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

   1. 1. The program or facility shall:

      1. a. For critical regulatory requirements, demonstrate 100% compliance;
      2. b. For noncritical regulatory requirements with multiple elements, the certification audit team will make a determination of compliance as provided in department procedures that shall require (i) an acceptable percentage of compliance with the entire regulatory requirement or (ii) any single element; or
      3. c. For all noncritical regulatory requirements, demonstrate an acceptable percentage compliance as provided in department procedures.

   2. 2. The program or facility shall not have:

      1. a. Any circumstance or condition constituting a pattern of action that presents a concern for the health, welfare, or safety of the residents, program participants, or staff; or
      2. b. Any circumstance or condition that presents an immediate threat to the health, welfare, or safety of the residents, program participants, or staff.
2. B. The determination of noncompliance shall be a decision made by the entire certification team.
3. C. For purposes of calculating percentage of compliance, the determination of what constitutes individual regulatory requirements (e.g., section, subsection, subdivision, or element in a list in the regulatory chapter) will be specified as provided in department procedures.

Statutory Authority

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

Historical Notes

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