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 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. 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 Methods to prevent the use of outdated, damaged, or contaminated medications;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 22 VAC 40-73-670;
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. Name of the resident;
2. Date prescribed;
3. Drug product name;
4. Strength of the drug;
5. Dosage;
6. Diagnosis, condition, or specific indications for administering the drug or supplement;
7. Route (e.g., by mouth);
8. How often medication is to be taken;
9. Date and time given and initials of direct care staff administering the medication;
10. Dates the medication is discontinued or changed;
11. Any medication errors or omissions;
12. Description of significant adverse effects suffered by the resident;
13. For “as needed” (PRN) medications:

a.     Symptoms for which medication was given;

b.     Exact dosage given; and

c.     Effectiveness; and

1. 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. Give evidence of financial responsibility and solvency.
2. Be of good character and reputation in accordance with § 63.2-1702 of the Code of Virginia. Character and reputation investigation includes background checks as required by § 63.2-1721 of the Code of Virginia.
3. Meet the requirements specified in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22 VAC 40-90).
4. Act in accordance with General Procedures and Information for Licensure (22 VAC 40-80).
5. Protect the physical and mental well-being of residents.
6. Exercise general supervision over the affairs of the licensed facility and establish policies and procedures concerning its operation in conformance with applicable law, this chapter, and the welfare of the residents.
7. Ensure that he, his agents, the facility administrator, or facility staff or the relatives of any of these persons shall not act as, seek to become, or become the conservator or guardian of any resident unless specifically so appointed by a court of competent jurisdiction pursuant to Article 1 (§ 64.2-2000 et seq.) of Chapter 20 of Title 64.2 of the Code of Virginia.
8. Ensure that the current license is posted in the facility in a place conspicuous to the residents and the public.
9. Ensure that the facility keeps and maintains at the facility records, reports, plans, schedules, and other information as required by this chapter for licensed assisted living facilities.
10. Ensure that any document required by this chapter to be posted shall be in at least 12-point type or equivalent size, unless otherwise specified.
11. Make certain that when it is time to discard records, they are disposed of in a manner that ensures confidentiality.
12. Ensure that at all times the department’s representative is afforded reasonable opportunity to inspect all of the facility’s buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in § 63.2-1706 of the Code of Virginia.