Licensure and Certification


State and federal regulatory programs guard the health, safety, and welfare of the public by establishing and enforcing minimum standards to assure quality health care.

Different entities are responsible for licensure, certification, and/or accreditation of healthcare and residential facilities and healthcare professionals. Assessment of a facility’s infection control program and its policies and procedures is one small part of the inspection (or survey) process.

State Agencies

Virginia Department of Health – Office of Licensure and Certification

  • Administers state licensing programs for hospitals, outpatient surgical hospitals, nursing facilities,home care organizations, and hospice programs. Conducts inspections to ensure compliance with state requirements.  Investigates consumer complaints and evaluate compliance with state requirements.
  • For nursing homes – more information on working with the VDH Office of Licensure and Certification

Virginia Department of Health Professionals

  • Licenses personal physicians, nurses, dentists, and other healthcare professionals. Also responsible for enforcing standards of practice and providing information to healthcare practitioners and the public.

Virginia Department of Social Services – Division of Licensing Programs

  • Licenses assisted living facilities, which are residential settings that provide or coordinate personal and health care services, 24-hour supervision, and assistance for the care of four or more adults who are aged, infirm, or disabled.
    • To report a complaint, call the statewide toll-free number: 1-800-543-7545. In the Richmond area, call 804-692-2394.
  • For more information for assisted living facilities on working with VDSS, Division of Licensing Programs, see the VDSS DOLP FAQ.

National Agencies

Accreditation Association for Ambulatory Health Care (AAAHC) – Accredits organizations in a wide variety of ambulatory healthcare settings, including (but not limited to) ambulatory surgical centers, community health centers, medical and dental group practices, and student health centers.

  • Accredited facilities must demonstrate assessment and improvement of the quality of its services and provide services addressed by the AAAHC Standards

American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) – not-for-profit association that accredits ambulatory surgery facilities.

Centers for Medicare and Medicaid Services (CMS)

  • Contracts with state survey agencies (in Virginia, the Office of Licensure and Certification) to certify that providers (patient care institutions such as hospitals and nursing homes) and suppliers (agencies for diagnosis and therapy such as ambulatory surgery centers) participating in the Medicare and Medicaid programs meet minimum health and safety standards.
  • More information on setting-specific certification and compliance requirements can be found here

Joint Commission

  • Accreditation
    • Accredits healthcare facilities such as hospitals, long-term care facilities, and ambulatory health care settings.
    • Accredited facilities must demonstrate assessment and improvement of the quality of its services and provide services addressed by the Joint Commission’s standards.
    • Approximately 82% of hospitals in the United States are accredited by Joint Commission.
  • Certification
    • Joint Commission-accredited facilities can earn certification for programs devoted to chronic diseases and conditions, such as asthma, diabetes and heart failure.
    • Providers of health care staffing services can also earn Joint Commission certification