• Name of the resident;
• Date prescribed;
• Drug product name;
• Strength of the drug;
• Dosage;
• Diagnosis, condition, or specific indications for administering the drug or supplement;
• Route (e.g., by mouth);
• How often medication is to be taken;
•  Date and time given and initials of direct care staff administering the medication;
•  Dates the medication is discontinued or changed;
• Any medication errors or omissions;
• Description of significant adverse effects suffered by the resident;
• For “as needed” (PRN) medications:
  • Symptoms for which medication was given;
  • Exact dosage given; and
  • Effectiveness; and
• The name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARs.

1. Methods to ensure an understanding of the responsibilities associated with medication management;
2. Standard operating procedures, including the facility’s standard dosing schedule and any general restrictions specific to the facility;
3. Methods to prevent the use of outdated, damaged, or contaminated medications;
4. Methods to ensure that each resident’s prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages;
5. Methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order;
6. Methods for monitoring medication administration and the effective use of the MARs for documentation;
7. Methods to ensure that MARs are maintained as part of the resident’s record;
8. Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes;
9. Methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670;
10. Methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration;
11. A plan for proper disposal of medication;
12. Methods to ensure that residents do not receive medications or dietary supplements to which they have known allergies;
13. Identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber;
14. Methods to ensure that staff who are responsible for administering medications are trained on the facility’s medication management plan; and
15. Procedures for internal monitoring of the facility’s conformance to the medication management plan.

1. Initial tuberculosis examination and report.
2. Each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
3. The risk assessment shall be no older than 30 days.
4. Subsequent tuberculosis evaluations and reports.

a.     Any staff person or household member required to be evaluated who comes in contact with a known case of infectious tuberculosis shall be screened as determined appropriate based on consultation with the local health department.

b.     Any staff person or household member required to be evaluated who develops chronic respiratory symptoms of three weeks duration shall be evaluated immediately for the presence of infectious tuberculosis.

c.     Each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.

3.     Any individual suspected to have infectious tuberculosis shall not be allowed to return to work or have any contact with the residents and personnel of the facility until a physician has determined that the individual is free of infectious tuberculosis.

4.     The facility shall report any active case of tuberculosis developed by a staff person or household member required to be evaluated to the local health department.

1. Description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources;

2. A written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them;

3. When and where the services will be provided;

4. The expected outcome and time frame for expected outcome;

5. Date outcome achieved; and

6. For a facility licensed for residential living care only, if a resident lives in a building housing 19 or fewer residents, a statement that specifies whether the resident does or does not need to have a staff member awake and on duty at night.

1. The storage area shall be locked.

1. The person’s name, address, and telephone number;
2. The date of the physical examination;
3. Height, weight, and blood pressure;
4. Significant medical history;
5. General physical condition, including a systems review as is medically indicated;
6. Any diagnosis or significant problems;
7. Any known allergies and description of the person’s reactions;
8. Any recommendations for care including medication, diet, and therapy;
9. Results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it;
10. A statement that the individual does not have any of the conditions or care needs prohibited by 22 VAC 40-73-310 H;
11. A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter;
12. A statement that specifies whether the individual is or is not capable of self-administering medication; and
13. The signature of the examining physician or his designee.

1. This inability shall be included in the resident’s individualized service plan.
2. The plan shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
3. Unless subsection C of this section is applicable, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. Any agreement for a different frequency must be in writing, specify the frequency, be signed and dated by the resident and the facility, and be retained in the resident’s record. If there is a change in the resident’s condition or care needs, the agreement shall be reviewed and if necessary, the frequency of rounds shall be adjusted. If an adjustment is made, the former agreement shall be replaced with a new agreement or with compliance with the frequency specified in this subdivision.
4. The facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained for two years.

1. Each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years.
2. Each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
3. A direct care staff member who is a registered nurse, licensed practical nurse, or currently certified emergency medical technician, first responder, or paramedic does not have to meet the requirements of subdivisions 1 and 2 of this subsection.
4. In each building, there shall either be (i) at least one staff person at all times who has current certification in first aid that meets the specifications of this section; or (ii) an on-duty registered nurse, licensed practical nurse, or currently certified emergency medical technician, first responder, or paramedic.