Virginia Record-Keeping Compliance and Administrative Policy Manual
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The Virginia ADM-1.0 Administration Policy establishes the framework for compliance with 12VAC5-371 and 12VAC30-120-900, which govern record-keeping requirements for nursing facilities and Medicaid waiver services in Virginia. This policy ensures that providers maintain accurate, secure, and comprehensive documentation to support service delivery, regulatory compliance, and audit readiness. Providers must adhere to the standards set forth by the Virginia Department of Health (VDH) and the Department of Medical Assistance Services (DMAS), as well as federal HIPAA regulations for confidentiality and data security.
Under this policy, nursing facilities must maintain organized clinical records that include resident identification, medical histories, physician orders, progress notes, and discharge summaries. Documentation must be completed promptly and retained for a minimum of five years post-discharge for adults or longer if required for minors. For Medicaid waiver services, providers must document eligibility criteria, service plans, backup plans, and all service-related activities to demonstrate compliance with DMAS requirements. Records must be stored securely in both physical and electronic formats, with access restricted to authorized personnel.
This policy emphasizes the importance of accurate record-keeping to ensure continuity of care, facilitate audits, and meet state and federal regulations. By aligning with 12VAC5-371 and 12VAC30-120-900, providers can uphold high standards of care while maintaining full compliance with Virginia’s regulatory framework for healthcare services.