Administrative Code

Virginia Administrative Code
Title 12. Health
Agency 35. Department of Behavioral Health and Developmental Services
10/19/2020

Chapter 210. Regulations to Govern Temporary Leave from State Facilities

12VAC35-210-10. Applicability.

This regulation shall not apply to individuals receiving services in a facility who are committed pursuant to Chapter 9 (§ 37.2-900 et seq.) of Title 37.2, Title 19.2, or Title 53.1 of the Code of Virginia.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-20. Definitions.

The following words or terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Authorized representative" or "AR" means a person permitted by law or regulation to authorize the disclosure of information or to consent to treatment and services or participation in human research.

"Community services board" or "CSB" means the public body established pursuant to § 37.2-501 of the Code of Virginia that provides mental health, developmental, and substance abuse services to individuals within each city or county that established it. For the purpose of this chapter, community services board also includes a behavioral health authority established pursuant to § 37.2-602 of the Code of Virginia.

"Day pass" means authorized leave from a state facility without a staff escort generally occurring during the day and not extending overnight.

"Department" means the Department of Behavioral Health and Developmental Services.

"Home visit" means an authorized overnight absence from a state hospital or training center that allows an individual to spend time with an authorized representative or other responsible person.

"Individual" means a person who is receiving services in a state hospital or training center. This term includes the terms "consumer," "patient," "resident," and "client."

"Individualized services plan" or "ISP" means a comprehensive and regularly updated written plan that describes the individual's needs, the measurable goals and objectives to address those needs, and strategies to reach the individual's goals. An ISP is person-centered, empowers the individual, and is designed to meet the needs and preferences of the individual. The ISP is developed through a partnership between the individual and the provider. An individual's treatment plan, habilitation plan, person-centered plan, or plan of care are all considered individualized services plans .

"Missing person" means an individual who is not physically present when and where he should be and his absence cannot be accounted for or explained.

"Responsible person" means an individual's parent, spouse, legal guardian, relative, friend, or other person whom the facility director determines is capable of providing the individual with the needed care and supervision and, if the individual has an AR, for whom the AR has given written consent to supervise the individual during temporary leave from the state facility.

"State facility" or "facility" means a state hospital or training center operated by the department for the care and treatment of individuals with mental illness or intellectual disability.

"Trial visit" means an authorized overnight absence from a state facility without a staff escort for the purpose of assessing an individual's readiness for discharge. Trial visits do not include special hospitalizations, facility-sponsored summer camps, or other facility-sponsored activities that involve staff supervision.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-30. General requirements for temporary leave.

A. Directors of state facilities shall develop written operating policies and procedures for authorizing and implementing the following types of temporary leave from the facility:

1. Day passes for periods that do not extend overnight;

2. Home visits and trial visits for a maximum of 28 consecutive days per episode for individuals in training centers; and

3. Home visits and trial visits for a maximum of 14 consecutive days per episode for individuals in state hospitals.

B. The justification for all temporary leave shall be documented in the ISP. This documentation shall include:

1. The reason for granting the specific type of leave;

2. The benefit to the individual;

3. How the individual participated in the decision-making related to temporary leave;

4. How the leave addresses a specific outcome in the individual's ISP; and

5. The signature of the facility director or designee authorizing the temporary leave.

C. Responsible persons during leave.

1. Adults and emancipated minors receiving services in state hospitals who are granted a day pass, home visit, or trial visit may be:

a. Placed in the care of a facility licensed by the department or a responsible person; or

b. Authorized to leave the facility on their own recognizance, when, in the judgment of the individual and the facility director, this leave is appropriate.

2. Individuals in training centers and minors receiving services in any state hospital, who are granted a day pass, home visit, or trial visit, shall be placed, with the prior written consent of the AR, in the care of a facility licensed by the department or a responsible person.

D. The state facility granting a trial or home visit to an individual shall not be liable for the individual's expenses during the period of that visit. Expenses incurred by an individual during a trial visit or home visit shall be the responsibility of the person into whose care the individual is entrusted or the appropriate local department of social services of the county or city in which the individual resided at the time of his admission to the facility, as appropriate, pursuant to § 37.2-837 B of the Code of Virginia.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-40. Day passes.

Each facility shall have specific policies for day passes that include:

1. Criteria for granting day passes;

2. Designation of staff members who are authorized to issue day passes; and

3. Any forms to be used by the facility regarding the issuance of day passes.

Statutory Authority

§§ 37.2-203 and 37.2-837 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007.

12VAC35-210-50. Trial visits.

A. The facility and the CSB may arrange trial visits for the purpose of assessing an individual's readiness for discharge from the facility. These trial visits shall be planned during the regularly scheduled review of the ISP or at other times in collaboration with (i) the individual, (ii) the individual's family or AR, or (iii) any other person requested by the individual. When trial visits are used in conjunction with discharge planning, the state facility treatment team shall meet with the individual to discuss the individual's preferences for residential settings and give due consideration to the individual's expressed preferences. If the treatment team cannot reasonably accommodate the individual's preferences, a member of the treatment team shall meet with the individual to discuss the reasons for this determination and the options that are available to the individual. The treatment team shall document in the individual's record that it has met with the individual to consider the individual's preferences and review the available options. All plans for trial visits shall be documented in the ISP and include consideration of the following:

1. The individual's preferences for residential setting; and

2. The individual's essential support needs and supervision requirements.

B. In advance of the trial visit, the facility shall work with the individual, CSB, and responsible persons, as appropriate, to develop an emergency contingency plan to ensure appropriate and timely crisis response.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-60. Home visits.

A. Home visits may include visits with the individual's immediate or extended family, AR, friends, or other persons arranged by the family or AR.

1. Training centers shall plan home visits in collaboration with the individual, the individual's family or AR, and when appropriate, the CSB;

2. State hospitals shall plan home visits in collaboration with the individual, the individual's family or AR, and when appropriate, the CSB.

B. When planning home visits, facilities shall:

1. Ensure all identified essential support needs are reviewed with the responsible person;

2. Develop plans to address potential emergencies or unexpected events;

3. Consider whether the visit has an impact on the treatment or training schedule for the individual and make appropriate accommodations; and

4. Give consideration to the individual's medical, behavioral, and psychiatric status.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-70. Required authorizations and documentation.

The facility shall not release individuals for day passes, trial visits, or home visits unless the required authorizations have been obtained and documentation is included in the individual's record.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-80. Illness or injury occurring during a day, home, or trial visit.

A. When a facility is notified that an individual is injured or ill and requires medical attention while on a day pass, trial visit, or home visit, the facility director or designee shall notify the (i) facility medical director, (ii) treatment team leader, (iii) risk manager, (iv) human rights advocate, and (v) the CSB. The facility director shall also ensure that all events are reported in accordance with department and facility policy and protocol for risk management and any applicable law or regulation.

B. The facility director or designee may assist the CSB or the responsible person to identify an appropriate setting for the evaluation and treatment of the individual. The facility medical director may also consult with the physician and any other medical personnel who are evaluating or treating the individual. However, the individual shall not return to the facility until he is medically stabilized.

C. Individuals who have been admitted to a state hospital on a voluntary basis and require acute hospital admission for illness or injury while on temporary leave from the state hospital may voluntarily return to the state hospital following discharge from an acute care hospital if they continue to meet the admission criteria.

D. If an individual has been legally committed to a state hospital and his length of stay in an acute care hospital exceeds the period of commitment to the state hospital, the hospital shall:

1. Discharge the individual in collaboration with the CSB; and

2. Notify the individual or the individual's AR in writing of the discharge.

E. If the facility is notified that an individual has died while on temporary leave, the facility director or designee shall:

1. Notify the appropriate facility and other department staff, including the medical director, risk manager, treatment team leader, and human rights advocate;

2. Notify the appropriate CSB and AR;

3. File the appropriate documentation of the death in accordance with department policies and procedures; and

4. Notify the state medical examiner in writing of the death in accordance with § 32.1-283 of the Code of Virginia.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-90. Failure to return to training centers.

A. When an individual fails to return to a training center from any authorized day pass, home visit, or trial visit within two hours of the scheduled deadline, the facility director or designee shall contact the responsible person into whose care the individual was placed to determine the cause of the delay.

B. Upon the request of the responsible person, the facility director may extend the period of a home or trial visit for up to 72 hours beyond the time the individual was scheduled to return when:

1. An emergency or unforeseen circumstances delay the individual's return to the training center; and

2. The individual's AR agrees to the extension.

Extensions for emergency or unforeseen circumstances shall not be granted in advance of the home visit or trial visit.

C. If an individual does not return to the training center from a day pass, trial visit, or home visit within two hours of the established deadline for the individual's return and the training center is unable to contact the responsible person into whose care the individual was placed, the facility director or designee may extend the period of the visit for up to 24 hours if, in his judgment, the extension is justified. During this period the facility shall continue efforts to contact the responsible person.

D. If an individual does not return to the training center and the individual's absence cannot be accounted for or reasonably explained by the responsible person or a family member, the individual shall be classified as a missing person, and the facility shall follow the department's policies and procedures for management of individuals who are missing.

E. If no emergency or unforeseen circumstances exist that may prevent the individual's return to the facility, and the responsible person does not agree to the return of the individual to the training center as scheduled, the facility director shall contact the CSB and discharge the individual. Written notification of discharge shall be sent to the individual's AR.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.

12VAC35-210-100. Failure to return to hospitals.

A. When an individual fails to return to a state hospital from any authorized day pass, home visit, or trial visit within two hours of the scheduled deadline, the facility director or designee shall contact the responsible person into whose care the individual was placed to determine the cause of the delay.

B. Upon the request of the responsible person, the facility director may extend the period of the visit for up to 72 hours beyond the time the individual was scheduled to return when:

1. An emergency or unforeseen circumstances delay the individual's return to the hospital; and

2. The individual, or if applicable, the individual's AR, agrees to the extension.

Extensions for emergency or unforeseen circumstances shall not be granted in advance of the home visit or trial visit.

C. If an individual agrees to return to the facility, the facility director or designee may assist the individual to make arrangements for his return in collaboration with the CSB and the responsible person, when necessary.

D. If an individual is unwilling to return to the facility, the facility director or facility director's designee shall contact the responsible person to determine whether continued hospitalization is appropriate or the individual should be discharged.

1. Except for an individual receiving services in a state hospital who is held upon an order of a court for a criminal proceeding, if there is no evidence that the individual meets the criteria for hospitalization then the facility shall discharge the individual in collaboration with the CSB.

2. If the individual has been legally committed to the hospital and the facility director determines that the individual currently meets commitment criteria and requires further hospitalization, or the individual cannot be located, the facility director shall:

a. Ensure that the commitment order is valid;

b. Classify the individual as a missing person;

c. Alert the CSB pursuant to the department's policies and procedures for management of individuals who are missing from state facilities;

d. Issue a warrant for the individual's return under § 37.2-834 of the Code of Virginia; and

e. Arrange for a physical examination at the time of the individual's return to the facility.

3. If the individual is on voluntary status or the commitment order is no longer valid, the facility director, after consulting with the appropriate clinical staff, shall:

a. Discharge the individual; and

b. Alert the CSB of the individual's status.

Statutory Authority

§ 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 35, Issue 10, eff. February 21, 2019.



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