mental capabilities or physical
• Incapacitation due to mental, physical or medical capabilities. Examples include: prior convictions for DUI/DWI, conditions inpatient/outpatient treatment, and bona fide mental health care for a condition affecting his/her abilities to function safely or Standard of Care / Fraud – 30 Points properly.
• Diagnosis/treatment was improper, delayed, or unsatisfactory. Also includes failure to diagnose/ Enter “10” if there was a sanction imposed by an employer, treat, & other diagnosis/treatment issues. another state or another entity due to the incident. Actions
• Performing unwarranted/unjust services taken by the employer could include termination, suspension or
• Falsification/alteration of patient records probation.
• Fraudulent patient billing
• Falsification of licensing/renewal documents Enter “10” if the respondent has any prior violations decided by the Virginia Board of Audiology & Speech-Language Pathology Unlicensed Activity – 30 Points, more than 2 years or the Virginia Department of Professional and Occupational 20 Points, 2 years or less Regulation as a Hearing Aide Specialist.
• Practicing a profession or occupation without holding a valid license as required by statute Enter “10”if the respondent has any prior similar Virginia or regulation to include: practicing on a revoked, Board of Audiology & Speech-Language Pathology or Virginia suspended, lapsed, or expired license, as well as aiding Department of Professional and Occupational Regulation and abetting the practice of unlicensed activity. Hearing Aide Specialist violations. Similar violations would be those listed under the same case type heading in Step 1.

Continuing Education – 10 Points

• Failure to obtain or document continuing Step 3: Total Worksheet Score education requirements Add all Case Type and Offense and Respondent Factor Scores for a Total Worksheet Score.

Step 2: Offense and Respondent Factors (score all that apply) Step 4: Recommendations for Sanctioning Score all factors related to the circumstances of the case or The Total Worksheet Score corresponds to the Sanctioning event presented. Reference Points recommendations at the bottom of the worksheet. To determine the appropriate recommended Enter “40” if the respondent was impaired at the time of the sanction, find the score range on the left that corresponds to offense due to substance abuse (alcohol or drugs) or mental/ the Total Worksheet Score that was calculated. That range then physical incapacitation. corresponds to a “Sanction Recommendation.” For instance, a Total Worksheet Score of 60 is recommended for “CE/Monetary Enter “40” if a patient was injured and/or required subsequent Penalty/Probation.” treatment from a licensed healthcare practitioner. Patient injury is indicated when a minimum of first aid is administered. This “Monetary Penalty Ranges” in the last column correspond to factor is scored without regard to a respondent’s intent to harm the point ranges in the first column. However, in order for (i.e. neglect or accidental injury). a sanction to be considered in agreement with the worksheet recommendation, it only has to correspond with the Sanction Enter “35” if this was an act of commission. An act of Recommendation column (agreement or disagreement with the commission is defined as purposeful or with knowledge.

Monetary Penalty Ranges column is not used when tracking Enter “30” if the respondent’s license has been previously compliance with the SRP worksheets). revoked, suspended, or summarily suspended by any state Step 5: Coversheet including Virginia.

Complete the coversheet, including the SRP sanction result, the imposed sanction and the reasons for departure if applicable................................................................................................................................................................................ 17

Audiology and Speech-Language Pathology SRP - Worksheet

Case Type (score only one) PointsPoints Score

Inability to Safely Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 scorescore Standard of Care / Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 onlyonly Unlicensed Activity - More than 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 oneone Unlicensed Activity - 2 years or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Continuing Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Case Type

Offense and Respondent Factors (score all that apply)

Respondent impaired during the incident (drugs, alcohol, mental, physical) . . 40 Patient injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Act of commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 License ever taken away . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 score all Patient especially vulnerable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 that Multiple patients involved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 apply Financial or material motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Past difficulties (drugs, alcohol, mental, physical) . . . . . . . . . . . . . . . . . . . . . . 20 Sanctioned by the employer, another state or entity due to the incident . . 10 One or more prior Board violations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Previous violation similar to current offense . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Offense and Respondent Factors

Total Worksheet Score

Recommendations for Sanctioning

Score Sanction Recommendation Monetary Penalty Ranges

0 - 50 Reprimand/CE/Monetary Penalty Up to $1500 51-100 CE/Monetary Penalty/Probation $500-$2500 101 or more Probation/Recommend Formal Hearing $2500 or more

Respondent Name: __________________________________________________ Date: ______________

Confidential pursuant to § 54.1-2400.2 of the Code of Virginia

anCtIOnIng RefeRenCe POIntS S instruction manual Board of Audiology & Speech-Language Pathology Prepared for Virginia Department of Health Professions Perimeter Center 9960 Mayland Drive, Suite 300 Henrico, Virginia 23233 (t) 804.367.4400 Prepared by VisualResearch, Inc.

Post Office Box 1025 Midlothian, Virginia 23113 (t) 804.794.3144 www.vis-res.com Adopted June 3, 2010 Revised November 3, 2011 Guidance Document 30-1 Table of Contents General Instructions Overview ................................................................................................................... 5 Background ............................................................................................................... 6 Goals ......................................................................................................................... 6 Methodology ............................................................................................................. 6

Qualitative ..................................................................................................... 7

Quantitative .................................................................................................. 7 Wide Sanctioning Ranges .......................................................................................... 8 The Sanctioning Factors ............................................................................................. 8 Three Sanctioning Thresholds .................................................................................... 9 Voluntary Nature ...................................................................................................... 9 Worksheet Not Used in Certain Cases ..................................................................... 10 Case Selection When Multiple Cases Exist .............................................................. 11

Sanctioning Reference Points Table .......................................... 11 Completing the Coversheet and Worksheet ............................................................. 12 Scoring Factor Instructions ...................................................................................... 12 Coversheet ................................................................................................................. 12 Determining a Specific Sanction ............................................................................ 14

Sanctioning Reference Points Threshold Table ........................................... 14 Sanctioning Reference Points Forms Coversheet ................................................................................................................. 15 Instructions .............................................................................................................. 16 Worksheet ................................................................................................................. 17 ............................................................................................................................................................................... 5 General Instructions Overview The Virginia Board of Health Professions (BHP) has spent the last 7 years studying sanctioning in disciplinary cases. The study is examining all 13 health regulatory boards, with the greatest focus most recently on the Board of Audiology Speech-Language Pathology. The Board of Audiology Speech-Language Pathology is now in a position to implement the results of the research by using a set of voluntary Sanctioning Reference Points. This manual contains some background on the project, the goals and purposes of the system, and the offense-based sanction worksheet that will be used to help Board members determine how a similarly situated respondent has been treated in the past. This sanctioning system is based on a specific sample of cases, and thus only applies to those persons sanctioned by the Virginia Board of Audiology Speech-Language Pathology. Moreover, the worksheet has not been tested or validated on any other groups of persons. Therefore, they should not be used at this point to sanction respondents coming before other health regulatory boards, other states, or other disciplinary bodies.

The Sanctioning Reference System uses a worksheet scoring case type, offense, and respondent factors identified through data analyses from this and previous Boards. Thresholds recommend sanction ranges for Board selection.

In addition to this instruction booklet, separate coversheets and worksheets are available to record case specific information, the recommended sanction, the actual sanction, and any reasons for departure (if applicable). The completed coversheets and worksheets will be evaluated as part of an on-going effort to monitor and refine the SRPs. These instructions and the use of the SRP system fall within current Department of Health Professions and Board of Audiology Speech-Language Pathology policies and procedures. Furthermore, all sanctioning recommendations are those currently available to the Board and are specified within existing Virginia statutes. 6 ................................................................................................................................................................................

Background In April of 2001, BHP approved a work plan to conduct an analysis of health regulatory board sanctioning and to consider the appropriateness of developing historically-based SRPs for health regulatory boards, including the Board of Audiology Speech-Language Pathology. BHP and project staff recognize the complexity and difficulty in sanction decision-making and have indicated that for any sanction reference system to be successful, it must be “developed with complete Board oversight, be value-neutral, be grounded in sound data analysis, and be totally voluntary”—that is, the system is viewed strictly as a Board decision tool.

BHP and the Board of Audiology & Speech-Language Pathology outline SRP purposes and goals:

• Making sanctioning decisions more predictable
• Providing an education tool for new Board members
• Adding an empirical element to the process/system

inherently subjective

• Providing a resource for the Board and those involved in

proceedings.

• “Neutralizing” sanctioning inconsistencies
• Validating Board/staff recall of past cases
• Constraining the influence of undesirable factors—e.g., Board

Member ID, Board makeup, race, ethnicity, etc.

• Helping predict future caseloads and need for probation

services and terms Methodology The fundamental question when developing a sanctioning reference system is deciding whether the supporting analysis should be grounded in historical data (a descriptive approach) or whether it should be developed normatively (a prescriptive approach). A normative approach reflects what policymakers feel sanction recommendations should be, as opposed to what they have been. SRPs can also be developed using historical data analysis with normative adjustments to follow.

This approach combines information from past practice with policy adjustments, in order to achieve some desired outcome. The Board of Audiology Speech-Language Pathology chose a descriptive approach with normative adjustments. The normative adjustments were largely based on data gathered through the ongoing monitoring of previously ............................................................................................................................................................................... 7 Methodology, continued implemented Boards. It was necessary, in part, to consider the experience of previous boards due to the relatively small Audiology Speech-Language Pathology disciplinary caseload.

Qualitative Analysis Researchers conducted personal interviews with select Board members, staff, and representatives from the Attorney General’s office. The interview results were used to build consensus regarding the purpose and utility of SRPs and to further frame the analysis. Additionally, interviews helped ensure the factors considered when sanctioning were included during the quantitative phase of the study. A literature review of sanctioning practice across the United States was also conducted earlier.

Quantitative Analysis Researchers analyzed detailed information on Audiology Speech-Language Pathology disciplinary cases ending in a violation between 1999 and 2010; approximately 9 sanctioning “events.” Over 50 different factors were collected on each case in order to describe the case attributes Board members identified as potentially impacting sanction decisions. Researchers used data available through the DHP case management system combined with primary data collected from hard copy files. The hard copy files contained investigative reports, Board notices, Board orders, and all other documentation that is made available to Board members when deciding a case sanction.

A database was created to analyze offense and respondent factors influencing sanctions.

The Board reviewed these factors and those considered important by other Boards in order to determine which factors would ultimately be used in the SRP development process. Weights (point values) were assigned to the selected factors based on their relative influence in the sanctioning process. Totaling the points on a worksheet resulted in a score that was translated into three sanctioning thresholds with recommended sanctions. These scoring factors and thresholds are the basis of the SRPs. 8 ................................................................................................................................................................................

Methodology, continued Offense factors such as financial gain and case severity (priority level) were analyzed as well as prior history factors such as substance abuse, and previous Board orders. Some collected factors were deemed inappropriate for use in a structured sanctioning reference system.

Though many factors, both “legal” and “extra-legal” can help explain sanction variation, only those “legal” factors the Board felt should consistently play a role in a sanction decision were included in the final product. By using this method, the hope is to achieve more neutrality in sanctioning, by making sure the Board considers the same set of “legal” factors in every case.

SRPs weigh offense circumstances and respondent traits, offering guidance for typical cases. Recognizing aggravating/mitigating factors, wide ranges allow for reasonable Board discretion.

All recommendations from SRPs must comply with Virginia law; laws override worksheet suggestions if severity differs.

The Sanctioning The Board indicated early in the study that sanctioning is influenced by a variety of circumstances. The analysis supported the notion that not only do case types affect sanctioning outcomes, but certain offense, respondent and prior record factors do as well. To this end, the Audiology Speech-Language Pathology SRP system scores two groups of factors in order to arrive at a sanctioning recommendation. The first set of factors relates to the case type. The second group relates to elements of the offense, the respondent, and his or her prior record.

Factors ............................................................................................................................................................................... 9 Therefore, a respondent before the Board for a standard of care case will receive points for the type of case and can potentially receive points for act of commission, multiple patient involvement, and/or for having a history of disciplinary violations.

The SRP worksheet employs three thresholds for sanction recommendations.

Scores are summed for a total, guiding the threshold recommendation at the worksheet's bottom. For example, a score of 40 suggests a Reprimand/CE/Monetary Penalty.

Thresholds Voluntary Nature The SRP system is a tool to be utilized by the Board of Audiology and Speech-Language Pathology. Compliance with the SRPs is voluntary.

The Board will use the system as a reference tool and may choose to sanction outside the recommendation. The Board maintains complete discretion in determining the sanction handed down. However, a structured sanctioning system is of little value if the Board is not provided with the appropriate coversheet and worksheet in every case eligible for scoring. A coversheet and worksheet should be completed in cases resolved by Informal Conferences and Pre-Hearing Consent Orders. The coversheet and worksheet will be referenced by Board members during Closed Session. 10 ................................................................................................................................................................................

SRPs are not used in certain cases as specified.

• Formal Hearings — SRPs are not used in cases reaching this level.
• Mandatory suspensions – Virginia law requires that under certain circumstances (conviction of a felony, declaration of legal incompetence or incapacitation, license revocation in another jurisdiction) the licensee must be suspended. The sanction is defined by law and is therefore excluded from the SRPs system.
• Compliance/reinstatements — SRPs apply only to new cases.
• Action by another Board – When a case which has already been adjudicated by a Board from another state appears before the Virginia Board of Audiology and Speech-Language Pathology, the Board often attempts to mirror the sanction handed down by the other Board. The Virginia Board of Audiology and Speech-Language Pathology usually requires that all conditions set by the other Board are completed or complied with in Virginia. The SRPs do not apply as the case has already been heard and adjudicated by another Board.
• Confidential Consent Agreements (CCA) - SRPs will not be used in cases settled by CCA. ............................................................................................................................................................................... 11

Case Selection When When multiple cases have been combined into one “event” (one order) Multiple Cases Exist for disposition by the Board, only one coversheet and worksheet should be completed and it should encompass the entire event. If a case (or set of cases) has more than one offense type, one case type is selected for scoring according to the offense group that appears highest on the following table and receives the highest point value. For example, a respondent found in violation for Fraud and Inability to Safely Practice would receive forty points, since Inability to Safely Practice is above Standard of Care/Fraud on the list and receives the most points. If an offense type is not listed, find the most analogous offense type and use the appropriate score.

Sanctioning Reference Points Case Type Table

Case Type Included Case Categories Applicable Points

Inability to Safely • Impairment due to use of alcohol, Practice illegal substances, or prescription drugs 40

• Incapacitation due to mental, physical or medical conditions

Standard of Care • Instances in which the diagnosis/treatment was / Fraud improper, delayed, or unsatisfactory. Also includes failure to diagnose/treat & other diagnosis/treatment issues. 30 • Performing unwarranted/unjust services

• Falsification/alteration of patient records
• Improper patient billing
• Falsification of licensing/renewal documents

Unlicensed Activity • Practicing a profession or occupation without more than 2 years holding a valid license as required by statute 30 or regulation to include: practicing on a revoked, 2 years or less 20 suspended, lapsed, or expired license, as well as aiding and abetting the practice of unlicensed activity

Continuing • Failure to obtain or document CE requirements 10 Education12 ................................................................................................................................................................................

Completing the Coversheet Ultimately, it is the responsibility of the Board to complete the SRP coversheet and worksheet in all applicable cases. & Worksheet The information relied upon to complete a coversheet and worksheet is derived from the case packet provided to the Board and respondent. It is also possible that information discovered at the time of the informal conference may impact worksheet scoring. The SRP coversheet and worksheet, once completed, are confidential under the Code of Virginia. However, copies of the SRP Manual, including blank coversheets and worksheets, can be found on the Department of Health Professions web site: www.dhp.virginia.gov (paper copy also available on request).

Scoring Factor To ensure accurate scoring, instructions are provided for scoring each factor on the SRP worksheet. When scoring a worksheet, the numeric values assigned to a factor on the worksheet cannot be adjusted. The scoring weights can only be applied as ‘yes or no’- with all or none of the points applied. In instances where a scoring factor is difficult to interpret, the Board has final say in how a case is scored.

Coversheet instructions ensure uniform case records and facilitate monitoring and evaluation.

If the Board feels the sanctioning threshold does not recommend an appropriate sanction, the Board is encouraged to depart either high or low when handing down a sanction. If the Board disagrees with the sanction recommendation and imposes a sanction greater or less than the recommended sanction, a short explanation should be recorded on the coversheet to explain the factors or reasons for departure. This process will ensure worksheets are revised appropriately to reflect current Board practice. If a particular reason is continually cited, the Board can examine the issue more closely to determine if the worksheets should be modified to better reflect Board practice. ............................................................................................................................................................................... 13 Aggravating and mitigating circumstances that may influence Board decisions can include, but should not be limited to, such things as:

• Prior record
• Dishonesty/Obstruction
• Motivation
• Remorse
• Restitution/Self-corrective action
• Multiple offenses/Isolated incident A space is provided on the coversheet to record the reason(s) for departure. Due to the uniqueness of each case, the reason(s) for departure may be wide-ranging. Sample scenarios are provided below: Departure Example #1 Sanction Threshold Recommendation: Probation /Recommend Formal Hearing Imposed Sanction: CE Reason(s) for Departure: Respondent displayed a lack of knowledge that could be corrected with further education Departure Example #2 Sanction Threshold Recommendation: Reprimand / CE /Monetary Penalty Imposed Sanction: Probation with Terms Reason(s) for Departure: Respondent has multiple prior violations for the same case type. 14 ................................................................................................................................................................................

Determining the Sanction The bottom of the SRP worksheet lists three sanction thresholds Recommendations that encompass a variety of specific sanction types. The table below lists the sanctions most often used by the Board that fall under each threshold. After considering the sanction recommendation, the Board should fashion a more detailed sanction(s) based on the individual case circumstances.

Sanctioning Threshold Table

Worksheet Score Available Sanctions Monetary Penalty Ranges

Reprimand 0-50 Continuing Education (CE) Up to $1500 Monetary Penalty

Continuing Education (CE) Monetary Penalty Probation Terms:

• CE audit 51-100 • Inform employer of probation and $500 to $2500 provide him/her with a copy of order
• Quarterly self reports
• On site visits
• Written statement to the Board reflecting documentation practices
• Submit annual performance evaluation

Probation Terms: 101 or more $2500 or more • CE audit

• Inform employer of probation and provide him/her with a copy of order
• Quarterly self reports
• On site visits
• Written statement to the Board reflecting documentation practices
• Submit annual performance evaluation Suspension Revocation Surrender Recommend Formal............................................................................................................................................................................... 15

Audiology and Speech-Language Pathology SRP - Coversheet

• Complete Case Type section.
• Complete the Offense and Respondent Factors section
• Determine Sanctioning Recommendation using scoring results and thresholds.
• Complete this coversheet.

Case Number(s)

Respondent Name Last First

License Number

Case Category … … Inability to Safely Practice Standard of Care /Fraud Unlicensed Activity Continuing Education

Sanction Threshold Result … … 0-50 51-100 101 or more

Imposed Sanction … … Reprimand Monetary Penalty $_______ Probation ___________ months CE _______ hours CE Audit Suspension Revocation Surrender Recommend Formal Other sanction _____________________________________________ ______________________________________________________________ Terms ____________________________________________________ ______________________________________________________________

Reasons for Departure from _____________________________________________________________ Sanction Threshold Result _____________________________________________________________ _____________________________________________________________

Worksheet Preparer(name) _______________________________ Date completed: ______________

Confidential per § 54.1-2400.2 of Virginia Code.

Audiology and Speech-Language Pathology SRP - Worksheet Instructions

Step 1: Case Type (score only one) Enter “30” if the patient is especially vulnerable. Patients in this Select the case type from the list and score accordingly. category fulfill at least one of the following descriptions: under age 18, over age 65, or mentally/physically handicapped.

When multiple cases have been combined into one “event” (one order) for disposition by the Board, only one case type can be selected. If a Enter “25” if the offense involves multiple patients. Patient case (or set of cases) has more than one offense type, one case type is involvement does not require direct contact with a patient (i.e. selected for scoring based on the offense group that receives the highest fraudulently billing multiple patients). point value.

Enter “25” if there was financial or material motivation by the respondent. Inability to Safely Practice – 40 Points

• Impairment due to use of alcohol, illegal substances, Enter “20” if the respondent has had any past difficulties in the or prescription drugs following areas: drugs, alcohol, mental capabilities or physical
• Incapacitation due to mental, physical or medical capabilities. Examples include: prior convictions for DUI/DWI, conditions inpatient/outpatient treatment, and bona fide mental health care for a condition affecting his/her abilities to function safely or Standard of Care / Fraud – 30 Points properly.
• Diagnosis/treatment was improper, delayed, or unsatisfactory. Also includes failure to diagnose/ Enter “10” if there was a sanction imposed by an employer, treat, & other diagnosis/treatment issues. another state or another entity due to the incident. Actions
• Performing unwarranted/unjust services taken by the employer could include termination, suspension or
• Falsification/alteration of patient records probation.
• Fraudulent patient billing
• Falsification of licensing/renewal documents Enter “10” if the respondent has any prior violations decided by the Virginia Board of Audiology & Speech-Language Pathology Unlicensed Activity – 30 Points, more than 2 years or the Virginia Department of Professional and Occupational 20 Points, 2 years or less Regulation as a Hearing Aide Specialist.
• Practicing a profession or occupation without holding a valid license as required by statute Enter “10”if the respondent has any prior similar Virginia or regulation to include: practicing on a revoked, Board of Audiology & Speech-Language Pathology or Virginia suspended, lapsed, or expired license, as well as aiding Department of Professional and Occupational Regulation and abetting the practice of unlicensed activity. Hearing Aide Specialist violations. Similar violations would be those listed under the same case type heading in Step 1.

Continuing Education – 10 Points

• Failure to obtain or document continuing Step 3: Total Worksheet Score education requirements Add all Case Type and Offense and Respondent Factor Scores for a Total Worksheet Score.

Step 2: Offense and Respondent Factors (score all that apply) Step 4: Recommendations for Sanctioning Score all factors related to the circumstances of the case or The Total Worksheet Score corresponds to the Sanctioning event presented. Reference Points recommendations at the bottom of the worksheet. To determine the appropriate recommended Enter “40” if the respondent was impaired at the time of the sanction, find the score range on the left that corresponds to offense due to substance abuse (alcohol or drugs) or mental/ the Total Worksheet Score that was calculated. That range then physical incapacitation. corresponds to a “Sanction Recommendation.” For instance, a Total Worksheet Score of 60 is recommended for “CE/Monetary Enter “40” if a patient was injured and/or required subsequent Penalty/Probation.” treatment from a licensed healthcare practitioner. Patient injury is indicated when a minimum of first aid is administered. This “Monetary Penalty Ranges” in the last column correspond to factor is scored without regard to a respondent’s intent to harm the point ranges in the first column. However, in order for (i.e. neglect or accidental injury). a sanction to be considered in agreement with the worksheet recommendation, it only has to correspond with the Sanction Enter “35” if this was an act of commission. An act of Recommendation column (agreement or disagreement with the commission is defined as purposeful or with knowledge.

Monetary Penalty Ranges column is not used when tracking Enter “30” if the respondent’s license has been previously compliance with the SRP worksheets). revoked, suspended, or summarily suspended by any state Step 5: Coversheet including Virginia.

Complete the coversheet with SRP sanction result, imposed sanction, and reasons for departure if applicable.

Audiology and Speech-Language Pathology SRP - Worksheet

Case Type (score only one) PointsPoints Score

Inability to Safely Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 scorescore Standard of Care / Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 onlyonly Unlicensed Activity - More than 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 oneone Unlicensed Activity - 2 years or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Continuing Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Case Type

Offense and Respondent Factors (score all that apply)

Respondent impaired during the incident (drugs, alcohol, mental, physical) . . 40 Patient injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Act of commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 License ever taken away . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 score all Patient especially vulnerable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 that Multiple patients involved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 apply Financial or material motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Past difficulties (drugs, alcohol, mental, physical) . . . . . . . . . . . . . . . . . . . . . . 20 Sanctioned by the employer, another state or entity due to the incident . . 10 One or more prior Board violations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Previous violation similar to current offense . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Offense and Respondent Factors

Total Worksheet Score

Recommendations for Sanctioning

Score Sanction Recommendation Monetary Penalty Ranges

0 - 50 Reprimand/CE/Monetary Penalty Up to $1500 51-100 CE/Monetary Penalty/Probation $500-$2500 101 or more Probation/Recommend Formal Hearing $2500 or more

Respondent Name: __________________________________________________ Date: ______________

Confidential pursuant to § 54.1-2400.2 of Virginia Code

Guidance Document: 30-9 Revised: August 8, 2023 Effective: October 26, 2023

Virginia Board of Audiology and Speech-Language Pathology

Guidance for Continuing Education (CE) Audits and Sanctioning for Failure to Complete CE

Acceptable types of continuing education (“CE”).

The Board makes the following recommendations concerning acceptable continuing education hours:

• If offered or approved by an accredited sponsor or organization as prescribed in 18VAC30-21-100, the following activities may be counted as acceptable CE:

o Hours spent in the reading, preparation and acquisition of new knowledge as a presenter may be counted for CE credit and are to be calculated hour for hour.

o Hours delivering a presentation at a workshop may be counted by the presenter for the first-time presentation of a continuing education program but may not be duplicated by hours credited for attendance at the program.

o Attendance at or presentation to virtual or online courses directly related to the practice of speech-language pathology and/or audiology may be counted for CE credit.

• Clinical supervision may not be used to meet CE requirements.

• Meetings with colleagues or employers that are not designated as an audiology or speech-language pathology professional learning experience for the licensee are not accepted as CE (i.e. billing procedures, required employer documentation, software usage).

CE extension requests.

For good cause shown, extensions of up to one year may be granted for the completion of CE requirements. A request for an extension must be received by the Board prior to the licensure renewal date of each year. Licensees who have not completed the CE requirements and submit a request after the renewal date may be subject to disciplinary action.

CE exemptions.

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

Page 1 of 3Guidance Document: 30-9 Revised: August 8, 2023 Effective: October 26, 2023

A licensee is exempt from completing CE requirements for the first renewal period after initial licensure in Virginia.

CE audit procedures.

• After each renewal cycle, the Board may audit the following licensees for compliance with CE requirements:

o Licensees who fail to respond or respond “no” to the CE renewal question on the annual license renewal form; and

o Licensees selected for random audit.

• If a practitioner is selected for audit:

o Board staff will notify licensees that they have been selected for audit via email if an address is available or by postal carrier if an email address is not available.

o The licensee will submit documentation of completion of required CE credits and complete the CE form. The licensee will:

 Provide certificates of completion of CE; or

 Provide a transcript from the American Speech-Language Hearing Association or the Academy of Audiology.

o Documentation submitted to verify CE completion will be reviewed by Board staff for compliance with the regulations.

o Licensees who have not completed required CE will be referred for possible disciplinary action.

Disciplinary action for non-compliance with CE requirements.

The Board provides the following guidelines for resolution of cases of non-compliance with CE requirements. 10 hours of CE are required in a one-year period. See 18VAC30-21-100. All monetary penalties are deposited in the Literary Fund. See Va. Code § 54.1-2401.

Cause Possible Action First offense; short 1 – 3 hours Confidential Consent Agreement 45 days to make up missing hours First offense; short 4 – 10 hours Consent Order; Monetary Penalty of $300 60 days to make up missing hours Second offense; short 1 – 10 hours Consent Order; Reprimand Monetary Penalty of $200 per missing hour up to a maximum of $2000

Page 2 of 3Guidance Document: 30-9 Revised: August 8, 2023 Effective: October 26, 2023

60 days to make up missing hours No response to audit notifications or three or Informal Fact-Finding Conference more offenses First Offense: Failure to respond with CE Confidential Consent Agreement documentation prior to initiation of board action

Second Offense: Failure to respond with CE Consent Order documentation prior to initiation of board action

NOTE: When probable cause is found that a licensee has falsely certified completion of the required CE for renewal of his license, the Board may offer a pre-hearing consent order or hold an informal fact-finding conference.

References:

18VAC30-21-100 Va. Code § 54.1-2401

Page 3 of 3

Guidance Document: 30-9 Revised: August 8, 2023 Effective: October 26, 2023

Virginia Board of Audiology and Speech-Language Pathology

Guidance for Continuing Education (CE) Audits and Sanctioning for Failure to Complete CE

Acceptable types of continuing education (“CE”).

The Board recommends acceptable continuing education hours:

• If approved by an accredited sponsor as in 18VAC30-21-100, the following activities qualify as CE:

o Hours spent in the reading, preparation and acquisition of new knowledge as a presenter may be counted for CE credit and are to be calculated hour for hour.

o Hours delivering a presentation at a workshop may be counted by the presenter for the first-time presentation of a continuing education program but may not be duplicated by hours credited for attendance at the program.

o Attendance at or presentation to virtual or online courses directly related to the practice of speech-language pathology and/or audiology may be counted for CE credit.

• Clinical supervision cannot meet CE requirements.

• Meetings with colleagues or employers not designated as professional learning experiences for audiology or speech-language pathology are not accepted as CE (e.g., billing, documentation, software).

CE extension requests.

For good cause, extensions of up to one year may be granted for CE completion. Requests must be received before each year's renewal date; late requests may face disciplinary action.

CE exemptions.

The Board may grant exemptions for all or part of CE requirements due to circumstances beyond the licensee's control, such as temporary disability, military service, or declared disasters.

Page 1 of 3Guidance Document: 30-9 Revised: August 8, 2023 Effective: October 26, 2023

A licensee is exempt from CE requirements for the first renewal after initial licensure in Virginia.

CE audit procedures.

• After each renewal cycle, the Board may audit licensees for CE compliance:

o Licensees who fail to respond or respond “no” to the CE renewal question on the annual license renewal form; and

o Licensees selected for random audit.

• If a practitioner is selected for audit:

o Board staff will notify licensees that they have been selected for audit via email if an address is available or by postal carrier if an email address is not available.

o The licensee will submit documentation of completion of required CE credits and complete the CE form. The licensee will:

 Provide certificates of completion of CE; or

 Provide a transcript from the American Speech-Language Hearing Association or the Academy of Audiology.

o Documentation submitted to verify CE completion will be reviewed by Board staff for compliance with the regulations.

o Licensees who have not completed required CE will be referred for possible disciplinary action.

Disciplinary action for CE non-compliance.

The Board's guidelines for non-compliance: 10 CE hours per year. Penalties go to the Literary Fund. See 18VAC30-21-100 and § 54.1-2401.

Cause Possible Action First offense; short 1 – 3 hours Confidential Consent Agreement 45 days to make up missing hours First offense; short 4 – 10 hours Consent Order; Monetary Penalty of $300 60 days to make up missing hours Second offense; short 1 – 10 hours Consent Order; Reprimand Monetary Penalty of $200 per missing hour up to a maximum of $2000

Page 2 of 3Guidance Document: 30-9 Revised: August 8, 2023 Effective: October 26, 2023

60 days to make up missing hours No response to audit notifications or three or Informal Fact-Finding Conference more offenses First Offense: Failure to respond with CE Confidential Consent Agreement documentation prior to initiation of board action

Second Offense: Failure to respond with CE Consent Order documentation prior to initiation of board action

Note: If probable cause shows a licensee falsely certified CE completion for renewal, the Board may offer a pre-hearing consent order or hold an informal conference.

References:

18VAC30-21-100 Va. Code § 54.1-2401

Page 3 of 3

Guidance Document: 30-8

Revised: February 9, 2021

Effective: April 1, 2021 Virginia Board of Audiology and Speech-Language Pathology

Requirements to Hold Licensure in Virginia to Practice Speech-Language Pathology

General Licensure Requirements

Question: Is a license required to practice speech-language pathology in Virginia?

Answer: Yes, pursuant to § 54.1-2603 of the Code of Virginia (Code) in order to practice speech-language pathology within the Commonwealth of Virginia, a license issued by the Virginia Board of Audiology and Speech-Language Pathology (BASLP) is required.

Q: Is a license required to practice speech-language pathology via telepractice into Virginia?

A: If the practice of speech-language pathology is being provided to a client within Virginia, regardless of delivery method, a license issued by the BASLP is required. The license type required is dependent upon the practice setting. If providing services via telepractice solely in a public school division as outlined in the “Practice in Schools” section below, then a school speech-language pathology license is appropriate. The inclusion of any other setting (i.e. home, private school, medical facility, etc.) would require a full speech-language pathology license. (Note: Guidance Document 30-12, Guidance for Telepractice is available for review)

Q: What happens if the practice of speech-language pathology occurs without a license?

A: For those individuals who are qualified to be licensed and practiced speech-language pathology without obtaining a license, the individual may be subject to public disciplinary action by BASLP. For those individuals who are not qualified to be licensed and practiced speech-language pathology, the matter is referred to the appropriate Commonwealth’s Attorney for possible criminal prosecution.

Practice in Schools

Q: Is there a licensure requirement for an SLP working in a public school division?

A: Yes, one of the following licenses is required to work in a public school division: -School speech-language pathology license issued by BASLP; -Provisional speech-language pathology license issued by BASLP; or -Full speech-language pathology license issued by BASLP.

Q: What constitutes practicing solely in a public school division?

A: A licensee who has been granted a school speech-language pathology license by statute shall practice solely in public school divisions and may not provide treatment to clients privately. Additional clarification is provided in the following scenarios:

• When a public school student receives speech-language pathology services in a setting other than a public school such as a preschool or homebound/home-based setting, a school, provisional or full speech-language pathology license is required. 1 Guidance Document: 30-8

Revised: February 9, 2021

Effective: April 1, 2021

• When a public school student is placed by a public school division into a private school/facility and receives speech-language pathology services which are being paid for by the public school division, a school, provisional or full speech-language license is required.
• When a private school student is placed in a private school by a parent but qualifies for a service plan and receives speech-language pathology services at the public school, a school, provisional or full speech-language pathology license is required.
• When a private school student is placed into a private school by a parent with no public school funding and receives speech-language pathology services by a private school speech-language pathologist, a provisional or full license speech-language pathology license is required.

Q: What type of license is required for practice in another setting?

A: A provisional or full speech-language pathology license is needed to practice outside of a public school division. Additional clarification is provided in the following scenarios:

• When a private school student is placed into a private school by a parent with no public school funding and receives speech-language pathology services, a provisional or full speech-language pathology licensed is required.
• When a student, public or private, receives services not paid for by a public school division, a provisional or full speech-language pathology licensee is required.

Q: What is the licensure requirement for an SLP working in a public school division but placed and compensated by a private contractor?

A: An SLP employed by a school or a contractor may practice in a public school division with a school, provisional or a full speech-language pathology license issued by the BASLP.

Practice as a Student, Intern or Trainee

Q: Who is considered a student, intern or trainee in speech-language pathology?

A: Any person who is pursuing a course of study in speech-language pathology at an accredited university or college or working in a recognized training center.

Q: What is a recognized training center?

A: A training facility that has a connection to an accredited university or college.

Q: Is a clinical fellowship year required for licensure in Virginia?

A: As of January 15, 2015, a Certificate of Clinical Competence from the American Speech-Language-Hearing Association (ASHA) is required in order to receive an initial license from BASLP. ASHA requires a clinical fellowship year in order to issue an SLP a Certificate of Clinical Competence.

Q: Is licensure required while completing a clinical fellowship year?

A: Licensure requirements during a clinical fellowship year are dependent upon the following:

• If a clinical fellowship year is being completed prior to graduation from an accredited university or college and the SLP is placed in a clinical fellowship program as part of the course of study or working in a recognized training center, an SLP is considered a student/intern/trainee and is exempt from licensure pursuant to § 54.1-2601 of the Code of Virginia. 2 Guidance Document: 30-8

Revised: February 9, 2021

Effective: April 1, 2021

• Upon graduation, an SLP completing a clinical fellowship year must hold a provisional license issued by BASLP in order to practice in Virginia.

Practicing without a license may result in a public disciplinary action.

Licensure Renewal and Practice

Q: When must a license be renewed?

A: School and full speech-language pathology licenses issued by BASLP expire each June 30th and must be renewed prior to this date. A provisional license expires 18 months from the date of issuance.

Q: Who is responsible for licensure renewal?

A: The licensee is responsible for licensure renewal regardless of whether a renewal notice was received. Therefore, the BASLP recommends that each licensee have a personal reminder method for this important task. Ensure that the address of record and the email address are current by accessing the online account system or contacting the board office.

Q: What is practicing with a lapsed license?

A: Any practice of speech-language pathology without a current, valid license after June 30th or expiration date of a provisional license is considered practicing with a lapsed license. Practicing with a lapsed license may result in public disciplinary action against a licensee.

Q: Is there a grace period to practice speech-language pathology without a license or with a lapsed license?

A: No, there are no grace periods to practice without a license. 3

Guidance Document: 30-8

Revised: February 9, 2021

Effective: April 1, 2021 Virginia Board of Audiology and Speech-Language Pathology

Requirements to Hold Licensure in Virginia to Practice Speech-Language Pathology

General Licensure Requirements

Question: Is a license required to practice speech-language pathology in Virginia?

A: Yes, per § 54.1-2603 of the Virginia Code, practicing speech-language pathology in Virginia requires a license from BASLP.

Q: Is a license needed for telepractice into Virginia?

A: Providing speech-language pathology to a client in Virginia requires a BASLP license, regardless of method. Telepractice in schools needs a school license; other settings require a full license. See Guidance Document 30-12.

Q: What if speech-language pathology is practiced without a license?

A: Qualified individuals practicing without a license may face BASLP disciplinary action; unqualified individuals may be referred for criminal prosecution.

Practice in Schools

Q: Is licensure required for an SLP in public schools?

A: Yes, to work in public schools, an SLP must hold a school, provisional, or full license issued by BASLP.

Q: What defines practicing only in public schools?

A: A licensee with a school license must practice only in public schools and cannot treat clients privately. Additional details follow.

• When a public school student receives speech-language pathology services in a setting other than a public school such as a preschool or homebound/home-based setting, a school, provisional or full speech-language pathology license is required. 1 Guidance Document: 30-8

Revised: February 9, 2021

Effective: April 1, 2021

• If a public school division places a student in a private school and pays for speech-language services, a school, provisional, or full license is required.
• If a private school student is placed by a parent into a private school and receives speech-language services at a public school under a service plan, a license is required.
• If a parent places a private school student into a private school with no public funding and the student receives speech-language services from a private speech-language pathologist, a license is required.

Q: What type of license is required for practice in another setting?

A: A provisional or full speech-language pathology license is needed to practice outside of a public school division. Additional clarification is provided in the following scenarios:

• If a parent places a private school student into a private school with no public funding and the student receives speech-language services, a license is required.
• If a student (public or private) receives services not paid by a public school division, a license is required.

Q: What license is needed for an SLP in public schools employed by a private contractor?

A: An SLP employed by a school or a contractor may practice in a public school division with a school, provisional or a full speech-language pathology license issued by the BASLP.

Practice as a Student, Intern or Trainee

Q: Who is considered a student, intern or trainee in speech-language pathology?

A: Anyone studying speech-language pathology at an accredited university or working in a recognized training center.

Q: What is a recognized training center?

A: A training facility connected to an accredited university or college.

Q: Is a clinical fellowship year required for licensure in Virginia?

A: Since Jan 15, 2015, an ASHA Certificate of Clinical Competence is required for initial licensure; ASHA mandates a clinical fellowship for this certificate.

Q: Is licensure needed during a clinical fellowship?

A: Licensure during a clinical fellowship year depends on the following:

• If a clinical fellowship year is being completed prior to graduation from an accredited university or college and the SLP is placed in a clinical fellowship program as part of the course of study or working in a recognized training center, an SLP is considered a student/intern/trainee and is exempt from licensure pursuant to § 54.1-2601 of the Code of Virginia. 2 Guidance Document: 30-8

Revised: February 9, 2021

Effective: April 1, 2021

• Upon graduation, an SLP completing a clinical fellowship year must hold a provisional license issued by BASLP in order to practice in Virginia.

Practicing without a license may result in a public disciplinary action.

Licensure Renewal and Practice

Q: When must a license be renewed?

A: School and full speech-language pathology licenses issued by BASLP expire each June 30th and must be renewed prior to this date. A provisional license expires 18 months from the date of issuance.

Q: Who is responsible for licensure renewal?

A: The licensee is responsible for renewal regardless of notice. BASLP recommends personal reminders. Keep address and email current via online system or contact the board.

Q: What is practicing with a lapsed license?

A: Any practice of speech-language pathology without a current, valid license after June 30th or expiration date of a provisional license is considered practicing with a lapsed license. Practicing with a lapsed license may result in public disciplinary action against a licensee.

Q: Is there a grace period to practice without or with a lapsed license?

A: No, no grace periods exist to practice without a license.

Requirements Imposed on Hospitals, Other Health Care Institutions and Organizations, and Assisted Living Facilities to Report Disciplinary Actions Against, Allegations of Misconduct by, and Impairment of Certain Health Care Practitioners to The Virginia Department of Health Professions or The Office of Licensure and Certification of The Virginia Department of Health

Guidance Document No. 76-34

Updated: October 3, 2024 Updated: October 3, 2024

TABLE OF CONTENTS

I. Requirements of § 54.1-2400.6 ................................................................................................... 2 A. General Requirements. ........................................................................................................... 2 B. 2024 Changes in Legislation Limiting Reporting .................................................................. 2 II. Who may be reported under § 54.1-2400.6 ................................................................................ 3 III. Exemption from Reporting ....................................................................................................... 4 IV. Specific Guidance Concerning Required Reports .................................................................... 4 A. What is meant by “hospital, other health care institution, or assisted living facility”? ......... 4 B. What constitutes a “home care organization” or “home health organization”? ..................... 5 C. What constitutes a “hospice organization”? ........................................................................... 6 D. What specific information is required in reports? .................................................................. 6 E. When must reports be made? ................................................................................................. 6 F. To whom must reports be made? ............................................................................................ 7 G. What information should not or need not be reported or disclosed? ..................................... 7

1 Updated: October 3, 2024

Requirements Imposed on Certain Healthcare Entities to Report Disciplinary Actions Against, Allegations of Misconduct by, and Impairment of Certain Health Care Practitioners to the Virginia Department of Health Professions or the Office of Licensure and Certification of the Virginia Department of Health

I. Requirements of § 54.1-2400.6

A. General Requirements.

Virginia Code § 54.1-2400.6 details reporting requirements which impact certain healthcare facilities. For the most recent statutory version, please refer to the Legislative Information System at law.lis.virginia.gov or use the hyperlink in the statutory cite above.

B. 2024 Changes in Legislation Limiting Reporting

Previous statutory language required reporting of any information of which the reporter became aware in his official capacity indicating a reasonable belief that a health professional needs treatment or was voluntarily admitted as a patient for treatment of substance abuse or a psychiatric illness that may render the health professional a danger to himself, the public, or patients.

Changes in the 2024 General Assembly Session removed a portion of the previous requirement. Following those changes, reporting is required for “a reasonable belief that such a health professional has been involuntarily admitted as a patient . . . for treatment of substance abuse or a psychiatric illness.” See Va. Code § 54.1-2400.6(A)(1).

The current requirement for reporting voluntary admission is found in § 54.1-2400.6(A)(2) and only applies if the psychiatric illness or substance abuse may continue for more than 30 days after admission. Additionally, such a report is required to be made five days after the 30-day period concludes and is not required if the physician, physician assistant, or nurse practitioner treating the health professional provides written confirmation to the reporting entity that the health professional is no longer a danger to himself, the public, or patients.

2 Updated: October 3, 2024

II. Who may be reported under § 54.1-2400.6

Individuals (i) licensed, certified or registered by a health regulatory board, (ii) applying for such licensure, certification or registration, and (iii) holding a multistate license privilege to practice nursing are subject to reporting under § 54.1-2400.6 unless an exemption applies (see below). The list of practitioners under the jurisdiction of a regulatory board of DHP at the time of this revision include:

Board of Audiology/Speech Language Pathology: audiologists; speech-language pathologists

Board of Counseling: marriage and family therapists; professional counselors; substance abuse treatment practitioners; rehabilitation providers; substance abuse counselors; substance abuse counseling assistants; qualified mental health provider; peer recovery specialists; residents in counseling, marriage and family therapy or substance abuse treatment; art therapists; behavioral health technicians; behavioral health technician assistants.

Board of Dentistry: dentists; oral and maxillofacial surgeons; dental hygienists; dental assistants II.

Board of Funeral Directors and Embalmers: funeral service licensees; funeral directors; funeral embalmers; funeral trainees.

Board of Medicine: doctors of medicine, including interns and residents; doctors of osteopathic medicine; chiropractors; podiatrists; physician assistants; radiologic technologists; radiologic technologists, limited; radiologist assistants; respiratory therapists; occupational therapists; occupational therapy assistants; acupuncturists; athletic trainers; professional midwives; polysomnographers; behavioral analysts; assistant behavioral analysts; genetic counselors; surgical assistants; surgical technologists.

Board of Nursing: registered nurses; practical nurses; advanced practice registered nurses, including clinical nurse specialists, nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists; massage therapists; certified nurse aides; advanced certified nurse aides; medication aides; advanced medication aides.

Board of Long-Term Care Administrators: nursing home administrators; assisted living facility administrators; administrators-in-training.

Board of Optometry: optometrists.

Board of Pharmacy: pharmacists; pharmacist interns; pharmacy technicians; pharmacy technician trainees.

3 Updated: October 3, 2024

Board of Physical Therapy: physical therapists; physical therapist assistants.

Board of Psychology: applied psychologists; clinical psychologists; school psychologists; school psychologist-limited; certified sex offender treatment providers; psychological practitioners.

Board of Social Work: clinical social workers; master’s social workers; baccalaureate social workers; music therapists.

Board of Veterinary Medicine: veterinarians; veterinary technicians; equine dental technicians.

III. Exemption from Reporting

Records or information learned about by the reporting entity or person which are covered by federal confidentiality provisions concerning substance abuse treatment are exempt from reporting requirements of § 54.1-2400.6. Va. Code § 54.1-2400.6(D).

IV. Specific Guidance Concerning Required Reports

A. What is meant by “hospital, other health care institution, or assisted living facility”?

For the purpose of reporting requirements, “hospital, other health care institutions or assisted living facilities” includes:

1. General hospitals;

1. Outpatient surgical hospitals;

1. Mental or psychiatric hospitals, including, for the purposes of § 54.1-2400.6, every facility and training center operated by the Virginia Department of Behavioral Health and Developmental Services;

1. Hospitals operated by the University of Virginia and Virginia Commonwealth University;

1. Hospitals known by varying nomenclature or designation such as sanatoriums, sanitariums, acute, rehabilitation, chronic disease, short-term, long-term, and inpatient or outpatient maternity hospitals;

1. Nursing homes and certified nursing facilities; and

4 Updated: October 3, 2024

1. Assisted living facilities licensed by the Department of Social Services.

Physician offices and group medical practices are not included in the terms “hospital and other health care institutions.” This list, however, is not exclusive and other entities not included may be subject to the reporting requirement contained in § 54.1-2400.6.

B. What constitutes a “home care organization” or “home health organization”?

The definition of “home care organization” provided in Virginia Code § 32.1-162.7 represents “home care organizations” and “home health organizations” for the purpose of reporting requirements under Virginia Code § 54.1-2400.6. Virginia Code § 32.1-162.7 defines “home care organization” as:

any public or private organization, whether operated for profit or not for profit, that provides, at the residence of a patient or individual in the Commonwealth of Virginia, one or more of the following services:

1. Home health services, including services provided by or under the direct supervision of any health care professional under a medical plan of care in a patient’s residence on a visit or hourly basis to patients who have or are at risk of injury, illness, or a disabling condition and require short-term or long-term interventions;

1. Personal care services, including assistance in personal care to include activities of daily living provided in an individual’s residence on a visit or hourly basis to individuals who have or are at risk of an illness, injury or disabling condition; or

1. Pharmaceutical services, including services provided in a patient’s residence, which include the dispensing and administration of a drug or drugs, and parenteral nutritional support, associated patient instruction, and such other services as identified by the Board of Health by regulation.

Va. Code § 32.1-162.7. Quotation of statutory language found above is accurate as of the revised date of this Guidance Document. Individuals should refer to § 32.1-162.7 provided by the Commonwealth of Virginia on the Legislative Information System for up to date statutory language which incorporates changes from legislative sessions.

5 Updated: October 3, 2024

C. What constitutes a “hospice organization”?

For the purpose of reporting requirements, “hospice organization” means an administrative group, individual or legal entity that has a distinct organizational structure, accountable to the governing authority directly or through a chief executive officer, that administers a coordinated program of home and inpatient care providing palliative and supportive medical and other health services to terminally ill patients and their families.

D. What specific information is required in reports?

Virginia Code § 54.1-2400.6(A) requires reports to be in writing. That provision also lists the information required to be contained in the written report as follows:

1. The name, address, and date of birth of the person who is the subject of the report;

1. A full description of the circumstances surrounding the facts required to be reported;

1. Names and contact information of individuals with knowledge about the facts required to be reported;

1. Names and contact information of individuals from whom the hospital or health care institution sought information to substantiate the facts required to be reported;

1. All relevant medical records if patient care or the health professional's health status is at issue; and

1. If relevant, notice to the Board that it has submitted a report to the National Practitioner Data Bank under the Health Care Quality Improvement Act, 42 U.S.C. § 11101, et seq.

Va. Code § 54.1-2400.6(A).

A report to the National Practitioner Data Bank alone is not sufficient to satisfy the requirements of Virginia Code § 54.1-2400.6 and DOES NOT constitute reporting to DHP or OLC or constitute “actual notice” of the reporting to DHP or OLC.

E. When must reports be made?

Pursuant to Virginia Code § 54.1-2400.6(A), reports must be made within 5 calendar days when any practitioner regulated by any health regulatory board has been involuntarily admitted as a patient for the treatment of substance abuse or a psychiatric illness.

6 Updated: October 3, 2024

Reports must be made within 30 days of any of these triggering events:

• The date a CEO, COS, administrator, or director becomes aware that a practitioner regulated by any health regulatory board has been voluntarily admitted as a patient for treatment of substance abuse or a psychiatric illness if the treatment may continue for more than 30 days after admission. Reporting is not required if the treating physician, physician assistant, or nurse practitioner confirms in writing that the health professional is no longer a danger to themselves, the public, or patients.

• The date a CEO, COS, or administrator, or director determines that there is a reasonable probability that a practitioner regulated by any health regulatory board may have engaged in unethical, fraudulent or unprofessional conduct, as defined in the relevant licensing statutes and regulations.

• The date of written communication to a practitioner notifying him of a disciplinary proceeding for reportable conduct.

• The date of written communication to a practitioner notifying him of a disciplinary action for reportable conduct.

• The date of a practitioner’s resignation, restriction or expiration of privileges while under investigation or subject to disciplinary proceedings for reportable conduct.

F. To whom must reports be made?

Reports by hospital CEOs and COS and ALF administrators should be made to the Director of the Virginia Department of Health Professions, 9960 Mayland Drive, Suite 300, Henrico, Virginia 23233; FAX (804) 527-4434; email: director@dhp.virginia.gov.

Reports by home health and hospice organizations should be made to the Office of Licensure and Certification, Virginia Department of Health, 9960 Mayland Drive, Suite 401, Henrico, Virginia 23233; FAX (804) 527-4502; email: OLC-Complaints@vdh.virginia.gov.

G. What information should not or need not be reported or disclosed?

Medical records or information learned or maintained about a practitioner in connection with an alcohol or drug prevention function that is conducted, regulated, or directly or indirectly assisted by any federal department or agency should not be reported if reporting would violate 42 U.S.C. § 290dd-2 or related regulations. Va. Code § 54.1-2400.6(D).

Hospitals, other health care institutions and assisted living facilities are not required to submit any “proceedings, minutes, records, or reports” that are privileged under Va. Code §

1. 01-581.17. Va. Code § 54.1-2400.6(A)(5).

When a required reporter has actual notice that the report has already been made, another such report is not required. Va. Code § 54.1-2400.6(A).

7 Updated: October 3, 2024

H. How does the Department of Health Professions investigate complaints of noncompliance of § 54.1-2400.6?

1. Personnel and medical records are reviewed from allegedly reportable incident. The investigator confirms that the individual was a licensee of the Department at the time of incident and that the facility documented that the individual was a health care provider.

1. The non-reporting facility is notified of the complaint, usually via letter sent to the individual responsible for reporting per the statute (e.g., CEO, Chief of Staff, Director of Home Health or Hospice, etc.).

1. By same letter to the facility/CEO, the facility is asked to respond to the failure to report allegation (i.e., rationale for decision not to report, awareness of conduct and related required reporting law). The response may be collected via letter, email, phone call or personal visit.

1. The facility is asked if it has an existing reporting policy, and if the policy was in place at the time of the event, and to produce the policy (or any reporting policies that were produced subsequent to the failure to report).

1. If relevant, witnesses to the failure to report and related circumstances are also interviewed.

8

Requirements on hospitals, health care institutions, and assisted living facilities to report disciplinary actions, misconduct allegations, and impairments of certain practitioners to Virginia DHP or Office of Licensure and Certification.

Guidance Document No. 76-34

Updated: October 3, 2024 Updated: October 3, 2024

TABLE OF CONTENTS

I. Requirements of § 54.1-2400.6 ................................................................................................... 2 A. General Requirements. ........................................................................................................... 2 B. 2024 Changes in Legislation Limiting Reporting .................................................................. 2 II. Who may be reported under § 54.1-2400.6 ................................................................................ 3 III. Exemption from Reporting ....................................................................................................... 4 IV. Specific Guidance Concerning Required Reports .................................................................... 4 A. What is meant by “hospital, other health care institution, or assisted living facility”? ......... 4 B. What constitutes a “home care organization” or “home health organization”? ..................... 5 C. What constitutes a “hospice organization”? ........................................................................... 6 D. What specific information is required in reports? .................................................................. 6 E. When must reports be made? ................................................................................................. 6 F. To whom must reports be made? ............................................................................................ 7 G. What information should not or need not be reported or disclosed? ..................................... 7

1 Updated: October 3, 2024

Requirements for certain healthcare entities to report disciplinary actions, misconduct, and impairments of specific practitioners to Virginia DHP or Office of Licensure and Certification.

I. Requirements of § 54.1-2400.6

A. General Requirements.

Virginia Code § 54.1-2400.6 details reporting requirements affecting certain healthcare facilities; refer to law.lis.virginia.gov for the latest version.

B. 2024 Changes in Legislation Limiting Reporting

Previous law required reporting any knowledge indicating a health professional needed treatment or was voluntarily admitted for substance abuse or psychiatric illness that could endanger themselves, the public, or patients.

2024 legislation removed part of previous requirement; now reporting is required for reasonable belief of involuntary admission for substance abuse or psychiatric illness. See Va. Code § 54.1-2400.6(A)(1).

Current reporting for voluntary admission in § 54.1-2400.6(A)(2) applies if illness or substance abuse lasts over 30 days; report due five days after, unless provider confirms no longer a danger.

2 Updated: October 3, 2024

II. Who may be reported under § 54.1-2400.6

Individuals licensed, certified, registered, applying for licensure, certification, registration, or holding multistate nursing privileges are subject to reporting under § 54.1-2400.6, unless exempted. The practitioners under DHP jurisdiction include:

Board of Audiology/Speech Language Pathology: audiologists; speech-language pathologists

Board of Counseling: marriage and family therapists; professional counselors; substance abuse practitioners; rehab providers; counselors; counseling assistants; mental health providers; peer recovery specialists; residents; art therapists; behavioral health technicians and assistants.

Board of Dentistry: dentists; oral/maxillofacial surgeons; dental hygienists; dental assistants II.

Board of Funeral Directors and Embalmers: funeral licensees; directors; embalmers; trainees.

Board of Medicine: MDs (including interns/residents); DOs; chiropractors; podiatrists; PAs; radiologic technologists; radiologist assistants; respiratory therapists; occupational therapists/assistants; acupuncturists; trainers; midwives; polysomnographers; behavioral analysts; genetic counselors; surgical assistants/technologists.

Board of Nursing: RNs; LPNs; APRNs (CNSs, NPs, CNMs, CRNAs); massage therapists; nurse aides; advanced aides; medication aides.

Board of Long-Term Care Administrators: nursing home; assisted living administrators; trainees.

Board of Optometry: optometrists.

Board of Pharmacy: pharmacists; interns; technicians; technician trainees.

3 Updated: October 3, 2024

Board of Physical Therapy: PTs; PT assistants.

Board of Psychology: applied; clinical; school psychologists; limited; sex offender treatment providers; practitioners.

Board of Social Work: clinical; master's; baccalaureate social workers; music therapists.

Board of Veterinary Medicine: veterinarians; veterinary technicians; equine dental technicians.

III. Exemption from Reporting

Records or info covered by federal confidentiality provisions concerning substance abuse treatment are exempt from reporting requirements of § 54.1-2400.6. Va. Code § 54.1-2400.6(D).

IV. Specific Guidance Concerning Required Reports

A. What is meant by “hospital, other health care institution, or assisted living facility”?

For reporting, “hospital, health care institutions or assisted living facilities” includes:

1. General hospitals;

1. Outpatient surgical hospitals;

1. Mental or psychiatric hospitals, including facilities and training centers operated by the Virginia Department of Behavioral Health and Developmental Services, per § 54.1-2400.6;

1. Hospitals operated by UVA and VCU;

1. Hospitals with various designations like sanatoriums, acute, rehab, chronic, short-term, long-term, inpatient or outpatient maternity hospitals;

1. Nursing homes and certified nursing facilities; and

4 Updated: October 3, 2024

1. Assisted living facilities licensed by DSS.

Physician offices and group practices are not included in “hospital and health care institutions,” but other entities not listed may be subject to reporting in § 54.1-2400.6.

B. What constitutes a “home care organization” or “home health organization”?

Virginia Code § 32.1-162.7 defines “home care organization” as:

any public or private organization, profit or not, providing services at a Virginia resident's home:

1. Home health services provided by or under supervision of health professionals under a medical plan in a patient’s residence, on a visit or hourly basis, for patients at risk or with injury, illness, or disability, requiring short- or long-term care;

1. Personal care services, including assistance with activities of daily living in a residence, on a visit or hourly basis, for individuals at risk or with illness, injury, or disability;

1. Pharmaceutical services in a patient’s residence, including dispensing, administration, parenteral nutrition, patient instruction, and other services as regulated by the Board of Health.

Va. Code § 32.1-162.7. Refer to this for current statutory language, including legislative updates.

5 Updated: October 3, 2024

C. What constitutes a “hospice organization”?

A “hospice organization” is an administrative group, individual, or legal entity with a distinct structure, accountable to the governing body or CEO, providing coordinated home and inpatient palliative and supportive care to terminally ill patients and families.

D. What specific information is required in reports?

Virginia Code § 54.1-2400.6(A) requires written reports with the following information:

1. Name, address, and DOB of the report subject;

1. Full description of circumstances surrounding reportable facts;

1. Names and contacts of individuals with knowledge of reportable facts;

1. Names and contacts of individuals from whom the hospital sought info to substantiate reportable facts;

1. All relevant medical records if patient care or health status is at issue;

1. If relevant, notice to the Board of report submission to the NPDB under 42 U.S.C. § 11101;

Va. Code § 54.1-2400.6(A).

Reporting only to the National Practitioner Data Bank does not satisfy Virginia Code § 54.1-2400.6 or constitute notice to DHP or OLC.

E. When must reports be made?

Under Virginia Code § 54.1-2400.6(A), reports are due within 5 days of involuntary admission of a regulated practitioner for substance abuse or psychiatric treatment.

6 Updated: October 3, 2024

Reports must be made within 30 days of these triggering events:

• Date a CEO, COS, administrator, or director learns a regulated practitioner was admitted for substance abuse or psychiatric treatment exceeding 30 days; no report needed if provider confirms no longer a danger.

• Date a CEO, COS, administrator, or director determines a regulated practitioner may have engaged in unethical, fraudulent, or unprofessional conduct as defined in licensing statutes;

• Date of written notice to practitioner of disciplinary proceeding for reportable conduct.

• Date of written notice to practitioner of disciplinary action for reportable conduct.

• Date a practitioner resigns, is restricted, or privileges expire while under investigation or disciplinary proceedings for reportable conduct.

F. To whom must reports be made?

Hospital CEOs, COS, and ALF administrators must report to the Director, Virginia Department of Health Professions, 9960 Mayland Drive, Suite 300, Henrico, VA 23233; FAX: (804) 527-4434; email: director@dhp.virginia.gov.

Home health and hospice reports go to the Office of Licensure and Certification, Virginia Dept. of Health, 9960 Mayland Drive, Suite 401, Henrico, VA 23233; FAX: (804) 527-4502; email: OLC-Complaints@vdh.virginia.gov.

G. What information should not or need not be reported or disclosed?

Medical info about practitioners related to federally regulated alcohol or drug prevention should not be reported if it violates 42 U.S.C. § 290dd-2 or related regs. Va. Code § 54.1-2400.6(D).

Hospitals, health care institutions, and assisted living facilities are not required to submit privileged proceedings, minutes, records, or reports under Va. Code §

1. 01-581.17. Va. Code § 54.1-2400.6(A)(5).

If a required reporter knows a report was already made, another is not needed. Va. Code § 54.1-2400.6(A).

7 Updated: October 3, 2024

H. How does the Department of Health Professions investigate noncompliance of § 54.1-2400.6?

1. Personnel and medical records from alleged incident are reviewed; investigator confirms individual was a licensed health care provider at the time, and documented as such.

1. Non-reporting facility is notified of the complaint via letter to the responsible individual (e.g., CEO, Chief of Staff, Director of Home Health/Hospice).

1. Same letter requests response to failure-to-report allegation, including rationale, awareness, and law compliance; responses via letter, email, call, or visit.

1. Facility is asked if it has a reporting policy, if it was in place at the event, and to produce it or subsequent policies.

1. Relevant witnesses to failure to report and circumstances are interviewed.

8

Guidance Document: 30-5 Revised: March 14, 2023 Effective Date: May 11, 2023

Board of Audiology and Speech-Language Pathology

Equivalent Accrediting Body

To issue a license in audiology, the Board has determined that the Accreditation Commission for Audiology Education (ACAE) is “an equivalent accrediting body” for documentation of didactic coursework required for the doctoral degree, as specified in 18VAC30-21-60(A)(3) and 18VAC30-21-70(A)(2)(a).

Relevant Regulations:

18VAC30-21-60

18VAC30-21-70

Guidance Document: 30-5 Revised: March 14, 2023 Effective Date: May 11, 2023

Board of Audiology and Speech-Language Pathology

Equivalent Accrediting Body

To issue a license in audiology, the Board has determined that the Accreditation Commission for Audiology Education (ACAE) is “an equivalent accrediting body” for documentation of didactic coursework required for the doctoral degree, as specified in 18VAC30-21-60(A)(3) and 18VAC30-21-70(A)(2)(a).

Relevant Regulations:

18VAC30-21-60

18VAC30-21-70

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.06 Disciplinary Process for Cases Involving Non-compliance with Virginia Code § 54.1-2400.6 The purpose of this policy is to promote the prompt adjudication of allegations which may present evidence that a hospital, other health care institution, home health, hospice, or a licensed assisted living facility failed to properly report disciplinary actions against certain categories of health professionals. The policy covers all maters which may result in action by the Director of the Department of Health Professions (“DHP Director”) pursuant to Virginia Code § 54.1-2400.6.

For purposes of this policy, “subordinate” means (1) one or more members of a board, (2) one or more staff members or employees of a board, or (3) any other persons designated by the DHP Director.

Procedures

A question of non-compliance with Virginia Code § 54.1-2400.6 arises, most likely in the context of investigation of a complaint against a licensee, certificate holder, or registration holder.

The Enforcement Division investigates the potential non-compliance with Virginia Code § 54.1-2400.6.

The report of investigation is sent to the DHP Director or designee. The DHP Director may take one of the following actions: a. Determine that probable cause does not exist for a finding of non-compliance with Virginia Code § 54.1-2400.6. The DHP Director will then issue a closure letter to the hospital, other health care institution, home health organization, hospice organization, or assisted living facility stating that the matter is concluded. b. Determine that probable cause exists for a finding of non-compliance with Virginia Code § 54.1-2400.6. The DHP Director may then: i. Send a letter of concern to the entity at issue; ii. Issue a pre-hearing consent order (“PHCO”); or iii. Refer the matter for an administrative proceeding.

If the case may be settled by a PHCO, the Administrative Proceedings Division (“APD”) will draft a PHCO which contains findings of facts, conclusions of law, and, if appropriate, a monetary penalty for the DHP Director’s review and approval. The DHP Director may then offer the PHCO to the respondent. If accepted by the respondent, the PHCO will be presented to the DHP Director for entry. If a draft PHCO is not approved by the DHP Director or is offered to and rejected by the respondent, then the case will proceed to an Informal Fact-Finding Conference (“IFC”).

If not closed or settled by a PHCO, the DHP Director may appoint one or more subordinates to consider the case at IFC. The subordinate will convene an IFC pursuant to a notice drafted by APD. An IFC before the subordinate will be conducted in the same manner as an IFC before a committee of a regulatory board. The case will be presented by APD staff, the respondent may be represented by counsel, and all parties may present information to the subordinate to support their respective positions. Following the presentation of information by the parties, the subordinate will consider the evidence presented and do one of the following: 1 Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.06 a. The subordinate may recommend to the DHP Director that there be a finding of no violation or that insufficient evidence exists to determine that the statute has been violated, resulting in a dismissal letter to the respondent; b. The subordinate may recommend to the DHP Director that the case be referred to a formal administrative hearing; or c. The subordinate may determine that a violation of Virginia Code § 54.1-2400.6 has occurred and recommend findings of fact, conclusions of law, and a monetary penalty. With the assistance of APD, the recommendations of the subordinate are incorporated into a draft consent order, which is presented to the DHP Director for approval, rejection, or modification. If approved or modified by the DHP Director, the consent order is then offered to the respondent. If accepted by the respondent, the consent order will be presented to the DHP Director for entry. If a consent order is not approved by the DHP Director or a consent order is offered and rejected by the respondent, the case proceeds to a formal administrative hearing.

After an IFC is conducted, if a case is referred to a formal administrative hearing and not settled by a consent order, a formal administrative hearing will be convened. A notice of formal hearing will be drafted by APD staff and, after approval by the Office of the Attorney General, will be sent to the respondent under the appropriate designee’s signature. The rules that normally apply to formal administrative hearings will apply. The case will be presented by APD staff or the Office of the Attorney General, the respondent may be represented by counsel, evidence may be presented on behalf of the Commonwealth and the respondent, witnesses may be subpoenaed to testify, witnesses may be examined and cross-examined, and the proceedings will occur on the record and transcribed by a court reporter. a. Formal administrative hearings will be heard by a hearing officer appointed pursuant to Virginia Code § 2.2-4024. b. The provisions of Virginia Code § 2.2-4020 C, D, and F will apply to cases heard by a hearing officer, to include the requirement that the hearing officer make recommendations to the DHP Director regarding findings of fact and conclusions of law. After considering the hearing officer’s recommendations, as well as any exceptions filed, the DHP Director will accept, reject, or modify the hearing officer’s recommendations and enter an order.

References Va. Code § 54.1-2400.6 2

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.06 Disciplinary Process for Cases Involving Non-compliance with Virginia Code § 54.1-2400.6. This policy promotes prompt adjudication of allegations indicating hospitals, health care institutions, home health, hospice, or assisted living facilities failed to report disciplinary actions against certain health professionals. It covers all matters resulting in action by the DHP Director under Virginia Code § 54.1-2400.6.

For this policy, “subordinate” means (1) board members, (2) staff or employees of a board, or (3) persons designated by the DHP Director.

Procedures

Non-compliance with Virginia Code § 54.1-2400.6 typically arises during complaint investigations against licensees, certificate, or registration holders.

The Enforcement Division investigates the potential non-compliance with Virginia Code § 54.1-2400.6.

The investigation report is sent to the DHP Director or designee, who may: a. Find no probable cause and issue a closure letter; or b. Find probable cause and: i. send a concern letter, ii. issue a pre-hearing consent order (“PHCO”), or iii. refer for an administrative proceeding.

If settleable by a PHCO, the APD drafts it with findings, conclusions, and possibly a monetary penalty for DHP Director’s review. If accepted, it is presented for entry; if rejected, the case proceeds to an IFC.

If not settled by PHCO, the DHP Director may appoint subordinates to consider the case at an IFC, conducted like a regulatory board hearing, with APD presenting, respondent may be counsel, and parties support their positions. After presentations, the subordinate will decide to: 1. recommend no violation or insufficient evidence, resulting in dismissal; 2. refer for a formal hearing; or 3. find a violation and recommend findings, conclusions, and a monetary penalty, which are incorporated into a draft consent order for DHP Director’s approval or rejection, leading to settlement or a formal hearing.

Revised: April 11, 2025

The subordinate may recommend: a) no violation or insufficient evidence for dismissal; b) referral for a formal hearing; or c) violation with findings, conclusions, and a monetary penalty, incorporated into a draft consent order for DHP Director’s approval. If approved or rejected, the case proceeds accordingly.

If not settled by a consent order, a formal hearing is convened, with APD drafting the notice, approved by the Attorney General, and sent to the respondent. The hearing follows applicable rules, with evidence, witnesses, and cross-examination, recorded by a court reporter. A hearing officer, appointed under Virginia Code § 2.2-4024, presides, makes recommendations to the DHP Director, who then accepts, rejects, or modifies them to issue an order.

References Va. Code § 54.1-2400.6 2

Guidance document: 30-11 Reaffirmed: February 9, 2021 Effective: April 1, 2021

Virginia Board of Audiology and Speech-Language Pathology

Guidelines for Processing Applications for Licensure

The Executive Director for the Board of Audiology and Speech-Language Pathology has delegated authority to issue an initial license, renew a license or reinstate a license for those applicants who meet the qualifications as set forth in the law and regulations provided no grounds exist to refuse to issue a license pursuant to 18VAC30-21-160 of the Regulations Governing the Practice of Audiology and Speech-Language Pathology.

Affirmative responses to any questions on applications for licensure for which the Board may refuse to issue a license shall be referred to the Board President as to how to proceed. The Executive Director, or designee, may approve the application without referral in the following case:

The applicant has been disciplined by another board of audiology and speech-language pathology in a U.S. jurisdiction for failure to complete continuing education and has evidence of compliance with that board’s order.

An applicant whose license has been revoked or suspended for any reason other than nonrenewal by another jurisdiction is not eligible for licensure in Virginia unless the license has been reinstated by the jurisdiction which revoked or suspended it. Pursuant to §54.1-2408 of the Code of Virginia, such applicants shall be advised in writing of their ineligible status by the Executive Director.

Guidance document: 30-11 Reaffirmed: February 9, 2021 Effective: April 1, 2021

Virginia Board of Audiology and Speech-Language Pathology

Guidelines for Processing Applications for Licensure

The Executive Director for the Board of Audiology and Speech-Language Pathology is delegated authority to issue, renew, or reinstate licenses for applicants meeting legal and regulatory qualifications, provided no grounds exist to refuse under 18VAC30-21-160.

Affirmative responses on licensure applications that may lead to refusal shall be referred to the Board President for action. The Executive Director or designee may approve without referral if:

An applicant disciplined by another U.S. audiology or speech-language pathology board for failure to complete continuing education and who has evidence of compliance is eligible.

Applicants with licenses revoked or suspended for reasons other than nonrenewal by another jurisdiction are ineligible unless reinstated by that jurisdiction. Pursuant to §54.1-2408, the Executive Director shall notify them in writing of ineligibility.

Guidance Document: 30-3

Revised: March 14, 2023

Effective Date: May 11, 2023

Board of Audiology and Speech-Language Pathology Confidential Consent Agreements The Board is authorized by Virginia Code § 54.1-2400(14) to resolve certain allegations of practitioner misconduct by means of a Confidential Consent Agreement (“CCA”). A CCA may be used by a board in lieu of public discipline, but only in cases involving minor misconduct and non-practice related infractions, where there is little or no injury to a patient or the public, and little likelihood of repetition by the practitioner.

See Va. Code § 54.1-2400(14).

The Board adopts the following list of violations of regulations or statute that may qualify for resolution by a CCA.

1. Failure to notify the Board of a change of address or name change in accordance with current regulations.
2. Failure to maintain and submit patient records and documentation when requested.
3. Failure to meet required continuing competency requirements without an approved request for an exception or an exemption.
4. Misrepresentation in advertising of name or credentials by a licensee.
5. Inadvertent breach of confidentiality.
6. Failure to report a violation.

Related Statutes:

Va. Code § 54.1-2400(14)

Guidance Document: 30-3

Revised: March 14, 2023

Effective Date: May 11, 2023

Board of Audiology and Speech-Language Pathology Confidential Consent Agreements The Board is authorized by Virginia Code § 54.1-2400(14) to resolve certain misconduct allegations via a Confidential Consent Agreement (“CCA”). A CCA replaces public discipline only for minor misconduct, non-practice infractions, minimal injury, and low repetition risk.

See Va. Code § 54.1-2400(14).

The Board adopts the following violations of regulations or statute that may qualify for resolution by a CCA.

1. Failure to notify the Board of address or name change as per regulations.
2. Failure to maintain and submit patient records when requested.
3. Failure to meet continuing competency requirements without approved exception or exemption.
4. Misrepresentation in advertising of name or credentials.
5. Inadvertent breach of confidentiality.
6. Failure to report a violation.

Related Statutes:

Va. Code § 54.1-2400(14)

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-80.12 Extension of Time for Active Duty Servicemembers and Spouses The Department of Health Professions will make arrangements as necessary to ensure that persons serving on active duty as a member of the military or in the foreign service outside of the United States, or their spouses, are afforded the benefit of an extension of time for any deadline or requirement pertaining to renewal of a license, certification, or registration. Extensions should be granted for at least 60 days after the individual’s return to the United States, not to exceed five years from the date of expiration.

The executive director of each health regulatory board will ensure that the benefit provided in Virginia Code § 54.1-117 is adequately publicized by inclusion of information on websites, newsletters, or other means of communication.

All staff who process renewals or audit continuing competency requirements should be aware of the policy to assist licensees who may be eligible for this benefit.

A copy of military orders or form DD214 placing the licensee on active duty outside of the United States will be considered sufficient documentation to determine eligibility. A request for an extension of renewal fee or continuing education deadlines should include the projected return date to the United States.

If the spouse of a servicemember accompanies the servicemember during periods of service outside the United States, the extension may also apply. Proof that the spouse has accompanied the servicemember outside the United States must be provided.

If a licensee qualifies for the extension, staff of the boards should contact Technology and Business Services staff to assist with modification of the licensee’s record in the internal licensure software system to ensure that the license is maintained as active and current beyond the renewal date through the period of the assignment outside of the United States.

To maintain the ordinary renewal cycle for the licensee and give the benefit to the licensee, the license should be made current until the next renewal date beyond the expected date of return, even if the renewal date is beyond 60 days after the return to the United States. The licensee will not owe renewal fees for previous renewal cycles to the board, and the licensee’s continuing education requirements will be waived for the renewal cycles in which the licensee is outside the United States. The following provides an example: CAPT Jones holds a license that is renewed annually. CAPT Jones left the United States for an active duty assignment in Germany in June 2022. He expects to return to the United States in June 2025.

His license should be made current until the next renewal date of December 2025. He does not pay the renewal fees that were due in December 2022, December 2023, or December 2024, nor is he responsible for submitting evidence of or obtaining continuing education for those three renewal cycles. 1 Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-80.12 If a licensee voluntarily pays renewal fees, the board may accept such payment. A refund is not necessary. If it is determined, however, that any person who meets the criteria set out in Virginia Code § 54.1-117 has been improperly charged a late fee or required to reinstate a license, that person is eligible for a refund from the agency. Staff must submit a refund request to Finance to complete re-payment.

References Va. Code § 54.1-117 2

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-80.12 Extension of Time for Active Duty Servicemembers and Spouses The Department of Health Professions will arrange to ensure active duty military or foreign service members and spouses receive license, certification, or registration renewal extensions. Extensions are at least 60 days after return, up to five years from expiration.

The executive director of each health regulatory board will ensure the benefit in Virginia Code § 54.1-117 is publicized via websites, newsletters, or other means.

All staff processing renewals or auditing continuing competency should be aware of the policy to assist eligible licensees.

A copy of military orders or DD214 placing the licensee on active duty outside the U.S. is sufficient documentation. Requests for extensions should include the projected return date.

If a servicemember's spouse accompanies them abroad, the extension may apply. Proof of spouse's accompaniment must be provided.

If eligible, board staff should contact Technology and Business Services to modify the licensee’s record, ensuring the license remains active beyond the renewal date during the assignment abroad.

The license should be current until the next renewal date beyond the expected return, even if beyond 60 days after return. No renewal fees or continuing education are owed for prior cycles during the absence. Example: CAPT Jones, licensed annually, left for Germany in June 2022, returning June 2025.

His license remains current until December 2025. He owes no renewal fees or continuing education for December 2022-2024 cycles. 1 Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-80.12 If a licensee voluntarily pays renewal fees, the board may accept them without refund. If someone meeting Virginia Code § 54.1-117 was improperly charged a late fee or required to reinstate, they are eligible for a refund. Staff must request refunds from Finance.

References Va. Code § 54.1-117 2

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.24 Summary Suspension or Restriction This guidance document is intended to promote the prompt adjudication of allegations which may present evidence of substantial danger to the public health or safety and provide for prompt service of a regulatory board’s notice and order in cases in which a summary suspension or restriction action is taken.

Application

This guidance document covers matters which may result in action by regulatory boards of the Department of Health Professions pursuant to Virginia Code §§ 54.1-2408.1, 54.1-3224, and 54.1-3434.3.

Procedures

1. The Enforcement Division will investigate a possible summary suspension or restriction case in a manner that ensures that the regulatory board possesses all relevant evidence to make an informed decision regarding the summary suspension or restriction and provide this evidence to the regulatory board as soon as practical. Such evidence will be presented without undue delay to the appropriate member(s) of the regulatory board or designated board staff to determine probable cause and whether the evidence meets the regulatory board’s criteria for a summary suspension or restriction.

1. Regulatory board staff will coordinate legal services with the Administrative Proceedings Division (APD) necessary for the board to take action.
2. APD will immediately coordinate the assignment of the case as a possible summary suspension or restriction to an Adjudication Specialist and an Assistant Attorney General (AAG). APD will advise board staff the identity of the assigned AAG.

1. APD will analyze the investigative report as a possible summary suspension or restriction, draft all required legal documents as soon as practically possible, and provide these draft documents and related evidence to the assigned AAG for approval.
2. If the AAG agrees that there is evidence that the continued practice of the individual’s or entity’s regulated activity may constitute a substantial danger to the public health and safety, board staff will schedule a meeting for the Board to consider the summary suspension or restriction of the continued practice of the individual’s or entity’s regulated activity. If the AAG prosecutor does not agree that there is evidence that the continued practice of the individual’s or entity’s regulated activity may constitute a substantial danger to the public health and safety, the AAG prosecutor will discuss the case with the Executive Director or designee. In the event the AAG prosecutor and the Executive Director or designee are unable to reach a consensus, then the Executive Director or designee may discuss the case with Board counsel and/or with the Board president to determine how to proceed further.
3. If it is determined to proceed with the presentation of the information as a possible summary suspension or restriction, board staff will post the meeting on the Virginia Regulatory Town Hall and the Board’s calendar of events. Board staff will coordinate the scheduling of the presentation of the possible summary action case to the Board and notify Board counsel, APD and the AAG as soon as the matter is scheduled. Communication with 1 Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.24 the board members regarding their participation will be limited solely to their availability to meet by telephone or in person. Discussion of the merits of the case is prohibited. All board members shall be provided with an electronic draft copy of the Statement of Allegations prior to the summary being heard.

1. Regardless of whether the presentation is conducted in person or by telephone conference call, after the presentation of the case by the AAG prosecutor, the board members may ask questions and then may enter into closed meeting to deliberate pursuant to Virginia Code § 54.1-3711(A)(27). It is not, however, required that a board enter into closed session prior to voting on the matter before it.
2. If the board votes to summarily suspend or restrict the license, certificate, registration or permit, APD will provide the approved and finalized summary suspension or restriction order, notice and statement of allegations to board staff upon approval by the AAG or within one business day of the summary suspension meeting, whichever occurs first.
3. Board staff will ensure that the service of the summary suspension or restriction order is initiated to the respondent or entity within two business days of the date that the finalized documents are provided to board staff by APD. Service may be accomplished by private process server, by the United States Postal Service (USPS), or by other means approved by Board counsel. If the order is delivered by USPS or any other courier/mail service, it should be sent with a required return receipt for delivery verification. 10. Board staff will schedule the formal hearing within a reasonable time of the date of the summary suspension or restriction. 11. Upon entry of the summary suspension or restriction order, board staff will post the order on the Department of Health Professions website.

References

Va. Code § 54.1-2408.1 Va. Code § 54.1-3224 Va. Code § 54.1-3434.3 2

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.24 Summary Suspension or Restriction promotes prompt adjudication of allegations indicating danger to public health or safety and ensures timely service of notices and orders for summary suspension or restriction.

Application

This guidance covers matters leading to action by Department of Health Professions regulatory boards under Virginia Code §§ 54.1-2408.1, 54.1-3224, and 54.1-3434.3.

Procedures

1. The Enforcement Division will investigate possible summary suspension or restriction cases to ensure the regulatory board has all relevant evidence promptly, and present it without undue delay for probable cause and criteria assessment.

1. Board staff will coordinate legal services with APD for action.
2. APD will assign the case as a possible summary suspension or restriction to an Adjudication Specialist and AAG, and notify staff of the AAG’s identity.

1. APD will analyze the report, draft legal documents promptly, and submit drafts and evidence to the AAG for approval.
2. If the AAG finds evidence of a substantial danger, board staff will schedule a meeting for the Board to consider suspension or restriction. If not, the AAG will discuss with the Executive Director or designee, and if no consensus, the case may be discussed with Board counsel or president to decide next steps.
3. If proceeding, staff will post the meeting on Virginia Regulatory Town Hall and the Board’s calendar, coordinate scheduling, and notify counsel, APD, and AAG once scheduled.

Revised: April 11, 2025

Guidance Document: 76-10.24 limits board members' participation to availability for meetings by phone or in person. Case merits discussion is prohibited. Members receive an electronic draft of the Statement of Allegations before the hearing.

1. After the AAG presentation, board members may ask questions and may enter closed session for deliberation under Virginia Code § 54.1-3711(A)(27). Closed session before voting is not required.
2. If the board votes to suspend or restrict, APD will provide the final order, notice, and allegations to staff upon AAG approval or within one business day of the meeting.
3. Staff will serve the order within two business days via approved methods, schedule a hearing promptly, and post the order on the Department’s website after entry.

References

Virginia Code §§ 54.1-2408.1, 54.1-3224, 54.1-3434.3

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-20.04 Disclosure of Non-Investigative Information The following information regarding licensees1 will be made available upon request and may be published.

A. Name B. Public address or address of record if no public (alternative) address has been provided C. License number D. Date of initial licensure E. Dates of licensure expiration, withdrawal, restriction, suspension, surrender, or revocation F. Date of license renewal, reinstatement, or reactivation G. Any conditions, limitations, or restrictions on the licensee’s practice H. Notice of any disciplinary proceeding I. All orders or similar documents, including decisional or closure letters that dispose of an informal conference, which result from a disciplinary proceeding not vacated J. Owner of a licensed facility and designated person-in-charge or responsible party Information contained in applications for licensure may not be disclosed, except to the applicant, unless specified above or unless a specific decision has been made by the custodian of the record, with documentation in the record of the applicant or minutes of the board that such disclosure is authorized.

In accordance with Virginia Code § 2.2-3705.1, email addresses furnished to a board for the purpose of receiving board email is exempt from disclosure, provided that the email recipient has requested that the board not disclose such information.

All board agenda materials will be clearly segregated into public and confidential information.

The following information may be shared with specified entities as follows without further documentation:

1. Social security number or Department of Motor Vehicles number to the following: a. The Department of Medical Assistance Services, its agents, or its contractors; b. The Neurological Birth Related Injury Fund; c. The Secretary of the Commonwealth; d. The Department of Social Services; e. The Department of Motor Vehicles; and f. The Medical College of Virginia Hospital Authority. 1 Where this guidance document uses the term “license,” that term includes “certificate” and “registration.” 1 Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-20.04

1. Other state licensing authorities or their related entities for the purpose of identification of disciplined practitioners, provided such numbers are not further released for other purposes.
2. Information for any coordinated licensure or data system maintained by a national healthcare or licensure compact to which Virginia is a party pursuant to legislative action by the General Assembly.
3. Email addresses, telephone numbers, and fax numbers to the Department of Health for the purpose of expediting the dissemination of public health information, information about health emergencies, or serving during a public health emergency pursuant to Virginia Code § 54.1-2506.1.
4. Email addresses, telephone numbers, and fax numbers of licensed veterinarians to the State Veterinarian for the purpose of disseminating information about an animal health emergency pursuant to Virginia Code § 54.1-2506.1.

Nothing in this guidance document inhibits disclosure of information to duly authorized personnel within the Office of the Attorney General.

Nothing in this guidance document compels or prohibits release of information where specific state or federal law requires or permits otherwise.

References

Va. Code § 2.2-3705.1 Va. Code § 54.1-2506.1 2

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-20.04 Disclosure of Non-Investigative Information Licensees' information will be available upon request and may be published.

A. Name B. Public address or record address if no public address provided C. License number D. Initial licensure date E. Licensure expiration, withdrawal, restriction, suspension, surrender, or revocation dates F. License renewal, reinstatement, or reactivation date G. Conditions, limitations, or restrictions on practice H. Disciplinary proceeding notice I. Orders or similar documents from disciplinary proceedings J. Owner and responsible party of licensed facility Information in licensure applications may not be disclosed except to the applicant or as authorized by record documentation or board minutes.

Per Virginia Code § 2.2-3705.1, email addresses provided for board communication are exempt from disclosure if the recipient requests non-disclosure.

All agenda materials will be segregated into public and confidential information.

The following information may be shared with specified entities without further documentation:

1. SSN or DMV number to: a. Medical Assistance Services, its agents, or contractors; b. Neurological Birth Injury Fund; c. Secretary of the Commonwealth; d. Social Services; e. DMV; f. Medical College of Virginia Hospital Authority. "License" includes "certificate" and "registration."

Revised: April 11, 2025

Guidance Document: 76-20.04

1. Other state licensing authorities may share discipline-related identifiers, not for other purposes.
2. Information for national healthcare or licensure compact systems Virginia participates in.
3. Contact info to the Department of Health for public health info or emergencies under Virginia Code § 54.1-2506.1.
4. Veterinarian contact info to the State Veterinarian for animal health emergencies under Virginia Code § 54.1-2506.1.

This guidance does not inhibit disclosure to authorized Office of the Attorney General personnel.

This guidance does not affect release of information where law requires or permits otherwise.

References

Va. Code § 2.2-3705.1, § 54.1-2506.1

Policy Implementation(76-90) Prescription Drug Monitoring Advisory Committee(76-90.01) Adopted Date: 5/2/2017 Approved By:_______________________________

Policy Name Prescription Drug Monitoring Advisory Policy Number 76-90.01 Committee Section Title Policy Implementation Section 76- Former Policy 76-2.5 Number 90 No.

Approval Authority Agency Director Effective Date 5/2/2017 Responsible Executive Agency Director Revised Date 8/12/2016 Responsible Office Director's Office Last Reviewed 5/2/2017 Responsible Reviewer Yeatts,Elaine

Purpose:

To establish an advisory panel within the department to assist in the implementation and evaluation of the Prescription Drug Monitoring Program as authorized by Chapter 25.2 of Title 54.1 of the Code of Virginia.

Policy:

The Department’s policy is to seek internal and external advice and opinion regarding implementation of the Prescription Drug Monitoring Program, including establishment of criteria that indicates potential misuse of covered substances.

Authority:

§ 54.1-2520. Program establishment; Director's regulatory authority.

E. The Director shall also establish an advisory committee within the Department to assist in the implementation and evaluation of the Prescription Monitoring Program. Such advisory committee shall provide guidance to the Director regarding information disclosed pursuant to subdivision C 9 of § 54.1-2523.

Procedures:

A. There is hereby established an Advisory Panel appointed by the Director with thefollowing composition:

1. Two pharmacists, one of whom practices in a community pharmacy;

1 of 2 Policy Implementation(76-90) Prescription Drug Monitoring Advisory Committee(76-90.01) Adopted Date: 5/2/2017 Approved By:_______________________________

1. A doctor of medicine or osteopathic medicine in primary practice;
2. A doctor of medicine or osteopathic medicine with a specialty in pain management, treating in an outpatient setting;
3. A licensed nurse practitioner or physician assistant with prescriptive authority;
4. A representative of the Department of State Police;
5. A representative of the Office of the Medical Examiner;
6. A representative of Medicaid Fraud Control Unit of the Office of the Attorney General;
7. A representative of the Department of Behavioral Health and Developmental Services concerned with the delivery or substance abuse treatment services;
8. A representative of an organization concerned with the adequate relief of pain and the appropriate use of scheduled drugs; and 10. A representative of the Department of Medical Assistance Services.

B. The Director may appoint additional persons to serve on ad hoc panels or committees for the purpose of making policy recommendation or advising on data use/analysis.

C. Members shall be appointed for a term of two years and shall be eligible for reappointment for two additional two-year terms. A member who is appointed to fill a vacancy for the remainder of an unexpired term shall be eligible for three full two-year terms. Representatives of state agencies designated by their agency leadership are not subject to term limits. Terms of appointment shall begin on July 1 of each calendar year.

D. The Committee shall elect a Chairman and Vice-Chairman for a one-year term ending June 30 of each calendar year.

E. The Committee shall meet not less than once a year and shall conduct all business according to Robert’s Rules of Order. Six members shall constitute a quorum. The Committee may adopt by-laws to govern its operations as it deems necessary to conduct its business and as consistent with law and regulations.

F. The Director shall have the authority to remove a member.

2 of 2

Policy Implementation(76-90) Prescription Drug Monitoring Advisory Committee(76-90.01) Adopted Date: 5/2/2017 Approved By:_______________________________

Policy Name Prescription Drug Monitoring Advisory Policy Number 76-90.01 Committee Section Title Policy Implementation Section 76- Former Policy 76-2.5 Number 90 No.

Approval Authority Agency Director Effective Date 5/2/2017 Responsible Executive Agency Director Revised Date 8/12/2016 Responsible Office Director's Office Last Reviewed 5/2/2017 Responsible Reviewer Yeatts,Elaine

Purpose:

Establish an advisory panel within the department to assist in implementing and evaluating the Prescription Drug Monitoring Program as authorized by Chapter 25.2 of Title 54.1 of the Code of Virginia.

Policy:

The Department’s policy is to seek internal and external advice on implementing the Prescription Drug Monitoring Program, including establishing criteria indicating potential misuse of covered substances.

Authority:

§ 54.1-2520. Program establishment; Director's regulatory authority.

E. The Director shall establish an advisory committee within the Department to assist in implementing and evaluating the Prescription Monitoring Program, providing guidance on information disclosed under § 54.1-2523 C 9.

Procedures:

A. There is hereby established an Advisory Panel appointed by the Director with thefollowing composition:

1. Two pharmacists, one practicing in a community pharmacy;

1 of 2 Policy Implementation(76-90) Prescription Drug Monitoring Advisory Committee(76-90.01) Adopted Date: 5/2/2017 Approved By:_______________________________

1. A doctor of medicine or osteopathic medicine in primary practice;
2. A doctor of medicine or osteopathic medicine specializing in outpatient pain management;
3. A licensed nurse practitioner or physician assistant with prescriptive authority;
4. A Department of State Police representative;
5. A Medical Examiner representative;
6. A Medicaid Fraud Control Unit representative of the Attorney General;
7. A Department of Behavioral Health and Developmental Services representative involved in substance abuse treatment;
8. An organization representative concerned with pain relief and scheduled drug use; and a Department of Medical Assistance Services representative.

B. The Director may appoint additional persons to serve on ad hoc panels or committees for policy recommendations or advising on data use/analysis.

C. Members serve two-year terms, eligible for two reappointments; vacancies for unexpired terms are eligible for three full terms. State agency representatives are not limited. Terms begin July 1.

D. The Committee shall elect a Chairman and Vice-Chairman annually, ending June 30.

E. The Committee shall meet at least once annually, conduct business per Robert’s Rules, with six members constituting a quorum. It may adopt bylaws as needed, consistent with law.

F. The Director may remove a member.

2 of 2

Guidance Document: 30-12 Adopted: August 8, 2023 Effective: November 9, 2023

Virginia Board of Audiology and Speech-Language Pathology

Guidance for Telepractice

1. What is telepractice?

Telepractice may be defined as the use of telecommunications and information technologies for delivery of speech-language pathology or audiology professional services by linking a client and clinician for assessment, intervention or consultation.

1. May a practitioner licensed in another state provide services to a client located in Virginia?

To provide audiology or speech-language pathology services to a client in the Commonwealth of Virginia via telepractice, a practitioner must hold a Virginia license and comply with relevant laws and regulations governing practice.

1. Are there any regulations specific to providing audiology or speech-language pathology services via telepractice?

Telepractice is considered a method of service delivery. The current, applicable regulations apply to all methods of service delivery, including telepractice. The licensee is responsible for using professional judgment to determine if the type of service can be delivered via telepractice at the same standard of care as in-person service.

1. To provide the same standard of care as an in-person visit, what are some of the responsibilities of a practitioner when providing audiology or speech-language pathology services via telepractice?

• To determine the appropriateness of providing assessment and intervention services via telepractice for each client and each situation;

• To ensure confidentiality and privacy of clients and their transmissions;

• To maintain appropriate documentation including informed consent for use of telepractice;

• To be responsible for the performance and activities of any unlicensed assistant or facilitator who may be used at the client site, in accordance with Virginia regulation,

18VAC30-21-140;

• To ensure that equipment used for telepractice is in good working order and is properly maintained at both site locations;

Page 1 of 2Guidance Document: 30-12 Adopted: August 8, 2023 Effective: November 9, 2023

• To comply with Virginia and federal (such as HIPAA and FERPA) requirements regarding maintenance of patient records and confidentiality of client information; and

• To ensure that confidential communications obtained and stored electronically cannot be recovered and accessed by unauthorized individuals when the licensee disposes of electronic equipment and data.

1. What factors should be considered when determining if telepractice is appropriate to use?

Factors to consider include, but are not limited to:

• The quality of electronic transmissions for both the patient and practitioner should be appropriate for the provision of telepractice as if those services were provided in person;

• The practitioner should only utilize technology for which he/she has been trained and is competent;

• The practitioner should consider the client’s behavioral, physical and cognitive abilities in determining appropriateness of telepractice;

• The practitioner should assess the ability of the client to safely and competently use electronic transmission equipment; and

• The scope, nature and quality of services provided via telepractice should be comparable to those provided during in-person sessions.

1. May a practitioner licensed in Virginia provide services to a client located in another state?

The Virginia Board does not have jurisdiction over practice in another state. An audiologist or speech-language pathologist seeking to practice via telepractice with a client in another jurisdiction should contact the board for the other state to determine its licensure requirements.

1. Can a practitioner seek reimbursement for services provided by telepractice?

The Board has no jurisdiction over billing and reimbursement for services.

Page 2 of 2

Guidance Document: 30-12 Adopted: August 8, 2023 Effective: November 9, 2023

Virginia Board of Audiology and Speech-Language Pathology

Guidance for Telepractice

1. What is telepractice?

Telepractice is the use of telecommunications and information technologies to deliver speech-language pathology or audiology services by linking client and clinician for assessment, intervention, or consultation.

1. May a practitioner licensed in another state provide services to a client located in Virginia?

To provide audiology or speech-language pathology services in Virginia via telepractice, a practitioner must hold a Virginia license and comply with applicable laws and regulations.

1. Are there any regulations specific to providing audiology or speech-language pathology services via telepractice?

Telepractice is a service delivery method. Current regulations apply to all methods, including telepractice. Licensees must use professional judgment to ensure telepractice meets the same standard of care as in-person services.

1. To ensure the same standard of care as in-person, what are a practitioner's responsibilities when providing audiology or speech-language pathology services via telepractice?

• To determine the appropriateness of assessment and intervention via telepractice for each client and situation;

• To ensure confidentiality and privacy of clients and their transmissions;

• To maintain documentation including informed consent for telepractice;

• To be responsible for the activities of any unlicensed assistant or facilitator at the client site, per Virginia regulation,

18VAC30-21-140;

• To ensure telepractice equipment is in good working order and maintained at both sites;

Page 1 of 2Guidance Document: 30-12 Adopted: August 8, 2023 Effective: November 9, 2023

• To comply with Virginia and federal (e.g., HIPAA, FERPA) requirements for maintaining patient records and confidentiality;

• To ensure confidential electronic communications cannot be recovered or accessed by unauthorized individuals when disposing of equipment and data.

1. What factors should be considered when determining telepractice appropriateness?

Factors to consider include, but are not limited to:

• Electronic transmission quality for both patient and practitioner should be suitable for telepractice as if in-person;

• Practitioners should only use technology they are trained and competent in;

• Practitioners should consider clients' behavioral, physical, and cognitive abilities when assessing telepractice suitability;

• Practitioners should assess clients' ability to safely and competently use electronic equipment;

• Services via telepractice should be comparable in scope, nature, and quality to in-person sessions.

1. May a Virginia-licensed practitioner provide services to a client in another state?

The Virginia Board lacks jurisdiction over practice in other states. Practitioners seeking telepractice with clients elsewhere should contact that state's board for licensure requirements.

1. Can a practitioner seek reimbursement for telepractice services?

The Board has no jurisdiction over billing or reimbursement.

Page 2 of 2

Guidance Document: 30-2 Revised: February 25, 2020 Effective: April 16, 2020

VIRGINIA BOARD OF AUDIOLOGY AND SPEECH-LANGUAGE PATHOLOGY

BYLAWS

ARTICLE I: GENERAL

The organizational year for the Board shall be from July 1st through June 30th. At the first board meeting of the organizational year, the Board shall elect from its members a Chair and Vice-Chair with an effective date of January 1st. The term of office shall be one year.

For purposes of these Bylaws, the Board schedules three full board meetings in each year with the right to change the date or cancel any board meeting, with the exception that a minimum of one meeting shall take place annually. Board members shall attend all board meetings in person, unless prevented by illness or similar unavoidable cause. A majority of the members of the Board shall constitute a quorum for the transaction of business. The current edition of Robert’s Rules of Order, revised, shall apply unless overruled by these bylaws or when otherwise agreed.

Members shall attend all scheduled meetings of the Board and committee to which they serve. In the event of two consecutive unexcused absences at any meeting of the Board or its committees, the Chair shall make a recommendation to the Director of the Department of Health Professions for referral to the Secretary of Health and Human Resources and Secretary of the Commonwealth.

ARTICLE II: OFFICERS OF THE BOARD

1. The Chair presides at all meetings and formal administrative hearings in accordance with parliamentary rules and the Administrative Process Act, and requires adherence of it on the part of the board members. The Chair shall appoint all committees and committee chairpersons unless otherwise ordered by the Board.

1. The Vice-Chair shall act as Chair in the absence of the Chair.

1. In the absence of both the Chair and Vice-Chair, the Chair shall appoint another board member to preside at the meeting and/or formal administrative hearing.

1. The Executive Director shall be the custodian of all Board records and all papers of value. She/He shall preserve a correct list of all applicants and licensees. She/He shall manage the correspondence of the Board and shall perform all such other duties as naturally pertain to this position.

1Guidance Document: 30-2

Revised: February 25, 2020

Effective: April 16, 2020

ARTICLE III: ORDER OF THE BUSINESS MEETINGS

The order of the business shall be as follows:

1. Call to order with statement made for the record of how many and which board members are present and that it constitutes a quorum.
2. Public Comment.
3. Approval of minutes.
4. The Executive Director and the Chair shall collaborate on the remainder of the agenda.

ARTICLE IV: COMMITTEES

There shall be the following committees:

A.

Standing Committees:

Special Conference Committee.

This committee shall consist of two board members who shall review information regarding alleged violations of the audiology and speech-language pathology laws and regulations and determine if probable cause exists to proceed with possible disciplinary action. The Chair may also designate another board member as an alternate on this committee in the event one of the standing committee members becomes ill or is unable to attend a scheduled conference date. Further, should the caseload increase to the level that additional special conference committees are needed, the Chair may appoint additional committees.

Credentials Committee.

The committee shall consist of two or more board members. The committee may review non-routine licensure applications to determine the credentials of the applicant and the applicability of the statutes and regulations when the Board Chair deems necessary. The committee shall not be required to meet collectively.

1. Legislative/Regulatory Committee.

The committee shall consist of at least three Board members of which one member shall be the Chair and shall include at least one audiologist and one speech-language pathologist. The Board delegates to the Legislative/Regulatory Committee the authority to consider and respond to petitions for rulemaking.

This committee is responsible for the development of proposals for new regulations or amendments to existing regulations with all required accompanying 2 Guidance Document: 30-2

Revised: February 25, 2020

Effective: April 16, 2020 documentation; the development of proposals for legislative initiatives of the Board; the drafting of Board responses to public comment as required in conjunction with rulemaking; conducting the required review of all existing regulations as required by the Board’s Public Participation Guidelines and any Executive Order of the Governor, and other required tasks related to regulations.

In accordance with the Administrative Process Act, any proposed draft regulation and response to public comment shall be reviewed and approved by the full Board prior to publication.

1. Continuing Education Committee. This committee shall consist of at least two board members who shall review applicants for approval of continuing audiology and/or speech-language pathology education programs and other matters related to continuing education. The Board delegates the approval of continuing audiology and/or speech-language pathology education programs to this committee.

B.

Ad Hoc Committees

There may be Ad Hoc Committees, appointed as needed, each of which shall consist of at least two persons appointed by the Board who are knowledgeable in the particular area of practice or education under consideration by the Board. The committee shall review matters as requested by the Board and advise the Board relative to the matters or make recommendations for consideration by the Board.

ARTICLE V: GENERAL DELEGATION OF AUTHORITY

1. The Board delegates to Board staff the authority to issue and renew licenses where minimum statutory and regulatory qualifications have been met.

1. The Board delegates to the Executive Director the authority to reinstate licenses when the reinstatement is due to the lapse of the license and not due to previous Board disciplinary action ,unless specified in the Board Order.
2. The Board delegates to Board staff the authority to develop and approve any and all forms used in the daily operations of the Board business, to include, but not limited to, licensure applications, renewal forms and documents used in the disciplinary process.

1. The Board delegates authority to the Executive Director to negotiate a Consent Order in consultation with the chair of a Special Conference Committee or formal hearing.

1. The Board delegates to the Executive Director the authority to sign as entered any Order or Consent Order resulting from the disciplinary process or other administrative proceeding. 3 Guidance Document: 30-2

Revised: February 25, 2020

Effective: April 16, 2020

1. The Board delegates to the Executive Director, who may consult with a special conference committee member, the authority to provide guidance to the agency’s Enforcement Division in situations wherein a complaint is of questionable jurisdiction and an investigation may not be necessary.
2. The Board delegates to the Executive Director the authority to review information regarding alleged violations of law or regulations and, in consultation with a member of a special conference committee, make a determination as to whether probable cause exists to proceed with possible disciplinary action.

1. The Board delegates authority to the Executive Director to close non-jurisdictional cases and fee dispute cases without review by a board member.

1. The Board delegates authority to the Executive Director to issue a Confidential Consent Agreement or offer a Consent Order for action consistent with any board-approved guidance document. 10. The Board delegates to the Executive Director the authority to grant continuing education extensions for up to one year for good cause shown upon a written request from the licensee prior to the renewal date.

11. The Board delegates to the Executive Director the authority to grant a continuing education exemption for all or part of the requirements for circumstances beyond the control of the licensee, such as temporary disability, mandatory military service or officially declared disasters. 12. The Board delegates to the Chair, the authority to represent the Board in instances where Board “consultation” or “review” may be requested where a vote of the Board is not required and a meeting is not feasible.

13. The Board delegates authority to the Executive Director to issue an Advisory Letter to the person who is the subject of complaint pursuant to Va. Code § 54.1-2400.2(F), when it is determined that a probable cause review indicates a disciplinary proceeding will not be instituted.

14. The Board delegates authority to the Executive Director to request and accept from a licensee, in lieu of disciplinary action, a Confidential Consent Agreement, pursuant to Va. Code § 54.1-2400(14), consistent with any guidance documents adopted by the Board. 4 Guidance Document: 30-2

Revised: February 25, 2020

Effective: April 16, 2020

ARTICLE VI. AMENDMENTS

Proposed amendments to these bylaws shall be presented in writing to all Board members, the Executive Director of the Board and the Board’s legal counsel prior to any regularly scheduled meeting of the Board. Amendments to the bylaws shall become effective with a favorable vote of at least two-thirds of the board members present at that regular meeting.

___________________________

Chair

Board of Audiology and Speech-Language Pathology 5

Guidance Document: 30-2 Revised: February 25, 2020 Effective: April 16, 2020

VIRGINIA BOARD OF AUDIOLOGY AND SPEECH-LANGUAGE PATHOLOGY

BYLAWS

ARTICLE I: GENERAL

The Board's organizational year runs July 1–June 30. At the first meeting, it elects a Chair and Vice-Chair effective January 1, each serving one year.

The Board schedules three meetings annually, with at least one mandatory. Members must attend in person unless prevented. A majority quorum is required. Robert’s Rules apply unless overruled.

Members must attend all scheduled Board and committee meetings. Two consecutive unexcused absences lead the Chair to recommend to the Director for referral to the Secretaries.

ARTICLE II: OFFICERS OF THE BOARD

1. The Chair presides over meetings and hearings per parliamentary rules and the Administrative Process Act, appointing all committees unless the Board orders otherwise.

1. The Vice-Chair acts as Chair when the Chair is absent.

1. If both are absent, the Chair shall appoint a member to preside at meetings or hearings.

1. The Executive Director shall hold all Board records, maintain a list of applicants and licensees, manage correspondence, and perform related duties.

1Guidance Document: 30-2

Revised: February 25, 2020

Effective: April 16, 2020

ARTICLE III: ORDER OF THE BUSINESS MEETINGS

The order of the business shall be as follows:

1. Call to order with record of present board members and quorum status.
2. Public Comment.
3. Approval of minutes.
4. The Executive Director and Chair shall coordinate the agenda.

ARTICLE IV: COMMITTEES

There shall be the following committees:

A.

Standing Committees:

Special Conference Committee.

This committee shall consist of two board members who shall review information regarding alleged violations of the audiology and speech-language pathology laws and regulations and determine if probable cause exists to proceed with possible disciplinary action. The Chair may also designate another board member as an alternate on this committee in the event one of the standing committee members becomes ill or is unable to attend a scheduled conference date. Further, should the caseload increase to the level that additional special conference committees are needed, the Chair may appoint additional committees.

Credentials Committee.

The committee shall consist of two or more board members. The committee may review non-routine licensure applications to determine the credentials of the applicant and the applicability of the statutes and regulations when the Board Chair deems necessary. The committee shall not be required to meet collectively.

1. Legislative/Regulatory Committee.

The committee has at least three members, including a Chair, one audiologist, and one speech-language pathologist. The Board delegates rulemaking petitions to the Legislative/Regulatory Committee.

This committee develops proposals for new or amended regulations with required documentation.

Revised: February 25, 2020

Effective April 16, 2020, this includes developing legislative proposals, drafting responses to public comments, reviewing regulations per guidelines and executive orders, and other regulatory tasks.

Per the Administrative Process Act, all draft regulations and responses require full Board review and approval before publication.

1. Continuing Education Committee. This committee shall consist of at least two board members who shall review applicants for approval of continuing audiology and/or speech-language pathology education programs and other matters related to continuing education. The Board delegates the approval of continuing audiology and/or speech-language pathology education programs to this committee.

B.

Ad Hoc Committees

There may be Ad Hoc Committees, appointed as needed, each of which shall consist of at least two persons appointed by the Board who are knowledgeable in the particular area of practice or education under consideration by the Board. The committee shall review matters as requested by the Board and advise the Board relative to the matters or make recommendations for consideration by the Board.

ARTICLE V: GENERAL DELEGATION OF AUTHORITY

1. The Board delegates staff authority to issue and renew licenses meeting minimum qualifications.

1. The Board delegates to the Executive Director authority to reinstate licenses due to lapse, unless specified in the Board Order.
2. The Board delegates staff authority to develop and approve forms for licensure, renewal, and disciplinary processes.

1. The Board delegates to the Executive Director authority to negotiate Consent Orders with the chair of a Special Conference or hearing.

1. The Board delegates to the Executive Director authority to sign Orders or Consent Orders from disciplinary or administrative proceedings.

Revised: February 25, 2020

Effective: April 16, 2020

1. The Board delegates to the Executive Director, possibly consulting a committee member, authority to guide Enforcement on jurisdictional or investigatory issues.
2. The Board delegates to the Executive Director authority to review violations and, with a committee member, determine probable cause for disciplinary action.

1. The Board delegates to the Executive Director authority to close non-jurisdictional and fee dispute cases without board review.

1. The Board delegates to the Executive Director authority to issue Confidential Consent Agreements, Consent Orders, and grant up to one-year CE extensions for good cause upon written request before renewal.

The Executive Director may grant CE exemptions for circumstances beyond control; the Chair may represent the Board in consultations or reviews without a full vote.

The Executive Director may issue Advisory Letters when probable cause review indicates no disciplinary action is needed, per Va. Code § 54.1-2400.2.

The Executive Director may accept Confidential Consent Agreements from licensees instead of disciplinary action, per Va. Code § 54.1-2400, following Board guidance.

Revised: February 25, 2020

Effective: April 16, 2020

ARTICLE VI. AMENDMENTS

Proposed bylaw amendments must be submitted in writing to all relevant parties before meetings and require at least two-thirds approval to become effective.

___________________________

Chair

Board of Audiology and Speech-Language Pathology 5

Guidance document: 30-10

Revised: March 14, 2023 Effective Date: May 11, 2023

Board of Audiology and Speech-Language Pathology

Disposition of Disciplinary Cases for Audiologists and Speech-Language Pathologists Practicing on Expired Licenses

The Board of Audiology and Speech-Language Pathology delegates to the Executive Director for the Board the authority to resolve disciplinary cases in which a licensee has been found to be practicing with an expired license consistent with the table below.

Disciplinary Action for Practicing with an Expired License The Board adopts the following guidelines for resolution of cases of practicing with an expired license: Cause Possible Action First offense; 90 days or less Confidential Consent Agreement First offense; 91 days to two years Consent Order; Monetary Penalty of $500 First offense; more than two years Consent Order; Monetary Penalty of $1000 Second offense Consent Order; Monetary Penalty of $1500

Guidance document: 30-10

Revised: March 14, 2023 Effective Date: May 11, 2023

Board of Audiology and Speech-Language Pathology

Disposition of Disciplinary Cases for Audiologists and Speech-Language Pathologists Practicing on Expired Licenses

The Board delegates to the Executive Director the authority to resolve disciplinary cases where a licensee practices with an expired license, as per the table below.

Disciplinary Action for Practicing with an Expired License: The Board adopts these guidelines: Cause, Possible Action; First offense, 90 days or less, Confidential Consent Agreement; First offense, 91 days to 2 years, Consent Order, $500 penalty; First offense, over 2 years, Consent Order, $1000 penalty; Second offense, Consent Order, $1500 penalty.

Department of Health Professions

Revised: April 17, 2025

Guidance Document: 76-40.01 Receipt and Investigation of Allegations of Misconduct The purpose of this guidance document is to ensure the appropriate handling of allegations of misconduct against Department licensees. Allegations of violations of applicable law or regulations by licensees of the Department will be received and logged in by the Enforcement Division. Only sworn personnel duly authorized by the Director pursuant to Virginia Code § 54.1-2506 may conduct investigations of alleged violations.

Department staff (other than Enforcement staff) who receive or become aware of information indicating a violation of law will refer such information to the Enforcement Division as soon as possible.

Enforcement staff will make an initial determination of whether the matter warrants investigation in accordance with Virginia Code § 54.1-2506.01.

Enforcement will refer any matters that do not appear to warrant investigation to the appropriate Board in writing. If the Board determines that it does have jurisdiction and the matter requires investigation, the case will be returned to Enforcement, along with an explanation of the Board’s recommendation. Upon receipt of the Board’s recommendation, the Enforcement’s Case Intake Unit will initiate investigation of the alleged misconduct.

References Va. Code § 54.1-2506.01 1

Department of Health Professions

Revised: April 17, 2025

Guidance Document: 76-40.01 Receipt and Investigation of Allegations of Misconduct The purpose is to ensure proper handling of misconduct allegations against Department licensees. Allegations of violations will be received and logged by the Enforcement Division. Only sworn personnel authorized by the Director pursuant to Virginia Code § 54.1-2506 may conduct investigations.

Department staff (excluding Enforcement) who learn of violations will refer such information to Enforcement promptly.

Enforcement staff will initially determine if the matter warrants investigation per Virginia Code § 54.1-2506.01.

Enforcement will refer non-warranted matters in writing to the appropriate Board. If the Board finds jurisdiction and investigation is needed, the case returns to Enforcement with its recommendation. Upon receipt, the Case Intake Unit will initiate investigation.

References Va. Code § 54.1-2506.01 1

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-20.05 Disclosure of Information to the Health Practitioners’ Monitoring Program Virginia Code § 54.1-2400.2(A)(6) permits disclosure of confidential information and records received and maintained by the Department of Health Professions (“DHP”) or a regulatory board to the Health Practitioner’s Monitoring Program (“HPMP”) in connection with health practitioners who may apply to or participate in the program. DHP will provide information concerning a person’s potential eligibility for acceptance in HPMP to facilitate the program’s operation and mandate to assist impaired practitioners.

The Enforcement Division of DHP will provide investigative information to the HPMP Program Manager in accordance with Virginia Code § 54.1-2400.2 at the time that the investigative report is presented to the relevant board.

The HPMP Program Manager will send the investigative report summary via encrypted email to the HPMP contractor.

Whenever notice of any proceeding is issued which alleges that a practitioner may be impaired as defined in Virginia Code § 54.1-2515, a copy of that notice will be provided by the Executive Director or designee of the relevant regulatory board to the HPMP Program Manager.

The HPMP Program Manager will send a copy to the HPMP contractor.

Any order, including consent orders, which makes a finding of impairment or any decision document issued subsequent to a notice described above will be transmitted by the Executive Director or designee of the relevant regulatory board to the HPMP Program Manager. The HPMP Program Manager will send a copy to the HPMP contractor.

References

Va. Code § 54.1-2400.2 Va. Code § 54.1-2515 1

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-20.05 Disclosure of Information to the Health Practitioners’ Monitoring Program Virginia Code § 54.1-2400.2(A)(6) permits DHP or a regulatory board to disclose confidential info and records to HPMP for practitioners applying or participating. DHP will provide info on potential eligibility to support HPMP’s mission to assist impaired practitioners.

The DHP Enforcement Division will provide investigative info to the HPMP Program Manager per Virginia Code § 54.1-2400.2 when the investigative report is submitted to the relevant board.

The HPMP Program Manager will send the investigative report summary via encrypted email to the HPMP contractor.

When a proceeding notice alleging practitioner impairment per Virginia Code § 54.1-2515 is issued, the Executive Director or designee will send a copy to the HPMP Program Manager.

The HPMP Program Manager will send a copy to the HPMP contractor.

Any order, including consent orders, making a finding of impairment or subsequent decision, will be transmitted by the Executive Director or designee to the HPMP Program Manager, who will send a copy to the contractor.

References

Va. Code § 54.1-2400.2, § 54.1-2515

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.17 Publication of Notices and Orders The Department is required by statute to post all final orders, together with any associated notices, which impose disciplinary action against licensees of the health regulatory boards on Department of Health Professions (“DHP”) websites available to the public. The Department will not post final orders, together with any associated notices, which do not result in a finding of a violation and disciplinary action. The Department has not posted any such notices and orders entered after June 17, 2008. Notices and orders entered prior to June 17, 2008 that did not result in a finding of a violation and disciplinary action may be removed from DHP websites upon written request by the licensee to the custodian of records for the appropriate health regulatory board.

The Department will not post notices that have not been adjudicated.

The following will be published:

1. Final orders, along with associated notices, which impose any disciplinary action will be published on the effective date of the final order which reflects the case decision;
2. Final orders, along with associated notices, which grant a license, certificate, registration, or other benefit or deny modification of a previous order imposing a term, condition, suspension, or revocation will be published on the effective date of the final order which reflects the case decision;
3. Final orders, along with associated notices, which grant or deny eligibility for reinstatement of a license, certificate, registration or other right or benefit will be published on the effective date of the final order which reflects the case decision;
4. Orders of summary suspension issued pursuant to Virginia Code § 54.1-2408.1, together with any accompanying statement of allegations;
5. Orders of mandatory suspension issued pursuant to Virginia Code § 54.1-2409, together with any incorporated documents; and
6. Orders of suspension of a license pursuant to Virginia Code § 54.1-104.

When a final order is appealed to court, the notice of appeal shall be published pending resolution of the appeal, along with any relevant court orders. Once the appeal is final, the website should be updated to reflect the appropriate documents.

Nothing in this policy prohibits the inspection and copying of records of disciplinary actions to the extent permitted under the Virginia Freedom of Information Act, Virginia Code §

1. 2-3700 et seq., and Virginia Code § 54.1-2400.2.

Nothing contained in this policy modifies the requirements for regulatory boards to maintain original copies of all notices and disposition documents.

Procedures for publications of notices and orders 1 Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.17 The Executive Director or designee of each regulatory board will identify any documents meeting the criteria set forth in this guidance document. Social security numbers, patient names, or other confidential information appearing on any document will be redacted prior to delivery for scanning.

The Executive Director or designee will forward documents meeting the criteria set forth in this document to be scanned for publication on the agency web sites to the Director of Technology and Business Services within one business day of entry or less.

The Director of Technology and Business Services will scan such documents within one business day of receipt and ensure publication associated with “License Lookup,” “Recent Case Decisions,” and the “Physician Information Project” (Physician Profile) found on DHP websites.

Removal of notices and orders A licensee may request removal of a notice and order that did not impose disciplinary action by written request to the applicable regulatory board.

If the Executive Director or designee determines that no disciplinary action was imposed by the Order, the written request for removal will be forwarded to the Director of Technology and Business Services.

The Director of Technology and Business Services or designee will remove the notice and order from DHP websites available to the public.

References Va. Code § 54.1-104 Va. Code § 54.1-2400.2(H) Va. Code § 54.1-2408.1 Va. Code § 54.1-2409 2

Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.17 The Department must post final orders and notices imposing disciplinary action against licensees on DHP websites. Orders not resulting in violations or disciplinary action are not posted; such notices entered after June 17, 2008, are not posted. Pre-2008 notices without violations may be removed upon licensee request.

The Department will not post unadjudicated notices.

The following will be published:

1. Final orders with notices imposing disciplinary action will be published on the final order’s effective date.
2. Final orders granting or denying licenses, benefits, or modifying previous orders will be published on the final order’s effective date.
3. Final orders granting or denying reinstatement of licenses or benefits will be published on the final order’s effective date.
4. Summary suspension orders under § 54.1-2408.1, with allegations, will be published.
5. Mandatory suspension orders under § 54.1-2409, with documents, will be published.
6. License suspension orders under § 54.1-104 will be published.

If a final order is appealed, the notice of appeal and court orders will be published pending resolution; after final, the website will be updated accordingly.

This policy does not prohibit inspection and copying of disciplinary records as permitted under Virginia Code §

1. 2-3700 et seq., and Virginia Code § 54.1-2400.2.

This policy does not alter regulatory boards' requirement to retain original notices and disposition documents.

Procedures for publications of notices and orders 1 Department of Health Professions

Revised: April 11, 2025

Guidance Document: 76-10.17 The Executive Director or designee will identify documents meeting criteria, redacting confidential info before scanning.

The Executive Director or designee will forward qualifying documents to the Director of Technology and Business Services within one business day for scanning.

The Director of Technology and Business Services will scan documents within one day and publish on “License Lookup,” “Recent Case Decisions,” and “Physician Profile” on DHP websites.

A licensee may request removal of notices and orders without disciplinary action by written request to the regulatory board.

If no disciplinary action was imposed, the Executive Director or designee will forward the removal request to the Director of Technology and Business Services.

The Director of Technology and Business Services will remove the notice and order from public DHP websites.

References Va. Code §§ 54.1-104, 54.1-2400.2(H), 54.1-2408.1, 54.1-2409.

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-40.05 Disciplinary Cases Involving Board Members This policy sets forth procedures for the receipt, assessment, investigation, management, and adjudication of disciplinary cases involving sources or respondents who are current members of one of the health regulatory boards within the Department of Health Professions. At each point in the process from receipt of a complaint or allegation to the final decision in a case involving a current member of a regulatory board, Department and board staff, board officers and other board members should act with objectivity and fairness in the management of the case to preclude any impropriety or favoritism. As with any other disciplinary matter, there should be strict adherence to confidentiality as required by Virginia Code § 54.1-2400.2 in responding to inquiries from board members, respondents, complainants or other interested parties.

Procedure for a case in which a board member is the respondent

Receipt of a complaint and determination of jurisdiction

• Complaints or reports of alleged violations may be received by anyone within the organizational structure of the Department, but all such allegations are required to be transferred immediately to the Enforcement Division of the Department.
• As soon as it is known that the subject of the complaint or allegation is a current member of one of the health regulatory boards, enforcement personnel should report that information to the Director of the Department and the Executive Director of the applicable board.
• Upon receipt, complaint intake personnel should make a preliminary determination as to whether the complaint or allegation is a possible violation or falls within the jurisdiction of the Department.
• If it is determined that the Department does not have jurisdiction or that the complaint should be referred to another agency, the referral should be handled routinely without reference to the board membership of the subject of the complaint or allegation.
• If it is determined that the Department does have jurisdiction, an appropriate priority and category should be assigned and the complaint or allegation entered as a “case” in accordance with agency policy.
• Upon receipt of information that a board member is the subject of a complaint, the Executive Director of the applicable board may consult with the Office of the Attorney General for guidance applicable to the case. Executive Directors should refrain from any discussion of the case with board members except as necessary for the proper administration and management of the case.

Investigation of a board member case o Once jurisdiction is established and a priority assigned, the case is referred for investigation. o Investigation of cases involving board members should be handled in the same manner as all other cases. To facilitate timely processing and in the interest of the respondent, the 1 Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-40.05 public and the efficient operation of the board, however, the investigation of such cases should be expedited to the extent possible. o Investigators should refrain from any discussion of the case with board members or others unless necessary to conduct an official investigation.

Consideration of a board member case by the regulatory board ▪ When the investigative report is complete, it is filed with the regulatory board and Enforcement staff should be immediately inform the Executive Director that the case involving a board member is at board level. ▪ Board policies vary regarding closing of cases for insufficient evidence or the determination that probable cause exists to believe a violation of law or regulation may have occurred. In some boards, professional board administrators are delegated authority to make a probable cause determination or to close a case. In other boards, the determination is made by one or more members of a disciplinary committee. ▪ In all cases in which a board member is a respondent, the Executive Director should consult with the board’s presiding officer or other duly authorized board member before a case is closed or moved forward for adjudication. If a board’s process is to have the probable cause decision made by one or more board members, the presiding officer or duly authorized board member should be utilized. ▪ If the presiding officer or disciplinary committee chair is the respondent, management of the case should be delegated to another officer or member. No board member should be involved in the probable cause determination or the adjudication of a case in which he or she is a respondent. ▪ All board members who will be involved in the probable cause determination or adjudication of the case should examine their relationship with the respondent and disclose any facts which could give rise to subsequent allegations of bias or prejudice. Such disclosures should be reviewed by board counsel and appropriate action taken.

Adjudication of a case by the regulatory board ➢ For a case in which a formal hearing is not required by law, the board may adjudicate the case through an informal fact-finding conference (IFC), use of a special conference committee, the offer of a pre-hearing consent order, or the issuance of confidential consent agreement or an advisory letter. For board member cases, the use of an agency subordinate to conduct the IFC may be advisable. ➢ If the scheduling of formal proceedings by the full board or a panel of the board is difficult or impossible due to recusal of other board members, the Executive Director should consult with board counsel and consider the need to secure a hearing officer. The hearing officer should be asked to prepare findings of fact and conclusions of law for board consideration.

The individual regulatory board, however, retains authority to adopt, reject or amend the hearing officer’s recommendations. ➢ As with other disciplinary cases at the IFC level, the board should avail itself of the guidance provided by its Sanction Reference Points in deciding the case. ➢ Board members who are respondents should not participate in either the determination of board findings or determination of a sanction for a finding of violation. It is also recommended that a board member respondent refrain from participation in disciplinary 2 Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-40.05 matters involving similar allegations, facts, issues or violations while his or her case is in active status.

Procedures for a case in which a board member is the source

• Notification that a board member is the source of a complaint should be made to the Executive Director simultaneously with referral of the case to the board for probable cause determination.
• If a board’s process is to have the probable cause decision made by one or more board members, the board member who is a source on the case shall not be utilized.
• No board member should be involved in the probable cause determination or the adjudication of a case in which he or she is a source. All board members who will be involved in the probable cause determination or adjudication of the case should examine their relationship with the board member/source and disclose any facts which could give rise to subsequent allegations of bias or prejudice. Such disclosures should be reviewed by board counsel and appropriate action taken. 3

Department of Health Professions

Revised: April 16, 2025

Guidance Document: 76-40.05 Disciplinary Cases Involving Board Members outlines procedures for receipt, assessment, investigation, management, and adjudication of disciplinary cases involving current board members. Throughout the process, staff and board members must act objectively and fairly to prevent impropriety or favoritism. Confidentiality must be strictly maintained as per Virginia Code § 54.1-2400.2 in responses to inquiries from involved parties.

Procedure for cases where a board member is the respondent

Receipt of complaint and jurisdiction determination

• All complaints or reports of violations must be immediately transferred to the Department's Enforcement Division.
• When the subject is a current board member, enforcement must report this to the Department Director and the applicable board’s Executive Director.
• Intake personnel should preliminarily determine if the complaint is a possible violation or within Department jurisdiction.
• If outside jurisdiction or referral is needed, handle routinely without considering the subject’s board membership.
• If within jurisdiction, assign priority, category, and enter as a case per agency policy.
• When a board member is the subject, the Executive Director may consult the Attorney General. Discussions with board members should be limited to case management.

Investigation of board member cases: after jurisdiction and priority, cases are referred for investigation, handled like other cases to ensure timely processing and respondent fairness.

Revised: April 16, 2025

Investigation should be expedited for board member cases. Investigators must avoid discussing cases with others unless necessary for official investigation.

When the investigation concludes, the report is filed, and the Executive Director informs the board. Policies vary on closing cases; the Executive Director must consult with the presiding officer before case closure or adjudication. If the presiding officer is the respondent, management is delegated. No involved board member should participate in probable cause or adjudication of their case. All involved members must disclose potential bias, reviewed by counsel for appropriate action.

For cases not requiring a formal hearing, the board may use IFC, special committee, pre-hearing consent, or confidential agreement. For board member cases, an agency subordinate may conduct IFC. If full board proceedings are hindered by recusals, the Executive Director should consult counsel and consider appointing a hearing officer to prepare findings and conclusions.

The board retains authority to adopt, reject, or amend the hearing officer’s recommendations. It should use Sanction Reference Points for decisions. Respondent board members must abstain from findings and sanctions decisions, and avoid participation in related disciplinary matters.

Revised: April 16, 2025

Respondent board members should refrain from participating in disciplinary matters involving similar allegations while their case is active.

Procedures when a board member is the source

• Notify the Executive Director of the board member source when referring the case for probable cause.
• If board members decide probable cause, the source member shall not be involved.
• Board members involved in probable cause or adjudication must disclose any bias or relationships, reviewed by counsel for appropriate action. 3