Chapter 105. Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services
Part I
General Provisions
Article 1
Authority and Applicability
12VAC35-105-10. Authority and applicability.
A. Section 37.2-404 of the Code of Virginia authorizes the commissioner to license providers subject to rules and regulations adopted by the State Board of Behavioral Health and Developmental Services.
B. No provider shall establish, maintain, conduct, or operate any service without first receiving a license from the commissioner.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Part II
Licensing Process
Article 2
Definitions
12VAC35-105-20. Definitions.
The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:
"Abuse" means, as defined by § 37.2-100 of the Code of Virginia, any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Virginia Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to an individual receiving care or treatment for mental illness, developmental disabilities, or substance abuse. Examples of abuse include acts such as:
1. Rape, sexual assault, or other criminal sexual behavior;
2. Assault or battery;
3. Use of language that demeans, threatens, intimidates, or humiliates the individual;
4. Misuse or misappropriation of the individual's assets, goods, or property;
5. Use of excessive force when placing an individual in physical or mechanical restraint;
6. Use of physical or mechanical restraints on an individual that is not in compliance with federal and state laws, regulations, and policies, professional accepted standards of practice, or the individual's individualized services plan; or
7. Use of more restrictive or intensive services or denial of services to punish an individual or that is not consistent with the individual's individualized services plan.
"Activities of daily living" or "ADLs" means personal care activities and includes bathing, dressing, transferring, toileting, grooming, hygiene, feeding, and eating. An individual's degree of independence in performing these activities is part of determining the appropriate level of care and services.
"Addiction" means a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Addiction is defined as the inability to consistently abstain, impairment in behavioral control, persistence of cravings, diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
"Admission" means the process of acceptance into a service as defined by the provider's policies.
"Allied health professional" means a professional who is involved with the delivery of health or related services pertaining to the identification, evaluation, and prevention of diseases and disorders, such as a certified substance abuse counselor, certified substance abuse counseling assistant, peer recovery support specialist, certified nurse aide, or occupational therapist.
"ASAM" means the American Society of Addiction Medicine.
"Assertive community treatment service" or "ACT" means a self-contained interdisciplinary community-based team of medical, behavioral health, and rehabilitation professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. ACT teams:
1. Provide person-centered services addressing the breadth of an individual's needs, helping the individual achieve his personal goals;
2. Serve as the primary provider of all the services that an individual receiving ACT services needs;
3. Maintain a high frequency and intensity of community-based contacts;
4. Maintain a very low individual-to-staff ratio;
5. Offer varying levels of care for all individuals receiving ACT services and appropriately adjust service levels according to each individual's needs over time;
6. Assist individuals in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles, such as worker, family member, resident, spouse, tenant, or friend;
7. Carry out planned assertive engagement techniques, including rapport-building strategies, facilitating meeting basic needs, and motivational interviewing techniques;
8. Monitor the individual's mental status and provide needed supports in a manner consistent with the individual's level of need and functioning;
9. Deliver all services according to a recovery-based philosophy of care; and
10. Promote self-determination, respect for the individual receiving ACT as an individual in such individual's own right, and engage peers in promoting recovery and regaining meaningful roles and relationships in the community.
"Authorized representative" means a person permitted by law or 12VAC35-115 to authorize the disclosure of information or consent to treatment and services or participation in human research.
"Behavior intervention" means those principles and methods employed by a provider to help an individual receiving services to achieve a positive outcome and to address challenging behavior in a constructive and safe manner. Behavior intervention principles and methods shall be employed in accordance with the individualized services plan and written policies and procedures governing service expectations, treatment goals, safety, and security.
"Behavioral treatment plan," "functional plan," or "behavioral support plan" means any set of documented procedures that are an integral part of the individualized services plan and are developed on the basis of a systematic data collection, such as a functional assessment, for the purpose of assisting individuals to achieve the following:
1. Improved behavioral functioning and effectiveness;
2. Alleviation of symptoms of psychopathology; or
3. Reduction of challenging behaviors.
"Board" or "state board" means, as defined by § 37.2-100 of the Code of Virginia, the State Board of Behavioral Health and Developmental Services. The board has statutory responsibility for adopting regulations that may be necessary to carry out the provisions of Title 37.2 of the Code of Virginia and other laws of the Commonwealth administered by the commissioner or the department.
"Brain injury" means any injury to the brain that occurs after birth that is acquired through traumatic or nontraumatic insults. Nontraumatic insults may include anoxia, hypoxia, aneurysm, toxic exposure, encephalopathy, surgical interventions, tumor, and stroke. Brain injury does not include hereditary, congenital, or degenerative brain disorders or injuries induced by birth trauma.
"Care," "treatment," or "support" means the individually planned therapeutic interventions that conform to current acceptable professional practice and that are intended to improve or maintain functioning of an individual receiving services delivered by a provider.
"Case management service" or "support coordination service" means services that can include assistance to individuals and their family members in accessing needed services that are responsive to the individual's needs. Case management services include identifying potential users of the service; assessing needs and planning services; linking the individual to services and supports; assisting the individual directly to locate, develop, or obtain needed services and resources; coordinating services with other providers; enhancing community integration; making collateral contacts; monitoring service delivery; discharge planning; and advocating for individuals in response to their changing needs. "Case management service" does not include assistance in which the only function is maintaining service waiting lists or periodically contacting or tracking individuals to determine potential service needs.
"Clinical experience" means providing direct services to individuals with mental illness or the provision of direct geriatric services or special education services. Experience may include supervised internships, practicums, and field experience.
"Clinically managed high-intensity residential care" or "Level of care 3.5" means a substance use treatment program that offers 24-hour supportive treatment of individuals with significant psychological and social problems by credentialed addiction treatment professionals in an interdisciplinary treatment approach. A clinically managed high-intensity residential care program provides treatment to individuals who present with significant challenges, such as physical, sexual, or emotional trauma; past criminal or antisocial behaviors, with a risk of continued criminal behavior; an extensive history of treatment; inadequate anger management skills; extreme impulsivity; and antisocial value system.
"Clinically managed low-intensity residential care" or "Level of care 3.1" means providing an ongoing therapeutic environment for individuals requiring some structured support in which treatment is directed toward applying recovery skills; preventing relapse; improving emotional functioning; promoting personal responsibility; reintegrating the individual into work, education, and family environments; and strengthening and developing adaptive skills that may not have been achieved or have been diminished during the individual's active addiction. A clinically managed low-intensity residential care program also provides treatment for individuals suffering from chronic, long-term alcoholism or drug addiction and affords an extended period of time to establish sound recovery and a solid support system.
"Clinically managed population specific high-intensity residential services" or "Level of care 3.3" means a substance use treatment program that provides a structured recovery environment in combination with high-intensity clinical services provided in a manner to meet the functional limitations of individuals. The functional limitations of individuals who are placed within this level of care are primarily cognitive and can be either temporary or permanent.
"Commissioner" means the Commissioner of the Department of Behavioral Health and Developmental Services.
"Community-based crisis stabilization" means services that are short term and designed to support an individual and the individual's natural support system following contact with an initial crisis response service or as a diversion to a higher level of care. Providers deliver community-based crisis stabilization services in an individual's natural environment and provide referrals and linkage to other community-based services at the appropriate level of care. Interventions may include mobile crisis response, brief therapeutic and skill-building interventions, engagement of natural supports, interventions to integrate natural supports in the de-escalation and stabilization of the crisis, and coordination of follow-up services. Coordination of specialized services to address the needs of co-occurring developmental disabilities and substance use disorders are also available through this service. Services include advocacy and networking to provide linkages and referrals to appropriate community-based services and assist the individual and the individual's family or caregiver in accessing other benefits or assistance programs for which the individual may be eligible. Community-based crisis stabilization is a non-center, community-based service. The goal of community-based crisis stabilization services is to stabilize the individual within the community and support the individual or the individual's support system (i) as part of an initial mobile crisis response; (ii) during the period between an initial mobile crisis response and entry into an established follow-up service at the appropriate level of care; (iii) as a transitional step-down from a higher level of care if the next level of care service is identified but not immediately available for access; or (iv) as a diversion to a higher level of care.
"Community gero-psychiatric residential services" means 24-hour care provided to individuals with mental illness, behavioral problems, and concomitant health problems who are usually 65 years of age or older in a geriatric setting that is less intensive than a psychiatric hospital but more intensive than a nursing home or group home. Services include assessment and individualized services planning by an interdisciplinary services team, intense supervision, psychiatric care, behavioral treatment planning and behavior interventions, nursing, and other health-related services.
"Complaint" means an allegation of a violation of this chapter or a provider's policies and procedures related to this chapter.
"Co-occurring disorders" means the presence of more than one and often several of the following disorders that are identified independently of one another and are not simply a cluster of symptoms resulting from a single disorder: mental illness, a developmental disability, substance abuse (substance use disorders), or brain injury.
"Co-occurring services" means individually planned therapeutic treatment that addresses in an integrated concurrent manner the service needs of individuals who have co-occurring disorders.
"Corrective action plan" means the provider's pledged corrective action in response to cited areas of noncompliance documented by the regulatory authority.
"Correctional facility" means a facility operated under the management and control of the Virginia Department of Corrections.
"Credentialed addiction treatment professional" means a person who possesses one of the following credentials issued by the appropriate health regulatory board: (i) an addiction-credentialed physician or physician with experience or training in addiction medicine; (ii) a licensed nurse practitioner or a licensed physician assistant with experience or training in addiction medicine; (iii) a licensed psychiatrist; (iv) a licensed clinical psychologist; (v) a licensed clinical social worker; (vi) a licensed professional counselor; (vii) a licensed nurse practitioner with experience or training in psychiatry or mental health; (viii) a licensed marriage and family therapist; (ix) a licensed substance abuse treatment practitioner; (x) a resident who is under the supervision of a licensed professional counselor (18VAC115-20-10), licensed marriage and family therapist (18VAC115-50-10), or licensed substance abuse treatment practitioner (18VAC115-60-10) and is registered with the Virginia Board of Counseling; (xi) a resident in psychology who is under supervision of a licensed clinical psychologist and is registered with the Virginia Board of Psychology (18VAC125-20-10); or (xii) a supervisee in social work who is under the supervision of a licensed clinical social worker and is registered with the Virginia Board of Social Work (18VAC140-20-10).
"Crisis" means a deteriorating or unstable situation often developing suddenly or rapidly that produces acute, heightened, emotional, mental, physical, medical, or behavioral distress.
"Crisis education and prevention plan" or "CEPP" means a department-approved, individualized, client-specific document that provides a concise, clear, and realistic set of supportive interventions to prevent or de-escalate a crisis and assist an individual who may be experiencing a behavioral loss of control. The goal of the CEPP is to identify problems that have arisen in the past or are emergent in order to map out strategies that offer tools for the natural support system to assist the individual in addressing and de-escalating problems in a healthy way and provide teaching skills that the individual can apply independently.
"Crisis planning team" means the team who is consulted to plan the individual's safety plan or crisis ISP. The crisis planning team consists, at a minimum, of the individual receiving services, the individual's legal guardian or authorized representative, and a member of the provider's crisis staff. The crisis planning team may include the individual's support coordinator, case manager, the individual's family, or other identified persons, as desired by the individual, such as the individual's family of choice.
"Crisis receiving center," "CRC," or "23-hour crisis stabilization" means a community-based, nonhospital facility providing short-term assessment, observation, and crisis stabilization services for up to 23 hours. This service is accessible 24 hours per day, seven days per week, 365 days per year, and is indicated when an individual requires a safe environment for initial assessment and intervention. This service includes a thorough assessment of an individual's behavioral health crisis, psychosocial needs, and supports in order to determine the least restrictive environment most appropriate for stabilization. Key service functions include rapid assessment, crisis intervention, de-escalation, short-term stabilization, and appropriate referrals for ongoing care. This distinct service may be co-located with other services such as crisis stabilization units.
"Crisis stabilization" means direct, intensive nonresidential or residential care and treatment to nonhospitalized individuals experiencing an acute crisis that may jeopardize their current community living situation. Crisis stabilization is intended to avert hospitalization or rehospitalization; provide normative environments with a high assurance of safety and security for crisis intervention; stabilize individuals in crisis; and mobilize the resources of the community support system, family members, and others for ongoing rehabilitation and recovery.
"Crisis stabilization unit," "CSU," or "residential crisis stabilization unit" is a community-based, short-term residential treatment unit. CSUs serve as primary alternatives to inpatient hospitalization for individuals who are in need of a safe, secure environment for assessment and crisis treatment. CSUs also serve as a step-down option from psychiatric inpatient hospitalization and function to stabilize and reintegrate individuals who meet medical necessity criteria back into their communities.
"Day support service" means structured programs of training, assistance, and specialized supervision in the acquisition, retention, or improvement of self-help, socialization, and adaptive skills for adults with a developmental disability provided to groups or individuals in nonresidential community-based settings. Day support services may provide opportunities for peer interaction and community integration and are designed to enhance the following: self-care and hygiene, eating, toileting, task learning, community resource utilization, environmental and behavioral skills, social skills, medication management, prevocational skills, and transportation skills. The term "day support service" does not include services in which the primary function is to provide employment-related services, general educational services, or general recreational services.
"Department" means the Virginia Department of Behavioral Health and Developmental Services.
"Developmental disability" means a severe, chronic disability of an individual that (i) is attributable to a mental or physical impairment or a combination of mental and physical impairments other than a sole diagnosis of mental illness; (ii) is manifested before the individual reaches 22 years of age; (iii) is likely to continue indefinitely; (iv) results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, or economic self-sufficiency; and (v) reflects the individual's need for a combination and sequence of special interdisciplinary or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated. An individual from birth to nine years of age, inclusive, who has a substantial developmental delay or specific congenital or acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described in clauses (i) through (v) if the individual without services and supports has a high probability of meeting those criteria later in life.
"Developmental services" means planned, individualized, and person-centered services and supports provided to individuals with developmental disabilities for the purpose of enabling these individuals to increase their self-determination and independence, obtain employment, participate fully in all aspects of community life, advocate for themselves, and achieve their fullest potential to the greatest extent possible.
"Diagnostic and Statistical Manual of Mental Disorders" or "DSM" means the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, DSM-5, of the American Psychiatric Association.
"Direct care position" means any position that includes responsibility for (i) treatment, case management, health, safety, development, or well-being of an individual receiving services or (ii) immediately supervising a person in a position with this responsibility.
"Discharge" means the process by which the individual's active involvement with a service is terminated by the provider, individual, or individual's authorized representative.
"Discharge plan" means the written plan that establishes the criteria for an individual's discharge from a service and identifies and coordinates delivery of any services needed after discharge.
"Dispense" means to deliver a drug to an ultimate user by or pursuant to the lawful order of a practitioner, including the prescribing and administering, packaging, labeling, or compounding necessary to prepare the substance for that delivery (§ 54.1-3400 et seq. of the Code of Virginia).
"Emergency service" means unscheduled and sometimes scheduled crisis intervention, stabilization, and referral assistance provided over the telephone or face-to-face, if indicated, available 24 hours a day and seven days per week. Emergency services also may include walk-ins, home visits, jail interventions, and preadmission screening activities associated with the judicial process.
"Group home or community residential service" means a congregate service providing 24-hour supervision in a community-based home having eight or fewer residents. Services include supervision, supports, counseling, and training in activities of daily living for individuals whose individualized services plan identifies the need for the specific types of services available in this setting.
"HCBS Waiver" means a Medicaid Home and Community Based Services Waiver.
"Home and noncenter based" means that a service is provided in the individual's home or other noncenter-based setting. This includes noncenter-based day support, supportive in-home, and intensive in-home services.
"Individual" or "individual receiving services" means a current direct recipient of public or private mental health, developmental, or substance abuse treatment, rehabilitation, or habilitation services and includes the terms "consumer," "patient," "resident," "recipient," or "client". When the term is used in this chapter, the requirement applies to every individual receiving licensed services from the provider.
"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 and includes an individual's treatment plan, habilitation plan, person-centered plan, or plan of care, which are all considered individualized service plans.
"Informed choice" means a decision made after considering options based on adequate and accurate information and knowledge. These options are developed through collaboration with the individual and the individual's authorized representative, as applicable, and the provider with the intent of empowering the individual and the individual's authorized representative to make decisions that will lead to positive service outcomes.
"Informed consent" means the voluntary written agreement of an individual or that individual's authorized representative to surgery, electroconvulsive treatment, use of psychotropic medications, or any other treatment or service that poses a risk of harm greater than that ordinarily encountered in daily life or for participation in human research. To be voluntary, informed consent must be given freely and without undue inducement; any element of force, fraud, deceit, or duress; or any form of constraint or coercion.
"Initial assessment" means an assessment conducted prior to or at admission to determine whether the individual meets the service's admission criteria; what the individual's immediate service, health, and safety needs are; and whether the provider has the capability and staffing to provide the needed services.
"Inpatient psychiatric service" means intensive 24-hour medical, nursing, and treatment services provided to individuals with mental illness or substance abuse (substance use disorders) in a hospital as defined in § 32.1-123 of the Code of Virginia or in a special unit of a hospital.
"Instrumental activities of daily living" or "IADLs" means meal preparation, housekeeping, laundry, and managing money. A person's degree of independence in performing these activities is part of determining appropriate level of care and services.
"Intellectual disability" means a disability originating before 18 years of age, characterized concurrently by (i) significant subaverage intellectual functioning as demonstrated by performance on a standardized measure of intellectual functioning administered in conformity with accepted professional practice that is at least two standard deviations below the mean and (ii) significant limitations in adaptive behavior as expressed in conceptual, social, and practical adaptive skills.
"Intensity of service" means the number, type, and frequency of staff interventions and other services provided during treatment at a particular level of care.
"Intensive in-home service" means family preservation interventions for children and adolescents who have or are at risk of serious emotional disturbance, including individuals who also have a diagnosis of developmental disability. Intensive in-home service is usually time-limited and is provided typically in the residence of an individual who is at risk of being moved to out-of-home placement or who is being transitioned back home from an out-of-home placement. The service includes 24-hour per day emergency response; crisis treatment; individual and family counseling; life, parenting, and communication skills; and case management and coordination with other services.
"Intermediate care facility/individuals with intellectual disability" or "ICF/IID" means a facility or distinct part of a facility certified by the Virginia Department of Health as meeting the federal certification regulations for an intermediate care facility for individuals with intellectual disability and persons with related conditions and that addresses the total needs of the residents, which include physical, intellectual, social, emotional, and habilitation, providing active treatment as defined in 42 CFR 435.1010 and 42 CFR 483.440.
"Investigation" means a detailed inquiry or systematic examination of the operations of a provider or its services regarding an alleged violation of regulations or law. An investigation may be undertaken as a result of a complaint, an incident report, or other information that comes to the attention of the department.
"Licensed mental health professional" or "LMHP" means a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, certified psychiatric clinical nurse specialist, licensed behavior analyst, or licensed psychiatric/mental health nurse practitioner.
"Location" means a place where services are or could be provided.
"Mandatory outpatient treatment order" means an order issued by a court pursuant to § 37.2-817 of the Code of Virginia.
"Medical detoxification" means a service provided in a hospital or other 24-hour care facility under the supervision of medical personnel using medication to systematically eliminate or reduce the presence of alcohol or other drugs in the individual's body.
"Medical evaluation" means the process of assessing an individual's health status that includes a medical history and a physical examination of an individual conducted by a licensed medical practitioner operating within the scope of his license.
"Medically managed intensive inpatient service" or "Level of care 4.0" means an organized service delivered in an inpatient setting, including an acute care general hospital, psychiatric unit in a general hospital, or a freestanding psychiatric hospital. This service is appropriate for individuals whose acute biomedical and emotional, behavioral, and cognitive problems are so severe that they require primary medical and nursing care. Services at this level of care are managed by a physician who is responsible for diagnosis, treatment, and treatment plan decisions in collaboration with the individual.
"Medically monitored intensive inpatient treatment" or "Level of care 3.7" means a substance use treatment program that provides 24-hour care in a facility under the supervision of medical personnel. The care provided includes directed evaluation, observation, medical monitoring, and addiction treatment in an inpatient setting. The care provided may include the use of medication to address the effects of substance use. This service is appropriate for an individual whose subacute biomedical, emotional, behavioral, or cognitive problems are so severe that they require inpatient treatment but who does not need the full resources of an acute care general hospital or a medically managed intensive inpatient treatment program.
"Medication" means prescribed or over-the-counter drugs or both.
"Medication administration" means the legally permitted direct application of medications, as enumerated by § 54.1-3408 of the Code of Virginia, by injection, inhalation, ingestion, or any other means to an individual receiving services by (i) persons legally permitted to administer medications or (ii) the individual at the direction and in the presence of persons legally permitted to administer medications.
"Medication assisted opioid treatment" or "opioid treatment service" means an intervention of administering or dispensing of medications, such as methadone, buprenorphine, or naltrexone approved by the federal Food and Drug Administration for the purpose of treating opioid use disorder.
"Medication assisted treatment" or "MAT" means the use of U.S. Food and Drug Administration approved medications in combination with counseling and behavioral therapies to provide treatment of substance use disorders. Medication assisted treatment includes medications for opioid use disorder as well as medications for treatment of alcohol use disorder.
"Medication error" means an error in administering a medication to an individual and includes when any of the following occur: (i) the wrong medication is given to an individual, (ii) the wrong individual is given the medication, (iii) the wrong dosage is given to an individual, (iv) medication is given to an individual at the wrong time or not at all, or (v) the wrong method is used to give the medication to the individual.
"Medication storage" means any area where medications are maintained by the provider, including a locked cabinet, locked room, or locked box.
"Mental Health Community Support Service" or "MCHSS" means the provision of recovery-oriented services to individuals with long-term, severe mental illness. MHCSS includes skills training and assistance in accessing and effectively utilizing services and supports that are essential to meeting the needs identified in the individualized services plan and development of environmental supports necessary to sustain active community living as independently as possible. MHCSS may be provided in any setting in which the individual's needs can be addressed, skills training applied, and recovery experienced.
"Mental health intensive outpatient service" means a structured program of skilled treatment services focused on maintaining and improving functional abilities through a time-limited, interdisciplinary approach to treatment. This service is provided over a period of time for individuals requiring more intensive services than an outpatient service can provide and may include individual, family, or group counseling or psychotherapy; skill development and psychoeducational activities; certified peer support services; medication management; and psychological assessment or testing.
"Mental health outpatient service" means treatment provided to individuals on an hourly schedule, on an individual, group, or family basis, and usually in a clinic or similar facility or in another location. Mental health outpatient services may include diagnosis and evaluation, screening and intake, counseling, psychotherapy, behavior management, psychological testing and assessment, laboratory, and other ancillary services, medical services, and medication services. Mental health outpatient service specifically includes:
1. Mental health services operated by a community services board or a behavioral health authority established pursuant to Chapter 5 (§ 37.2-500 et seq.) or Chapter 6 (§ 37.2-600 et seq.) of Title 37.2 of the Code of Virginia;
2. Mental health services contracted by a community services board or a behavioral health authority established pursuant to Chapter 5 (§ 37.2-500 et seq.) or Chapter 6 (§ 37.2-600 et seq.) of Title 37.2 of the Code of Virginia; or
3. Mental health services that are owned, operated, or controlled by a corporation organized pursuant to the provisions of either Chapter 9 (§ 13.1-601 et seq.) or Chapter 10 (§ 13.1-801 et seq.) of Title 13.1 of the Code of Virginia.
"Mental health partial hospitalization service" means time-limited active treatment interventions that are more intensive than outpatient services, designed to stabilize and ameliorate acute symptoms and serve as an alternative to inpatient hospitalization or to reduce the length of a hospital stay. Partial hospitalization is provided through a minimum of 20 hours per week of skilled treatment services focused on individuals who require intensive, highly coordinated, structured, and interdisciplinary ambulatory treatment within a stable environment that is of greater intensity than intensive outpatient, but of lesser intensity than inpatient.
"Mental illness" means, as defined by § 37.2-100 of the Code of Virginia, a disorder of thought, mood, emotion, perception, or orientation that significantly impairs judgment, behavior, capacity to recognize reality, or ability to address basic life necessities and requires care and treatment for the health, safety, or recovery of the individual or for the safety of others.
"Missing" means a circumstance in which an individual is not physically present when and where he should be and his absence cannot be accounted for or explained by his supervision needs or pattern of behavior.
"Mobile crisis response" means a type of community-based crisis stabilization service that is available 24 hours per day, seven days per week, 365 days per year to provide rapid response, assessment, and early intervention to individuals experiencing a behavioral health crisis. Services are deployed in real time to the location of the individual experiencing a behavioral health crisis. The purpose of this service is to (i) de-escalate the behavioral health crisis and prevent harm to the individual or others; (ii) assist in the prevention of the individual's acute exacerbation of symptoms; (iii) develop an immediate plan to maintain safety; and (iv) coordinate care and linking to appropriate treatment services to meet the needs of the individual.
"Motivational enhancement" means a person-centered approach that is collaborative, employs strategies to strengthen motivation for change, increases engagement in substance use services, resolves ambivalence about changing substance use behaviors, and supports individuals to set goals to change their substance use.
"Neglect" means, as defined by § 37.2-100 of the Code of Virginia, the failure by a person or a program or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, developmental disabilities, or substance abuse.
"Neurobehavioral services" means the assessment, evaluation, and treatment of cognitive, perceptual, behavioral, and other impairments caused by brain injury that affect an individual's ability to function successfully in the community.
"Office of Human Rights" means the Department of Behavioral Health and Developmental Services Office of Human Rights.
"Person-centered" means focusing on the needs and preferences of the individual; empowering and supporting the individual in defining the direction for his life; and promoting self-determination, community involvement, and recovery.
"Provider" means, as defined by § 37.2-403 of the Code of Virginia, any person, entity, or organization, excluding an agency of the federal government by whatever name or designation, that delivers (i) services to individuals with mental illness, developmental disabilities, or substance abuse (substance use disorders) or (ii) residential services for individuals with brain injury. The person, entity, or organization shall include a hospital as defined in § 32.1-123 of the Code of Virginia, community services board, behavioral health authority, private provider, and any other similar or related person, entity, or organization. It shall not include any individual practitioner who holds a license issued by a health regulatory board of the Department of Health Professions or who is exempt from licensing pursuant to §§ 54.1-2901, 54.1-3001, 54.1-3501, 54.1-3601, and 54.1-3701 of the Code of Virginia.
"Psychosocial rehabilitation service" means a program of two or more consecutive hours per day provided to groups of adults in a nonresidential setting. Individuals must demonstrate a clinical need for the service arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. This service provides education to teach the individual about mental illness, substance abuse, and appropriate medication to avoid complication and relapse and opportunities to learn and use independent skills and to enhance social and interpersonal skills within a consistent program structure and environment. Psychosocial rehabilitation includes skills training, peer support, vocational rehabilitation, and community resource development oriented toward empowerment, recovery, and competency.
"Qualified developmental disability professional" or "QDDP" means a person who possesses at least one year of documented experience working directly with individuals who have a developmental disability and who possesses one of the following credentials: (i) a doctor of medicine or osteopathy licensed in Virginia, (ii) a registered nurse licensed in Virginia, (iii) a licensed occupational therapist, or (iv) completion of at least a bachelor's degree in a human services field, including sociology, social work, special education, rehabilitation counseling, or psychology.
"Qualified mental health professional" or "QMHP" means a person who by education and experience is professionally qualified and registered by the Board of Counseling in accordance with 18VAC115-80 to provide collaborative mental health services for adults or children. A QMHP does not engage in independent or autonomous practice. A QMHP provides services as an employee or independent contractor of the department or a provider licensed by the department.
"Qualified mental health professional-adult" or "QMHP-A" means a person who by education and experience is professionally qualified and registered with the Board of Counseling in accordance with 18VAC115-80 to provide collaborative mental health services for adults. A QMHP-A provides services as an employee or independent contractor of the department or a provider licensed by the department. A QMHP-A may be an occupational therapist who by education and experience is professionally qualified and registered with the Board of Counseling in accordance with 18VAC115-80.
"Qualified mental health professional-child" or "QMHP-C" means a person who by education and experience is professionally qualified and registered with the Board of Counseling in accordance with 18VAC115-80 to provide collaborative mental health services for children. A QMHP-C provides services as an employee or independent contractor of the department or a provider licensed by the department. A QMHP-C may be an occupational therapist who by education and experience is professionally qualified and registered with the Board of Counseling in accordance with 18VAC115-80.
"Qualified mental health professional-trainee" or "QMHP-T" means a person receiving supervised training in order to qualify as a QMHP in accordance with 18VAC115-80 and who is registered with the Board of Counseling.
"Qualified paraprofessional in mental health" or "QPPMH" means a person who meets at least one of the following criteria: (i) is registered with the United States Psychiatric Association (USPRA) as an Associate Psychiatric Rehabilitation Provider (APRP); (ii) has an associate degree in a related field (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and at least one year of experience providing direct services to individuals with a diagnosis of mental illness; (iii) is licensed as an occupational therapy assistant, and supervised by a licensed occupational therapist, with at least one year of experience providing direct services to individuals with a diagnosis of mental illness; or (iv) has a minimum of 90 hours classroom training and 12 weeks of experience under the direct personal supervision of a QMHP-A providing services to individuals with mental illness and at least one year of experience, including the 12 weeks of supervised experience.
"Quality improvement plan" means a detailed work plan developed by a provider that defines steps the provider will take to review the quality of services it provides and to manage initiatives to improve quality. A quality improvement plan consists of systematic and continuous actions that lead to measurable improvement in the services, supports, and health status of the individuals receiving services.
"Recovery" means a journey of healing and transformation enabling an individual with a mental illness to live a meaningful life in a community of his choice while striving to achieve his full potential. For individuals with substance abuse (substance use disorders), recovery is an incremental process leading to positive social change and a full return to biological, psychological, and social functioning. For individuals with a developmental disability, the concept of recovery does not apply in the sense that individuals with a developmental disability will need supports throughout their entire lives although these may change over time. With supports, individuals with a developmental disability are capable of living lives that are fulfilling and satisfying and that bring meaning to themselves and others they know.
"REACH crisis therapeutic home" or "REACH CTH" means a residential home with crisis stabilization REACH service for individuals with a developmental disability and who are experiencing a mental health or behavior crisis.
"REACH mobile crisis response" means a REACH service that provides mobile crisis response for individuals with a developmental disability and who are experiencing a mental health or behavior crisis.
"Referral" means the process of directing an applicant or an individual to a provider or service that is designed to provide the assistance needed.
"Regional education assessment crisis services habilitation" or "REACH" means the statewide crisis system of care that is designed to meet the crisis support needs of individuals who have a developmental disability and are experiencing mental health or behavior crisis events that put the individuals at risk for homelessness, incarceration, hospitalization, or danger to self or others.
"Residential" or "residential service" means providing 24-hour support in conjunction with care and treatment or a training program in a setting other than a hospital or training center. Residential services provide a range of living arrangements from highly structured and intensively supervised to relatively independent and requiring a modest amount of staff support and monitoring. Residential services include residential treatment, group homes, supervised living, community gero-psychiatric residential, ICF/IID, sponsored residential homes, medical and social detoxification, and neurobehavioral services.
"Residential crisis stabilization service" means (i) providing short-term, intensive treatment to nonhospitalized individuals who require multidisciplinary treatment in order to stabilize acute psychiatric symptoms and prevent admission to a psychiatric inpatient unit; (ii) providing normative environments with a high assurance of safety and security for crisis intervention; and (iii) mobilizing the resources of the community support system, family members, and others for ongoing rehabilitation and recovery.
"Residential treatment service" means providing an intensive and highly structured clinically based mental health, substance abuse, or neurobehavioral service for co-occurring disorders in a residential setting other than an inpatient service.
"Respite care service" means providing for a short-term, time-limited period of care of an individual for the purpose of providing relief to the individual's family, guardian, or regular caregiver. Persons providing respite care are recruited, trained, and supervised by a licensed provider. These services may be provided in a variety of settings including residential, day support, in-home, or a sponsored residential home.
"Restraint" means the use of a mechanical device, medication, physical intervention, or hands-on hold to prevent an individual receiving services from moving his body to engage in a behavior that places him or others at imminent risk. There are three kinds of restraints:
1. Mechanical restraint means the use of a mechanical device that cannot be removed by the individual to restrict the individual's freedom of movement or functioning of a limb or portion of an individual's body when that behavior places him or others at imminent risk.
2. Pharmacological restraint means the use of a medication that is administered involuntarily for the emergency control of an individual's behavior when that individual's behavior places him or others at imminent risk and the administered medication is not a standard treatment for the individual's medical or psychiatric condition.
3. Physical restraint, also referred to as manual hold, means the use of a physical intervention or hands-on hold to prevent an individual from moving his body when that individual's behavior places him or others at imminent risk.
"Restraints for behavioral purposes" means using a physical hold, medication, or a mechanical device to control behavior or involuntarily restrict the freedom of movement of an individual in an instance when all of the following conditions are met: (i) there is an emergency; (ii) nonphysical interventions are not viable; and (iii) safety issues require an immediate response.
"Restraints for medical purposes" means using a physical hold, medication, or mechanical device to limit the mobility of an individual for medical, diagnostic, or surgical purposes, such as routine dental care or radiological procedures and related post-procedure care processes, when use of the restraint is not the accepted clinical practice for treating the individual's condition.
"Restraints for protective purposes" means using a mechanical device to compensate for a physical or cognitive deficit when the individual does not have the option to remove the device. The device may limit an individual's movement, for example, bed rails or a gerichair, and prevent possible harm to the individual or it may create a passive barrier, such as a helmet to protect the individual.
"Restriction" means anything that limits or prevents an individual from freely exercising his rights and privileges.
"Risk management" means an integrated system-wide program to ensure the safety of individuals, employees, visitors, and others through identification, mitigation, early detection, monitoring, evaluation, and control of risks.
"Root cause analysis" means a method of problem solving designed to identify the underlying causes of a problem. The focus of a root cause analysis is on systems, processes, and outcomes that require change to reduce the risk of harm.
"Screening" means the process or procedure for determining whether the individual meets the minimum criteria for initial assessment.
"Seclusion" means the involuntary placement of an individual alone in an area secured by a door that is locked or held shut by a staff person, by physically blocking the door, or by any other physical means so that the individual cannot leave the area.
"Serious incident" means any event or circumstance that causes or could cause harm to the health, safety, or well-being of an individual. The term "serious incident" includes death and serious injury.
"Level I serious incident" means a serious incident that occurs or originates during the provision of a service or on the premises of the provider and does not meet the definition of a Level II or Level III serious incident. Level I serious incidents do not result in significant harm to individuals but may include events that result in minor injuries that do not require medical attention or events that have the potential to cause serious injury, even when no injury occurs.
"Level II serious incident" means a serious incident that occurs or originates during the provision of a service or on the premises of the provider that results in a significant harm or threat to the health and safety of an individual that does not meet the definition of a Level III serious incident. "Level II serious incident" includes a significant harm or threat to the health or safety of others caused by an individual. Level II serious incidents include:
1. A serious injury;
2. An individual who is or was missing;
3. An emergency room visit;
4. An unplanned psychiatric or unplanned medical hospital admission of an individual receiving services other than licensed emergency services, except that a psychiatric admission in accordance with an individual's wellness plan shall not constitute an unplanned admission for the purposes of this chapter;
5. Choking incidents that require direct physical intervention by another person;
6. Ingestion of any hazardous material; or
7. A diagnosis of:
a. A decubitus ulcer or an increase in severity of level of previously diagnosed decubitus ulcer;
b. A bowel obstruction; or
c. Aspiration pneumonia.
"Level III serious incident" means a serious incident, whether or not the incident occurs while in the provision of a service or on the provider's premises, that results in:
1. Any death of an individual;
2. A sexual assault of an individual; or
3. A suicide attempt by an individual admitted for services, other than licensed emergency services, that results in a hospital admission.
"Serious injury" means any injury resulting in bodily hurt, damage, harm, or loss that requires medical attention by a licensed physician, doctor of osteopathic medicine, physician assistant, or nurse practitioner.
"Service" means, as defined by § 37.2-403 of the Code of Virginia, (i) planned individualized interventions intended to reduce or ameliorate mental illness, developmental disabilities, or substance abuse (substance use disorders) through care, treatment, training, habilitation, or other supports that are delivered by a provider to individuals with mental illness, developmental disabilities, or substance abuse (substance use disorders). Services include outpatient services, intensive in-home services, medication assisted opioid treatment services, inpatient psychiatric hospitalization, community gero-psychiatric residential services, assertive community treatment and other clinical services; day support, day treatment, partial hospitalization, psychosocial rehabilitation, and habilitation services; case management services; and supportive residential, special school, halfway house, in-home services, crisis stabilization, and other residential services; and (ii) planned individualized interventions intended to reduce or ameliorate the effects of brain injury through care, treatment, or other supports provided in residential services for persons with brain injury.
"Shall" means an obligation to act is imposed.
"Shall not" means an obligation not to act is imposed.
"Signed" or "signature" means a handwritten signature, an electronic signature, or a digital signature, as long as the signer showed clear intent to sign.
"Skills training" means systematic skill building through curriculum-based psychoeducational and cognitive-behavioral interventions. These interventions break down complex objectives for role performance into simpler components, including basic cognitive skills such as attention, to facilitate learning and competency.
"Sponsored residential home" means a service where providers arrange for, supervise, and provide programmatic, financial, and service support to families or persons (sponsors) providing care or treatment in their own homes for individuals receiving services.
"State methadone authority" means the Virginia Department of Behavioral Health and Developmental Services, which is authorized by the federal Center for Substance Abuse Treatment to exercise the responsibility and authority for governing the treatment of opiate addiction with an opioid drug.
"Substance abuse (substance use disorders)" means, as defined by § 37.2-100 of the Code of Virginia, the use of drugs enumerated in the Virginia Drug Control Act (§ 54.1-3400 et seq.) without a compelling medical reason or alcohol that (i) results in psychological or physiological dependence or danger to self or others as a function of continued and compulsive use or (ii) results in mental, emotional, or physical impairment that causes socially dysfunctional or socially disordering behavior; and (iii), because of such substance abuse, requires care and treatment for the health of the individual. This care and treatment may include counseling, rehabilitation, or medical or psychiatric care.
"Substance abuse intensive outpatient service" or "Level of care 2.1" means structured treatment provided to individuals who require more intensive services than is normally provided in an outpatient service but do not require inpatient services. Treatment consists primarily of counseling and education about addiction-related and mental health challenges delivered a minimum of nine to 19 hours of services per week for adults or six to 19 hours of services per week for children and adolescents. Within this level of care an individual's needs for psychiatric and medical services are generally addressed through consultation and referrals.
"Substance abuse outpatient service" or "Level of care 1.0" means a center-based substance abuse treatment delivered to individuals for fewer than nine hours of service per week for adults or fewer than six hours per week for adolescents on an individual, group, or family basis. Substance abuse outpatient services may include diagnosis and evaluation, screening and intake, counseling, psychotherapy, behavior management, psychological testing and assessment, laboratory and other ancillary services, medical services, and medication services. Substance abuse outpatient service includes substance abuse services or an office practice that provides professionally directed aftercare, individual, and other addiction services to individuals according to a predetermined regular schedule of fewer than nine contact hours a week. Substance abuse outpatient service also includes:
1. Substance abuse services operated by a community services board or a behavioral health authority established pursuant to Chapter 5 (§ 37.2-500 et seq.) or Chapter 6 (§ 37.2-600 et seq.) of Title 37.2 of the Code of Virginia;
2. Substance abuse services contracted by a community services board or a behavioral health authority established pursuant to Chapter 5 (§ 37.2-500 et seq.) or Chapter 6 (§ 37.2-600 et seq.) of Title 37.2 of the Code of Virginia; or
3. Substance abuse services that are owned, operated, or controlled by a corporation organized pursuant to the provisions of either Chapter 9 (§ 13.1-601 et seq.) or Chapter 10 (§ 13.1-801 et seq.) of Title 13.1 of the Code of Virginia.
"Substance abuse partial hospitalization services" or "Level of care 2.5" means a short-term, nonresidential substance use treatment program provided for a minimum of 20 hours a week that uses multidisciplinary staff and is provided for individuals who require a more intensive treatment experience than intensive outpatient treatment but who do not require residential treatment. This level of care is designed to offer highly structured intensive treatment to those individuals whose condition is sufficiently stable so as not to require 24-hour-per-day monitoring and care, but whose illness has progressed so as to require consistent near-daily treatment intervention.
"Suicide attempt" means a nonfatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior regardless of whether it results in injury.
"Supervised living residential service" means the provision of significant direct supervision and community support services to individuals living in apartments or other residential settings. These services differ from supportive in-home service because the provider assumes responsibility for management of the physical environment of the residence, and staff supervision and monitoring are daily and available on a 24-hour basis. Services are provided based on the needs of the individual in areas such as food preparation, housekeeping, medication administration, personal hygiene, treatment, counseling, and budgeting.
"Supportive in-home service" (formerly supportive residential) means the provision of community support services and other structured services to assist individuals, to strengthen individual skills, and that provide environmental supports necessary to attain and sustain independent community residential living. Services include drop-in or friendly-visitor support and counseling to more intensive support, monitoring, training, in-home support, respite care, and family support services. Services are based on the needs of the individual and include training and assistance. These services normally do not involve overnight care by the provider; however, due to the flexible nature of these services, overnight care may be provided on an occasional basis.
"Systemic deficiency" means violations of regulations documented by the department that demonstrate multiple or repeat defects in the operation of one or more services.
"Telehealth" shall have the same meaning as "telehealth services" in § 32.1-122.03:1 of the Code of Virginia.
“Telemedicine" shall have the same meaning as "telemedicine services" in § 38.2-3418.16 of the Code of Virginia.
"Therapeutic day treatment for children and adolescents" means a treatment program that serves (i) children and adolescents from birth through 17 years of age and under certain circumstances up to 21 years of age with serious emotional disturbances, substance use, or co-occurring disorders or (ii) children from birth through seven years of age who are at risk of serious emotional disturbance, in order to combine psychotherapeutic interventions with education and mental health or substance abuse treatment. Services include: evaluation; medication education and management; opportunities to learn and use daily living skills and to enhance social and interpersonal skills; and individual, group, and family counseling.
"Time out" means the involuntary removal of an individual by a staff person from a source of reinforcement to a different, open location for a specified period of time or until the problem behavior has subsided to discontinue or reduce the frequency of problematic behavior.
"Volunteer" means a person who, without financial remuneration, provides services to individuals on behalf of the provider.
"Written," "writing," and "in writing" include any representation of words, letters, symbols, numbers, or figures, whether (i) printed or inscribed on a tangible medium or (ii) stored in an electronic or other medium and retrievable in a perceivable form and whether an electronic signature authorized by Chapter 42.1 (§ 59.1-479 et seq.) of Title 59.1 of the Code of Virginia is or is not affixed.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 19, Issue 24, eff. September 18, 2003; Volume 23, Issue 10, eff. February 21, 2007; Volume 28, Issue 5, eff. December 7, 2011; Volume 35, Issue 4, eff. November 29, 2018; Volume 35, Issue 10, eff. February 21, 2019; Volume 35, Issue 19, eff. June 15, 2019; Errata, 36:5 VA.R. 421 October 28, 2019; amended, Virginia Register Volume 36, Issue 22, eff. August 1, 2020; Volume 39, Issue 11, eff. February 17, 2023; Volume 40, Issue 22, eff. July 17, 2024; Errata, 40:24 VA.R 1990 July 15, 2024.
12VAC35-105-30. Licenses.
A. Licenses are issued to providers who offer services to individuals who have mental illness, a developmental disability, or substance abuse (substance use disorders) or have brain injury and are receiving residential services.
B. Providers shall be licensed to provide specific services as defined in this chapter or as determined by the commissioner. These services include:
1. Assertive community treatment (ACT);
2. Case management;
3. Clinically managed high-intensity residential care or Level of care 3.5;
4. Clinically managed low-intensity residential care or Level of care 3.1;
5. Clinically managed population specific high-intensity residential or Level of care 3.3;
6. Community gero-psychiatric residential;
7. Community-based crisis stabilization;
8. Crisis receiving center;
9. Crisis stabilization unit;
10. Day support;
11. Day treatment, including therapeutic day treatment for children and adolescents;
12. Group home and community residential;
13. ICF/IID;
14. Inpatient psychiatric;
15. Intensive in-home;
16. Medically managed intensive inpatient service or Level of care 4.0;
17. Medically monitored intensive inpatient treatment or Level of care 3.7;
18. Medication assisted opioid treatment;
19. Mental health community support;
20. Mental health intensive outpatient;
21. Mental health outpatient;
22. Mental health partial hospitalization;
23. Psychosocial rehabilitation;
24. REACH CTH;
25. REACH mobile crisis response;
26. Residential treatment;
27. Respite care;
28. Sponsored residential home;
29. Substance abuse intensive outpatient;
30. Substance abuse outpatient;
31. Substance abuse partial hospitalization;
32. Supervised living residential; and
33. Supportive in-home.
C. A license addendum shall describe the services licensed, the disabilities of individuals who may be served, the specific locations where services are to be provided or administered, and the terms and conditions for each service offered by a licensed provider. For residential and inpatient services, the license identifies the number of individuals each residential location may serve at a given time.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 19, Issue 24, eff. September 18, 2003; Volume 23, Issue 10, eff. February 21, 2007; Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023; Errata, 39:14 VA.R. 2041 February 27, 2023; amended, Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-40. Application requirements.
A. All providers that are not currently licensed shall be required to apply for a license using the application designated by the commissioner. Providers applying for a license shall submit:
1. A working budget showing projected revenue and expenses for the first year of operation, including a revenue plan.
2. Documentation of working capital to include:
a. Funds or a line of credit sufficient to cover at least 90 days of operating expenses if the provider is a corporation, unincorporated organization or association, a sole proprietor, or a partnership.
b. Appropriated revenue if the provider is a state or local government agency, board or commission.
3. Documentation of authority to conduct business in the Commonwealth of Virginia.
4. A disclosure statement identifying the legal names and dates of any services licensed in Virginia or other states that the applicant holds or has held, previous sanctions or negative actions against any license to provide services that the applicant holds or has held in any other state or in Virginia, and the names and dates of any disciplinary actions involving the applicant's current or past licensed services.
B. Providers shall submit an application listing each service to be provided and submit the following items for each service:
1. A staffing plan;
2. Employee credentials and job descriptions containing all the elements outlined in 12VAC35-105-410 A;
3. A service description containing all the elements outlined in 12VAC35-105-580 C; and
4. Records management policy containing all the elements outlined in 12VAC35-105-390 and 12VAC35-105-870 A.
C. The provider shall confirm his intent to renew the license prior to the expiration date of the license and notify the department in advance of any changes in service or location.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September. 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-50. Issuance of licenses.
A. The commissioner may issue the following types of licenses:
1. A conditional license may be issued to a new provider for services that demonstrates compliance with administrative and policy regulations but has not demonstrated compliance with all the regulations.
a. A conditional license shall not exceed six months.
b. A conditional license may be renewed if the provider is not able to demonstrate compliance with all the regulations at the end of the license period. A conditional license and any renewals shall not exceed 12 successive months for all conditional licenses and renewals combined.
c. A provider holding a conditional license for a service shall demonstrate progress toward compliance.
d. A provider holding a conditional license shall not add services or locations during the conditional period.
e. A group home or community residential service provider shall be limited to providing services in a single location, serving no more than four individuals during the conditional period.
2. A provisional license may be issued to a provider for a service that has demonstrated an inability to maintain compliance with all applicable regulations, including this chapter and 12VAC35-115, has violations of human rights or licensing regulations that pose a threat to the health or safety of individuals receiving services, has multiple violations of human rights or licensing regulations, or has failed to comply with a previous corrective action plan.
a. A provisional license may be issued at any time.
b. The term of a provisional license shall not exceed six months.
c. A provisional license may be renewed; but a provisional license and any renewals shall not exceed 12 successive months for all provisional licenses and renewals combined.
d. A provider holding a provisional license for a service shall demonstrate progress toward compliance.
e. A provider holding a provisional license for a service shall not increase its services or locations or expand the capacity of the service.
f. A provisional license for a service shall be noted as a stipulation on the provider license. The stipulation shall also indicate the violations to be corrected and the expiration date of the provisional license.
3. A full license shall be issued after a provider or service demonstrates compliance with all the applicable regulations.
a. A full license may be granted to a provider for service for up to three years. The length of the license shall be in the sole discretion of the commissioner.
b. If a full license is granted for three years, it shall be referred to as a triennial license. A triennial license shall be granted to providers for services that have demonstrated full compliance with all applicable regulations. The commissioner may issue a triennial license to a provider for service that had violations during the previous license period if those violations did not pose a threat to the health or safety of individuals receiving services, and the provider or service has demonstrated consistent compliance for more than a year and has a process in place that provides sufficient oversight to maintain compliance.
c. If a full license is granted for one year, it shall be referred to as an annual license.
d. The term of the first full renewal license after the expiration of a conditional or provisional license shall not exceed one year.
B. The commissioner may add stipulations on a license issued to a provider that may place limits on the provider or to impose additional requirements on the provider.
C. A license shall not be transferred or assigned to another provider. A new application shall be made and a new license issued when there is a change in ownership.
D. No service shall be issued a license with an expiration date that is after the expiration date of the provider license.
E. A license shall continue in effect after the expiration date if the provider has submitted a renewal application before the date of expiration and there are no grounds to deny the application. The department shall issue a letter stating the provider or service license shall be effective for six additional months if the renewed license is not issued before the date of expiration.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-60. Modification.
A. A provider shall submit a written service modification application at least 45 days in advance of a proposed modification to its license. The modification may address the characteristics of individuals served (disability, age, or gender), the services offered, the locations where services are provided, existing stipulations, or the maximum number of individuals served under the provider license.
B. Upon receipt of the completed service modification application, the commissioner may revise the provider license. Approval of such request shall be at the sole discretion of the commissioner.
C. A change requiring a modification of the license shall not be implemented prior to approval by the commissioner. The department may send the provider a letter approving implementation of the modification pending the issuance of the modified license.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-70. Onsite reviews.
A. The department shall conduct an announced or unannounced onsite review of all new providers and services to determine compliance with this chapter.
B. The department shall conduct unannounced onsite reviews of licensed providers and each service at any time and at least annually to determine compliance with these regulations. The annual unannounced onsite reviews shall be focused on preventing specific risks to individuals, including an evaluation of the physical facilities in which the services are provided.
C. The department may conduct announced and unannounced onsite reviews at any time as part of the investigations of complaints or incidents to determine if there is a violation of this chapter.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-80. Complaint investigations.
The department shall investigate all complaints regarding potential violations of licensing regulations. Complaint investigations may be based on onsite reviews, a review of records, a review of provider reports or telephone interviews.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-90. Compliance.
A. The department shall determine the level of compliance with each regulation as follows:
1. "Compliance" (C) means the provider clearly meets the requirements of a regulation.
2. "Noncompliance" (NC) means the provider violates or fails to meet part or all of a regulation.
3. "Not Determined" (ND) means that the provider must provide additional information to determine compliance with a regulation.
4. "Not Applicable" (NA) means the provider is specifically exempted from or not required to demonstrate compliance with the provisions of a regulation.
B. The provider, including its employees, contract service providers, student interns, and volunteers, shall comply with all applicable regulations.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-100. Sanctions.
A. The commissioner may invoke the sanctions enumerated in § 37.2-419 of the Code of Virginia upon receipt of information that a licensed provider is:
1. In violation of the provisions of §§ 37.2-400 through 37.2-422 of the Code of Virginia, these regulations, or the provisions of the Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services (12VAC35-115); and
2. Such violation adversely affects the human rights of individuals, or poses an imminent and substantial threat to the health, safety or welfare of individuals.
The commissioner shall notify the provider in writing of the specific violations found and of his intention to convene an informal conference pursuant to § 2.2-4019 of the Code of Virginia at which the presiding officer will be asked to recommend issuance of a special order.
B. The sanctions contained in the special order shall remain in effect during the pendency of any appeal of the special order.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-110. Denial, revocation, or suspension of a license.
A. An application for a license or license renewal may be denied and a full, conditional, or provisional license may be revoked or suspended for one or more of the following reasons:
1. The provider or applicant has violated any provisions of Article 2 (§ 37.2-403 et seq.) of Chapter 4 of Title 37.2 of the Code of Virginia or these licensing regulations;
2. The provider's or applicant's conduct or practices are detrimental to the welfare of any individual receiving services or in violation of human rights identified in § 37.2-400 of the Code of Virginia or the human rights regulations (12VAC35-115);
3. The provider or applicant permits, aids, or abets the commission of an illegal act;
4. The provider or applicant fails or refuses to submit reports or to make records available as requested by the department;
5. The provider or applicant refuses to admit a representative of the department who displays a state-issued photo identification to the premises;
6. The provider or applicant fails to submit or implement an adequate corrective action plan; or
7. The provider or applicant submits any misleading or false information to the department.
B. A provider shall be notified in writing of the department's intent to deny, revoke, or suspend a license; the reasons for the action; the right to appeal; and the appeal process. The provider has the right to appeal the department's decision under the provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia).
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-115. Summary suspension.
A. In conjunction with any proceeding for revocation, denial , or other action, when conditions or practices exist that pose an immediate and substantial threat to the health, safety, and welfare of the individuals living there, the commissioner may issue an order of summary suspension of the license to operate any group home or residential service for adults when he believes the operation of the home or residential service should be suspended during the pendency of such proceeding.
B. Prior to the issuance of an order of summary suspension, the department shall contact the Executive Secretary of the Supreme Court of Virginia to obtain the name of a hearing officer. The department shall schedule the time, date, and location of the administrative hearing with the hearing officer.
C. The order of summary suspension shall take effect upon its issuance. It shall be delivered by personal service and certified mail, return receipt requested, to the address of record of the licensee as soon as practicable. The order shall set forth:
1. The time, date, and location of the hearing;
2. The procedures for the hearing;
3. The hearing and appeal rights; and
4. Facts and evidence that formed the basis for the order of summary suspension.
D. The hearing shall take place within three business days of the issuance of the order of summary suspension.
E. The department shall have the burden of proving in any summary suspension hearing that it had reasonable grounds to require the licensee to cease operations during the pendency of the concurrent revocation, denial, or other proceeding.
F. The administrative hearing officer shall provide written findings and conclusions together with a recommendation as to whether the license should be summarily suspended to the commissioner within five business days of the hearing.
G. The commissioner shall issue a final order of summary suspension or make a determination that the summary suspension is not warranted based on the facts presented and the recommendation of the hearing officer within seven business days of receiving the recommendation of the hearing officer.
H. The commissioner shall issue and serve on the group home or residential facility for adults or its designee by personal service or by certified mail, return receipt requested either:
1. A final order of summary suspension including (i) the basis for accepting or rejecting the hearing officer's recommendation, and (ii) notice that the licensee of the group home or residential service may appeal the commissioner's decision to the appropriate circuit court no later than 10 days following issuance of the order; or
2. Notification that the summary suspension is not warranted by the facts and circumstances presented and that the order of summary suspension is rescinded.
I. The licensee may appeal the commissioner's decision on the summary suspension to the appropriate circuit court no more than 10 days after issuance of the final order.
J. The outcome of concurrent revocation, denial, and other proceedings shall not be affected by the outcome of any hearing pertaining to the appropriateness of the order of summary suspension.
K. At the time of the issuance of the order of summary suspension, the department shall contact the appropriate agencies to inform them of the action and the need to develop relocation plans for the individuals receiving residential or center-based services, and ensure that any other legal guardians or responsible family members are informed of the pending action.
Statutory Authority
§ 37.2-203 of the Code of Virginia
Historical Notes
Derived from Virginia Register Volume 24, Issue 11, eff. March 5, 2008; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-120. Variances.
The commissioner may grant a variance to a specific regulation if he determines that such a variance will not jeopardize the health, safety, or welfare of individuals. A provider shall submit a request for such variance in writing to the commissioner. The request shall demonstrate that complying with the regulation would be a hardship unique to the provider and that the variance will not jeopardize the health, safety, or welfare of individuals. The department may limit the length of time a variance will be effective. The provider shall not implement a variance until it has been approved in writing by the commissioner.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-130. Confidentiality of records.
Records that are confidential under federal or state law shall be maintained as confidential by the department and shall not be further disclosed except as required or permitted by law.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Part III
Administrative Services
Article 1
Management and Administration
12VAC35-105-140. License availability.
The current license or a copy shall be prominently displayed for public inspection in all service locations.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-150. Compliance with applicable laws, regulations and policies.
The provider including its employees, contractors, students, and volunteers shall comply with:
1. This chapter;
2. The terms and stipulations of the license;
3. All applicable federal, state, or local laws and regulations including:
a. Laws regarding employment practices including the Equal Employment Opportunity Act;
b. The Americans with Disabilities Act and the Virginians with Disabilities Act;
c. For home and community-based services waiver settings subject to this chapter, 42 CFR 441.301(c)(1) through (4);
d. Occupational Safety and Health Administration regulations;
e. Virginia Department of Health regulations;
f. Virginia Department of Health Professions regulations;
g. Virginia Department of Medical Assistance Services regulations;
h. Uniform Statewide Building Code; and
i. Uniform Statewide Fire Prevention Code.
4. Section 37.2-400 of the Code of Virginia and related human rights regulations adopted by the state board; and
5. The provider's own policies. All required policies shall be in writing.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-155. Preadmission-screening, discharge planning, involuntary commitment, and mandatory outpatient treatment orders.
A. Providers responsible for complying with §§ 37.2-505 and 37.2-606 of the Code of Virginia regarding community services board and behavioral health authority preadmission screening and discharge planning shall implement policies and procedures that include:
1. Identification, qualification, training, and responsibilities of employees responsible for preadmission screening and discharge planning.
2. Completion of a discharge plan prior to an individual's discharge in consultation with the state facility that:
a. Involves the individual or his authorized representative and reflects the individual's preferences to the greatest extent possible consistent with the individual's needs.
b. Involves mental health, developmental disability, substance abuse, social, educational, medical, employment, housing, legal, advocacy, transportation, and other services that the individual will need upon discharge into the community and identifies the public or private agencies or persons that have agreed to provide them.
B. Any provider who serves individuals through an emergency custody order, temporary detention order, or mandatory outpatient treatment order shall implement policies and procedures to comply with §§ 37.2-800 through 37.2-817 of the Code of Virginia.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011; amended, Virginia Register Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-160. Reviews by the department; requests for information; required reporting.
A. The provider shall permit representatives from the department to conduct reviews to:
1. Verify application information;
2. Assure compliance with this chapter; and
3. Investigate complaints.
B. The provider shall cooperate fully with inspections and investigations and shall provide all information requested by the department.
C. The provider shall collect, maintain, and review at least quarterly all serious incidents, including Level I serious incidents, as part of the quality improvement program in accordance with 12VAC35-105-620 to include an analysis of trends, potential systemic issues or causes, indicated remediation, and documentation of steps taken to mitigate the potential for future incidents.
D. The provider shall collect, maintain, and report or make available to the department the following information:
1. Each allegation of abuse or neglect shall be reported to the department as provided in 12VAC35-115-230 A.
2. Level II and Level III serious incidents shall be reported using the department's web-based reporting application and by telephone or email to anyone designated by the individual to receive such notice and to the individual's authorized representative within 24 hours of discovery. Reported information shall include the information specified by the department as required in its web-based reporting application, but at least the following: the date, place, and circumstances of the serious incident. For serious injuries and deaths, the reported information shall also include the nature of the individual's injuries or circumstances of the death and any treatment received. For all other Level II and Level III serious incidents, the reported information shall also include the consequences that resulted from the serious incident. Deaths that occur in a hospital as a result of illness or injury occurring when the individual was in a licensed service shall be reported.
3. Instances of seclusion or restraint shall be reported to the department as provided in 12VAC35-115-230 C 4.
E. A root cause analysis shall be conducted by the provider within 30 days of discovery of Level II serious incidents and any Level III serious incidents that occur during the provision of a service or on the provider's premises.
1. The root cause analysis shall include at least the following information:
a. A detailed description of what happened;
b. An analysis of why it happened, including identification of all identifiable underlying causes of the incident that were under the control of the provider; and
c. Identified solutions to mitigate its reoccurrence and future risk of harm when applicable.
2. The provider shall develop and implement a root cause analysis policy for determining when a more detailed root cause analysis, including convening a team, collecting and analyzing data, mapping processes, and charting causal factors, should be conducted. At a minimum, the policy shall require for the provider to conduct a more detailed root cause analysis when:
a. A threshold number, as specified in the provider's policy based on the provider's size, number of locations, service type, number of individuals served, and the unique needs of the individuals served by the provider, of similar Level II serious incidents occur to the same individual or at the same location within a six-month period;
b. Two or more of the same Level III serious incidents occur to the same individual or at the same location within a six-month period;
c. A threshold number, as specified in the provider's policy based on the provider's size, number of locations, service type, number of individuals served, and the unique needs of the individuals served by the provider, of similar Level II or Level III serious incidents occur across all of the provider's locations within a six-month period; or
d. A death occurs as a result of an acute medical event that was not expected in advance or based on a person's known medical condition.
F. The provider shall make available and, when requested, submit reports and information that the department requires to establish compliance with these regulations and applicable statutes.
G. Records that are confidential under federal or state law shall be maintained as confidential by the department and shall not be further disclosed except as required or permitted by law; however, there shall be no right of access to communications that are privileged pursuant to § 8.01-581.17 of the Code of Virginia.
H. Additional information requested by the department if compliance with a regulation cannot be determined shall be submitted within 10 business days of the issuance of the licensing report requesting additional information. Extensions may be granted by the department when requested prior to the due date, but extensions shall not exceed an additional 10 business days.
I. Applicants and providers shall not submit any misleading or false information to the department.
J. The provider shall develop and implement a serious incident management policy, which shall be consistent with this section and which shall describe the processes by which the provider will document, analyze, and report to the department information related to serious incidents.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-170. Corrective action plan.
A. If there is noncompliance with any applicable regulation during an initial or ongoing review, inspection, or investigation, the department shall issue a licensing report describing the noncompliance and requesting the provider to submit a corrective action plan for each violation cited.
B. The provider shall submit to the department a written corrective action plan for each violation cited.
C. The corrective action plan shall include a:
1. Detailed description of the corrective actions to be taken that will minimize the possibility that the violation will occur again and correct any systemic deficiencies;
2. Date of completion for each corrective action; and
3. Signature of the person responsible for oversight of the implementation of the pledged corrective action.
D. The provider shall submit a corrective action plan to the department within 15 business days of the issuance of the licensing report. One extension may be granted by the department when requested prior to the due date, but extensions shall not exceed an additional 10 business days. An immediate corrective action plan shall be required if the department determines that the violations pose a danger to individuals receiving the service.
E. Upon receipt of the corrective action plan, the department shall review the plan and determine whether the plan is approved or not approved. The provider has an additional 10 business days to submit a revised corrective action plan after receiving a notice that the department has not approved the revised plan. If the submitted revised corrective action plan is not approved, the provider shall follow the dispute resolution process identified in this section.
F. When the provider disagrees with a citation of a violation or the disapproval of a revised corrective action plan, the provider shall discuss this disagreement with the licensing specialist initially. If the disagreement is not resolved, the provider may ask for a meeting with the licensing specialist's supervisor, in consultation with the director of licensing, to challenge a finding of noncompliance. The determination of the director is final.
G. The provider shall implement their written corrective action plan for each violation cited by the date of completion identified in the plan.
H. The provider shall monitor implementation and effectiveness of approved corrective actions as part of its quality improvement program required by 12VAC35-105-620. If the provider determines that an approved corrective action was fully implemented, but did not prevent the recurrence of a regulatory violation or correct any systemic deficiencies, the provider shall:
1. Continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies; or
2. Submit a revised corrective action plan to the department for approval.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-180. Notification of changes.
A. The provider shall notify the department in writing prior to implementing changes that affect:
1. Organizational or administrative structure, including the name of the provider;
2. Geographic location of the provider or its services;
3. Service description as defined in these regulations;
4. Significant changes to the staffing plan, position descriptions, or employee or contractor qualifications; or
5. Bed capacity for services providing residential or inpatient services.
B. The provider shall not implement the specified changes without the prior approval of the department.
C. The provider shall provide any documentation necessary for the department to determine continued compliance with these regulations after any of these specified changes are implemented.
D. A provider shall notify the department in writing of its intent to discontinue services 30 days prior to the cessation of services. The provider shall continue to provide all services that are identified in each individual's ISP after it has given official notice of its intent to cease operations and until each individual is appropriately discharged. The provider shall further continue to maintain substantial compliance with all applicable regulations as it discontinues its services.
E. All individuals receiving services and their authorized representatives shall be notified of the provider's intent to cease services in writing 30 days prior to the cessation of services. This written notification shall be documented in each individual's ISP.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-190. Operating authority, governing body and organizational structure.
A. The provider shall provide the following evidence of its operating authority:
1. Public organizations shall provide documents describing the administrative framework of the governmental department of which it is a component or describing the legal and administrative framework under which it was established and operates.
2. All private organizations except sole proprietorships shall provide a certificate from the State Corporation Commission.
B. The provider shall provide an organizational chart that clearly identifies its governing body and organizational structure.
C. The provider shall document the role and actions of the governing body, which shall be consistent with its operating authority. The provider shall identify its operating elements and services, the internal relationship among these elements and services, and its management or leadership structure.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-200. Appointment of administrator.
The provider shall appoint qualified persons to whom it delegates, in writing, the authority and responsibility for the administrative direction and day-to-day operation of the provider and its services.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-210. Fiscal accountability.
A. The provider shall document financial arrangements or a line of credit that are adequate to ensure maintenance of ongoing operations for at least 90 days on an ongoing basis. The amount needed shall be based on a working budget showing projected revenue and expenses.
B. At the end of each fiscal year, the provider shall prepare, according to generally accepted accounting principles (GAAP) or those standards promulgated by the Governmental Accounting Standards Board (GASB) and the State Auditor of Public Accounts:
1. An operating statement showing revenue and expenses for the fiscal year just ended.
2. A balance sheet showing assets and liabilities for the fiscal year just ended. The department may require an audit of all financial records by an independent Certified Public Accountant (CPA) or as otherwise provided by law or regulation.
3. Providers operating as a part of a local government agency are not required to provide a balance sheet; however, they shall provide a financial statement.
C. The provider shall have written internal controls to minimize the risk of theft or embezzlement of provider funds.
D. The provider shall identify in writing the title and qualifications of the person who has the authority and responsibility for the fiscal management of its services. At a minimum, the person who has the authority and responsibility for fiscal management shall be bonded or otherwise indemnified.
E. The provider shall notify the department in writing when its line of credit or other financial arrangement has been cancelled or significantly reduced at any time during the licensing period.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-220. Indemnity coverage.
To protect the interests of individuals, employees, and the provider from risks of liability, there shall be indemnity coverage to include:
1. General liability;
2. Professional liability;
3. Commercial vehicular liability; and
4. Property damage.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-230. Written fee schedule.
If the provider charges for services, the written schedule of rates and charges shall be available to the individual or authorized representative upon request.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-240. Policy on funds of individuals receiving services.
A. The provider shall implement a policy for handling funds of individuals receiving services, including providing for separate accounting of individual funds.
B. The provider shall have documented financial controls to minimize the risk of theft or embezzlement of funds of individuals receiving services.
C. The provider shall purchase a surety bond or otherwise provide assurance for the security of all funds of individuals receiving services deposited with the provider.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-250. Deceptive or false advertising.
A. The provider shall not use any advertising that contains false, misleading or deceptive statements or claims, or false or misleading disclosure of fees and payment for services.
B. The provider's name and service names shall not imply the provider is offering services for which it is not licensed.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
Article 2
Physical Environment
12VAC35-105-260. Building inspection and classification.
All locations shall be inspected and approved as required by the appropriate building regulatory entity. Documentation of approval shall be a Certificate of Use and Occupancy indicating the building is classified for its proposed licensed purpose. The provider shall submit a copy of the Certificate of Use and Occupancy to the department for new locations. This section does not apply to correctional facilities or home and noncenter-based services. Sponsored residential service providers shall certify that their sponsored residential homes comply with this regulation.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-265. Floor plans.
All services shall submit floor plans with room dimensions to the department for new locations. This does not apply to home or noncenter-based services.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-270. Building modifications.
A. The provider shall submit building plans and specifications for any planned construction at a new location, changes in the use of existing locations, and any structural modifications or additions to existing locations where services are provided for review by the department to determine compliance with the licensing regulations. This section does not apply to correctional facilities, jails, or home and noncenter-based services.
B. The provider shall submit an interim plan to the department addressing safety and continued service delivery if new construction involving structural modifications or additions to existing buildings is planned.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-280. Physical environment.
A. The physical environment, design, structure, furnishings, and lighting shall be appropriate to the individuals served and the services provided.
B. The physical environment shall be accessible to individuals with physical and sensory disabilities, if applicable.
C. The physical environment and furnishings shall be clean, dry, free of foul odors, safe, and well-maintained.
D. Floor surfaces and floor coverings shall promote mobility in areas used by individuals and shall promote maintenance of sanitary conditions.
E. The physical environment shall be well ventilated. Temperatures shall be maintained between 65°F and 80°F in all areas used by individuals.
F. Adequate hot and cold running water of a safe and appropriate temperature shall be available. Hot water accessible to individuals being served shall be maintained within a range of 100° to 110°F. If temperatures cannot be maintained within the specified range, the provider shall make provisions for protecting individuals from injury due to scalding.
G. Lighting shall be sufficient for the activities being performed and all areas within buildings and outside entrances and parking areas shall be lighted for safety.
H. Recycling, composting, and garbage disposal shall not create a nuisance, permit transmission of disease, or create a breeding place for insects or rodents.
I. If smoking is permitted, the provider shall make provisions for alternate smoking areas that are separate from the service environment. This subsection does not apply to home-based services.
J. For all program areas added after September 19, 2002, minimum room height shall be 7-1/2 feet.
K. This section does not apply to home-based and noncenter-based or crisis services. Sponsored residential services shall certify compliance of sponsored residential homes with this section.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 19, Issue 24, eff. September 18, 2003; Volume 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-290. Food service inspections.
Any location where the provider is responsible for preparing or serving food shall request inspection and shall obtain approval by state or local health authorities regarding food service and general sanitation at the time of the original application and annually thereafter. Documentation of the most recent three inspections and approval shall be kept on file. This section does not apply to sponsored residential services or to group homes or community residential homes.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-300. Sewer and water inspections.
A. Service locations shall be on a public water and sewage system or on a nonpublic water and sewage system. Prior to a location being licensed, the provider shall obtain the report from the building inspector pertaining to the septic system and its capacity. Nonpublic water and sewer systems shall be maintained in good working order and in compliance with local and state laws. Providers of sponsored residential home services shall certify that their sponsored residential homes comply with this section.
B. Service locations that are not on a public water system shall have a water sample tested prior to being licensed and annually by an accredited, independent laboratory for the absence of coliform. The water sample shall also be tested for lead or nitrates if recommended by the local health department. Documentation of the three most recent inspections shall be kept on file.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-310. Weapons.
The provider or facility shall have and implement a written policy governing the use and possession of firearms, pellet guns, air rifles, and other weapons on the premises, including parking areas, of the provider's services. The policy shall provide that no firearms, pellet guns, air rifles, and other weapons shall be permitted unless the weapons are:
1. In the possession of licensed security or sworn law-enforcement personnel;
2. Kept securely under lock and key; or
3. Used under the supervision of a responsible adult in accordance with policies and procedures developed by the provider for the weapons' lawful and safe use.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-320. Fire inspections.
The provider shall document at the time of its original application and annually thereafter that buildings and equipment in residential service locations serving more than eight individuals are maintained in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51). This section does not apply to correctional facilities or home and noncenter-based or sponsored residential home services.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-325. Community liaison.
Each residential service shall designate a staff person as a community liaison responsible for facilitating cooperative relationships with neighbors, local law-enforcement personnel, local government officials, and the community at large.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 3
Physical Environment of Residential and Inpatient Service Locations
12VAC35-105-330. Beds.
A. The provider shall not operate more beds than the number for which its service location is licensed.
B. An ICF/IID may not have more than 12 beds at any one location. This applies to new applications for services and not to existing services or locations licensed prior to December 7, 2011.
C. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-340. Bedrooms.
A. Bedrooms shall meet the following square footage requirements:
1. Single occupancy bedrooms shall have no less than 80 square feet of floor space.
2. Multiple occupancy bedrooms shall have no less than 60 square feet of floor space per individual.
3. This subsection does not apply to community gero-psychiatric residential services.
B. No more than four individuals shall share a bedroom, except in group homes where no more than two individuals shall share a room. This does not apply to group home locations licensed prior to December 7, 2011.
C. Each individual shall have adequate private storage space accessible to the bedroom for clothing and personal belongings.
D. This section does not apply to correctional facilities and jails or crisis services. Providers of sponsored residential home services shall certify that their sponsored residential homes comply with this section.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-350. Condition of beds.
A. Beds shall be clean, comfortable, and equipped with a mattress, pillow, blankets, and bed linens. When a bed is soiled, providers shall assist individuals with bathing as needed, and provide clean clothing and bed linens. Providers of sponsored residential home services shall certify that their sponsored residential homes comply with this section.
B. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-360. Privacy.
A. Bedroom and bathroom windows and doors shall provide privacy.
B. Bathrooms intended for use by more than one individual at the same time shall provide privacy for showers and toilets.
C. No required path of travel to the bathroom shall be through another bedroom.
D. This section does not apply to correctional facilities and jails or crisis services. Providers of sponsored residential home services shall certify that their sponsored residential homes comply with this section.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-370. Ratios of toilets, basins, and showers or baths.
For all residential and inpatient locations established, constructed, or reconstructed after January 13, 1995, there shall be at least one toilet, one hand basin, and shower or bath for every four individuals. This section does not apply to correctional facilities or jails or crisis services. Providers of sponsored residential home services shall certify that their sponsored residential homes comply with this section.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-380. Lighting.
Each service location shall have adequate lighting in halls and bathrooms at night. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter. Providers of sponsored residential home services shall certify that their sponsored residential homes comply with this section.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024.
Article 4
Human Resources
12VAC35-105-390. Confidentiality and security of personnel records.
A. The provider shall maintain an organized system to manage and protect the confidentiality of personnel files and records.
B. Physical and data security controls shall exist for personnel records maintained in electronic databases.
C. Providers shall comply with requirements of the Americans with Disabilities Act and the Virginians with Disabilities Act regarding retention of employee health-related information in a file separate from personnel files.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-400. Criminal background checks and registry searches.
A. Providers shall comply with the requirements for obtaining criminal history background checks as outlined in §§ 37.2-416, 37.2-506, and 37.2-607 of the Code of Virginia for individuals hired after July 1, 1999.
B. The provider shall develop a written policy for criminal history background checks and registry searches. The policy shall require at a minimum a disclosure statement stating whether the person has ever been convicted of or is the subject of pending charges for any offense and shall address what actions the provider will take should it be discovered that a person has a founded case of abuse or neglect or both, or a conviction or pending criminal charge.
C. The provider shall submit all information required by the department to complete the criminal history background checks and registry searches.
D. The provider shall maintain the following documentation:
1. The disclosure statement from the applicant stating whether he has ever been convicted of or is the subject of pending charges for any offense; and
2. Documentation that the provider submitted all information required by the department to complete the criminal history background checks and registry searches, memoranda from the department transmitting the results to the provider, if applicable, and the results from the Child Protective Registry search.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.f the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-410. Job description.
A. Each employee or contractor shall have a written job description that includes:
1. Job title;
2. Duties and responsibilities required of the position;
3. Job title of the immediate supervisor; and
4. Minimum knowledge, skills, and abilities, experience or professional qualifications required for entry level as specified in 12VAC35-105-420.
B. Employees or contractors shall have access to their current job description. The provider shall have written documentation of the mechanism used to advise employees or contractors of changes to their job responsibilities.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-420. Qualifications of employees or contractors.
A. Any person who assumes the responsibilities of any position as an employee or a contractor shall meet the minimum qualifications of that position as determined by job descriptions.
B. Employees and contractors shall comply, as required, with the regulations of the Department of Health Professions. The provider shall design, implement, and document the process used to verify professional credentials.
C. Supervisors shall have experience in working with individuals being served and in providing the services outlined in the service description.
D. Job descriptions shall include minimum knowledge, skills and abilities, professional qualifications and experience appropriate to the duties and responsibilities required of the position.
E. All staff shall demonstrate a working knowledge of the policies and procedures that are applicable to his specific job or position.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-430. Employee or contractor personnel records.
A. Employee or contractor personnel records, whether hard-copy or electronic, shall include:
1. Individual identifying information;
2. Education and training history;
3. Employment history;
4. Results of any provider credentialing process including methods of verification of applicable professional licenses or certificates;
5. Results of reasonable efforts to secure job-related references and reasonable verification of employment history;
6. Results of the required criminal background checks and searches of the registry of founded complaints of child abuse and neglect;
7. Results of performance evaluations;
8. A record of disciplinary action taken by the provider, if any;
9. A record of adverse action by any licensing and oversight bodies or organizations, if any; and
10. A record of participation in employee development activities, including orientation.
B. Each employee or contractor personnel record shall be retained in its entirety for a minimum of three years after the employee's or contractor's termination of employment.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-435. Provision of provider statement to any other provider.
Providers shall give a statement in writing regarding a current or past employee or other individual currently or previously associated with the provider in a capacity that requires a criminal history background check pursuant to § 37.2-416 or 37.2-506 of the Code of Virginia to any other licensed provider with which the current or past employee has applied for employment or to fill a role that requires a criminal history background check pursuant to § 37.2-416 or 37.2-506 of the Code of Virginia. The statement shall address the character, ability, and fitness for employment in or to otherwise fill the role for which the person has applied and shall be provided upon:
1. Receipt of a request for such information from the other licensed provider; and
2. Written consent to the disclosure of such information executed by the current or past employee or other individual currently or previously associated with the provider in a capacity that requires a criminal history background check pursuant to § 37.2-416 or 37.2-506 of the Code of Virginia.
Nothing in this provision shall require disclosure of information subject to privilege or confidentiality pursuant to § 8.01-581.16, 8.01-581.17, or 32.1-127.1:03 of the Code of Virginia or federal law.
Statutory Authority
§§ 37.2-100 and 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 37, Issue 2, eff. October 30, 2020.
12VAC35-105-440. Orientation of new employees, contractors, volunteers, and students.
New employees, contractors, volunteers, and students shall be oriented commensurate with their function or job-specific responsibilities within 15 business days. The provider shall document that the orientation covers each of the following policies, procedures, and practices:
1. Objectives and philosophy of the provider;
2. Practices of confidentiality including access, duplication, and dissemination of any portion of an individual's record;
3. Practices that assure an individual's rights including orientation to human rights regulations;
4. Applicable personnel policies;
5. Emergency preparedness procedures;
6. Person-centeredness;
7. Infection control practices and measures;
8. Other policies and procedures that apply to specific positions and specific duties and responsibilities; and
9. Serious incident reporting, including when, how, and under what circumstances a serious incident report must be submitted and the consequences of failing to report a serious incident to the department in accordance with this chapter.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-450. Employee training and development.
The provider shall provide training and development opportunities for employees to enable them to support the individuals receiving services and to carry out their job responsibilities. The provider shall develop a training policy that addresses the frequency of retraining on serious incident reporting, medication administration, behavior intervention, emergency preparedness, and infection control, to include flu epidemics. Employee participation in training and development opportunities shall be documented and accessible to the department.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-460. Emergency medical or first aid training.
There shall be at least one employee or contractor on duty at each location who holds a current certificate (i) issued by the American Red Cross, the American Heart Association, or comparable authority in standard first aid and cardiopulmonary resuscitation (CPR) or (ii) as an emergency medical technician. A licensed medical professional who holds a current professional license shall be deemed to hold a current certificate in first aid, but not in CPR. The certification process shall include a hands-on, in-person demonstration of first aid and CPR competency.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-470. Notification of policy changes.
All employees or contractors shall be kept informed of policy changes that affect performance of duties. The provider shall have written documentation of the process used to advise employees or contractors of policy changes.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-480. Employee or contractor performance evaluation.
A. The provider shall implement a written policy for evaluating employee and contractor performance.
B. Employee development needs and plans shall be a part of the performance evaluation.
C. The provider shall evaluate employee and contractor performance at least annually.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-490. Written grievance policy.
The provider shall implement a written grievance policy and shall inform employees of grievance procedures. The provider shall have documentation of the process used to advise employees of grievance procedures.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-500. Students and volunteers.
A. The provider shall implement a written policy that clearly defines and communicates the requirements for the use and responsibilities of students and volunteers including selection and supervision.
B. The provider shall not rely on students or volunteers to supplant direct care positions. The provider staffing plan shall not include volunteers or students.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-510. Tuberculosis screening.
A. Each new employee, contractor, student, or volunteer who will have direct contact with individuals receiving services shall obtain a statement of certification by a qualified licensed practitioner indicating the absence of tuberculosis in a communicable form within 30 days of employment or initial contact with individuals receiving services. The employee shall submit a copy of the original screening to the provider. A statement of certification shall not be required for a new employee who has separated from service with another licensed provider with a break in service of six months or less or who is currently working for another licensed provider.
B. All employees, contractors, students, or volunteers in substance abuse co-occurring outpatient or residential treatment services shall be certified as tuberculosis free on an annual basis by a qualified licensed practitioner.
C. Any employee, contractor, student, or volunteer who comes in contact with a known case of active tuberculosis disease or who develops symptoms of active tuberculosis disease (including, but not limited to fever, chills, hemoptysis, cough, fatigue, night sweats, weight loss , or anorexia) of three weeks duration shall be screened as determined appropriate for continued contact with employees, contractors, students, volunteers, or individuals receiving services based on consultation with the local health department.
D. An employee, contractor, student, or volunteer suspected of having active tuberculosis shall not be permitted to return to work or have contact with employees, contractors, students, volunteers , or individuals receiving services until a physician has determined that the person is free of active tuberculosis.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 5
Health and Safety Management
12VAC35-105-520. Risk management.
A. The provider shall designate a person responsible for the risk management function who has completed department approved training, which shall include training related to risk management, understanding of individual risk screening, conducting investigations, root cause analysis, and the use of data to identify risk patterns and trends.
B. The provider shall implement a written plan to identify, monitor, reduce, and minimize harms and risk of harm, including personal injury, infectious disease, property damage or loss, and other sources of potential liability.
C. The provider shall conduct systemic risk assessment reviews at least annually to identify and respond to practices, situations, and policies that could result in the risk of harm to individuals receiving services. The risk assessment review shall address at least the following:
1. The environment of care;
2. Clinical assessment or reassessment processes;
3. Staff competence and adequacy of staffing;
4. Use of high risk procedures, including seclusion and restraint; and
5. A review of serious incidents.
D. The systemic risk assessment process shall incorporate uniform risk triggers and thresholds as defined by the department.
E. The provider shall conduct and document that a safety inspection has been performed at least annually of each service location owned, rented, or leased by the provider. Recommendations for safety improvement shall be documented and implemented by the provider.
F. The provider shall document serious injuries to employees, contractors, students, volunteers, and visitors that occur during the provision of a service or on the provider's property. Documentation shall be kept on file for three years. The provider shall evaluate serious injuries at least annually. Recommendations for improvement shall be documented and implemented by the provider.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-530. Emergency preparedness and response plan.
A. The provider shall develop a written emergency preparedness and response plan for all of its services and locations that describes its approach to emergencies throughout the organization or community. This plan shall include an analysis of potential emergencies that could disrupt the normal course of service delivery including emergencies that would require expanded or extended care over a prolonged period of time. The plan shall address:
1. Specific procedures describing mitigation, preparedness, response, and recovery strategies, actions, and responsibilities for each emergency.
2. Documentation of coordination with the local emergency authorities to determine local disaster risks and community-wide plans to address different disasters and emergency situations.
3. The process for notifying local and state authorities of the emergency and a process for contacting staff when emergency response measures are initiated.
4. Written emergency management policies outlining specific responsibilities for provision of administrative direction and management of response activities, coordination of logistics during the emergency, communications, life safety of employees, contractors, students, volunteers, visitors, and individuals receiving services, property protection, community outreach, and recovery and restoration.
5. Written emergency response procedures for initiating the response and recovery phase of the plan including a description of how, when, and by whom the phases will be activated. This includes assessing the situation; protecting individuals receiving services, employees, contractors, students, volunteers, visitors, equipment, and vital records; and restoring services. Emergency procedures shall address:
a. Warning and notifying individuals receiving services;
b. Communicating with employees, contractors, and community responders;
c. Designating alternative roles and responsibilities of staff during emergencies including to whom they will report in the provider's organization command structure and when activated in the community's command structure;
d. Providing emergency access to secure areas and opening locked doors;
e. Evacuation procedures, including for individuals who need evacuation assistance;
f. Conducting evacuations to emergency shelters or alternative sites and accounting for all individuals receiving services;
g. Relocating individuals receiving residential or inpatient services, if necessary;
h. Notifying family members or authorized representatives;
i. Alerting emergency personnel and sounding alarms;
j Locating and shutting off utilities when necessary; and
k. Maintaining a 24 hour telephone answering capability to respond to emergencies for individuals receiving services.
6. Processes for managing the following under emergency conditions:
a. Activities related to the provision of care, treatment, and services including scheduling, modifying, or discontinuing services; controlling information about individuals receiving services; providing medication; and transportation services;
b. Logistics related to critical supplies such as pharmaceuticals, food, linen, and water;
c. Security including access, crowd control, and traffic control; and
d. Back-up communication systems in the event of electronic or power failure.
7. Specific processes and protocols for evacuation of the provider's building or premises when the environment cannot support adequate care, treatment, and services.
8. Supporting documents that would be needed in an emergency, including emergency call lists, building and site maps necessary to shut off utilities, designated escape routes, and list of major resources such as local emergency shelters.
9. Schedule for testing the implementation of the plan and conducting emergency preparedness drills. Fire and evacuation drills shall be conducted at least monthly.
B. The provider shall evaluate each individual and, based on that evaluation, shall provide appropriate environmental supports and adequate staff to safely evacuate all individuals during an emergency.
C. The provider shall implement annual emergency preparedness and response training for all employees, contractors, students, and volunteers. This training shall also be provided as part of orientation for new employees and cover responsibilities for:
1. Alerting emergency personnel and sounding alarms;
2. Implementing evacuation procedures, including evacuation of individuals with special needs (i.e., deaf, blind, nonambulatory);
3. Using, maintaining, and operating emergency equipment;
4. Accessing emergency medical information for individuals receiving services; and
5. Utilizing community support services.
D. The provider shall review the emergency preparedness plan annually and make necessary revisions. Such revisions shall be communicated to employees, contractors, students, volunteers, and individuals receiving services and incorporated into training for employees, contractors, students, and volunteers and into the orientation of individuals to services.
E. In the event of a disaster, fire, emergency, or any other condition that may jeopardize the health, safety, or welfare of individuals, the provider shall take appropriate action to protect the health, safety, and welfare of individuals receiving services and take appropriate actions to remedy the conditions as soon as possible.
F. Employees, contractors, students, and volunteers shall be knowledgeable in and prepared to implement the emergency preparedness plan in the event of an emergency. The plan shall include a policy regarding regularly scheduled emergency preparedness training for all employees, contractors, students, and volunteers.
G. In the event of a disaster, fire, emergency, or any other condition that may jeopardize the health, safety, or welfare of individuals, the provider should first respond and stabilize the disaster or emergency. After the disaster or emergency is stabilized, the provider should report the disaster or emergency to the department, but no later than 24 hours after the incident occurs.
H. Providers of residential services shall have at all times a three-day supply of emergency food and water for all residents and staff. Emergency food supplies should include foods that do not require cooking. Water supplies shall include one gallon of water per person per day.
I. All provider locations shall be equipped with at least one approved type ABC portable fire extinguisher with a minimum rating of 2A10BC installed in each kitchen.
J. All provider locations shall have an appropriate number of properly installed smoke detectors based on the size of the location, which shall include at a minimum:
1. At least one smoke detector on each level of multi-level buildings, including the basement;
2. At least one smoke detector in each bedroom in locations with bedrooms;
3. At least one smoke detector in any area adjacent to any bedroom in locations with bedrooms; and
4. Any additional smoke detectors necessary to comply with all applicable federal and state laws and regulations and local ordinances.
K. Smoke detectors shall be tested monthly for proper operation.
L. All provider locations shall maintain a floor plan identifying locations of:
1. Exits;
2. Primary and secondary evacuation routes;
3. Accessible egress routes;
4. Portable fire extinguishers; and
5. Flashlights.
M. This section does not apply to home and noncenter-based services.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-540. Access to telephone in emergencies; emergency telephone numbers.
A. Telephones shall be accessible for emergency purposes.
B. Instructions for contacting emergency services and telephone numbers shall be prominently posted near the telephone including how to contact provider medical personnel if appropriate.
C. This section does not apply to home and noncenter-based services and correctional facilities.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-550. First aid kit accessible.
A. A well-stocked first aid kit shall be maintained and readily accessible for minor injuries and medical emergencies at each service location and to employees or contractors providing in-home services or traveling with individuals. The minimum requirements of a well-stocked first aid kit that shall be maintained include a thermometer, bandages, saline solution, band-aids, sterile gauze, tweezers, instant ice-pack, adhesive tape, first-aid cream, and antiseptic soap.
B. A cardiopulmonary resuscitation (CPR) face guard or mask shall be readily accessible.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-560. Operable flashlights or battery lanterns.
Operable flashlights or battery lanterns shall be readily accessible to employees and contractors in services that operate between dusk and dawn to use in emergencies. This section does not apply to home and noncenter-based services.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Part IV
Services and Supports
Article 1
Service Description and Staffing
12VAC35-105-570. Mission statement.
Article 1
Service Description and Staffing
The provider shall develop a written mission statement that clearly identifies its philosophy, purpose, and goals.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-580. Service description requirements.
A. The provider shall develop, implement, review, and revise its descriptions of services offered according to the provider's mission and shall make service descriptions available for public review.
B. The provider shall outline how each service offers a structured program of individualized interventions and care designed to meet the individuals' physical and emotional needs; provide protection, guidance and supervision; and meet the objectives of any required individualized services plan.
C. The provider shall prepare a written description of each service it offers. Elements of each service description shall include:
1. Service goals;
2. A description of care, treatment, skills acquisition, or other supports provided;
3. Characteristics and needs of individuals to receive services;
4. Contract services, if any;
5. Eligibility requirements and admission, continued stay, and exclusion criteria;
6. Service termination and discharge or transition criteria; and
7. Type and role of employees or contractors.
D. The provider shall revise the written service description whenever the operation of the service changes.
E. The provider shall not implement services that are inconsistent with its most current service description.
F. The provider shall admit only those individuals whose service needs are consistent with the service description, for whom services are available, and for which staffing levels and types meet the needs of the individuals receiving services.
G. The provider shall provide for the physical separation of children and adults in residential and inpatient services and shall provide separate group programming for adults and children, except in the case of family services. The provider shall provide for the safety of children accompanying parents receiving services. Older adolescents transitioning from school to adult activities may participate in developmental day support services with adults.
H. The service description for substance abuse treatment services shall address the timely and appropriate treatment of pregnant women with substance abuse (substance use disorders).
I. If the provider plans to serve individuals as of a result of a temporary detention order to a service, prior to admitting those individuals to that service, the provider shall submit a written plan for adequate staffing and security measures to ensure the individual can receive services safely within the service to the department for approval. If the plan is approved, the department shall add a stipulation to the license authorizing the provider to serve individuals who are under temporary detention orders.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-590. Provider staffing plan.
A. The provider shall implement a written staffing plan that includes the types, roles, and numbers of employees and contractors that are required to provide the service. This staffing plan shall reflect the:
1. Needs of the individuals receiving services;
2. Types of services offered;
3. Service description;
4. Number of individuals to receive services at a given time; and
5. Adequate number of staff required to safely evacuate all individuals during an emergency.
B. The provider shall develop a written transition staffing plan for new services, added locations, and changes in capacity.
C. The provider shall meet the following staffing requirements related to supervision.
1. The provider shall describe how employees, volunteers, contractors, and student interns will be supervised in the staffing plan and how that supervision will be documented.
2. Supervision of employees, volunteers, contractors, and student interns shall be provided by persons who have experience in working with individuals receiving services and in providing the services outlined in the service description.
3. Supervision shall be appropriate to the services provided and the needs of the individual. Supervision shall be documented.
4. Supervision shall include responsibility for approving assessments and individualized services plans, as appropriate. This responsibility may be delegated to an employee or contractor who meets the qualification for supervision as defined in this section.
5. Supervision of mental health, substance abuse, or co-occurring services that are of an acute or clinical nature such as outpatient, inpatient, intensive in-home, or day treatment shall be provided by a licensed mental health professional or a mental health professional who is license-eligible and registered with a board of the Department of Health Professions.
6. Supervision of mental health, substance abuse, or co-occurring services that are of a supportive or maintenance nature, such as psychosocial rehabilitation or mental health supports, shall be provided by a QMHP-A, a licensed mental health professional, or a mental health professional who is license-eligible and registered with a board of the Department of Health Professions. An individual who is a QMHP-T may not provide this type of supervision.
7. Supervision of developmental services shall be provided by a person with at least one year of documented experience working directly with individuals who have developmental disabilities and holds at least a bachelor's degree in a human services field such as sociology, social work, special education, rehabilitation counseling, nursing, or psychology. Experience may be substituted for the education requirement.
8. Supervision of brain injury services shall be provided, at a minimum, by a clinician in the health professions field who is trained and experienced in providing brain injury services to individuals who have a brain injury diagnosis including (i) a doctor of medicine or osteopathy licensed in Virginia; (ii) a psychiatrist who is a doctor of medicine or osteopathy specializing in psychiatry and licensed in Virginia; (iii) a psychologist who has a master's degree in psychology from a college or university with at least one year of clinical experience; (iv) a social worker who has a bachelor's degree in human services or a related field (social work, psychology, psychiatric evaluation, sociology, counseling, vocational rehabilitation, human services counseling, or other degree deemed equivalent to those described) from an accredited college or university with at least two years of clinical experience providing direct services to individuals with a diagnosis of brain injury; (v) a Certified Brain Injury Specialist; (vi) a registered nurse licensed in Virginia with at least one year of clinical experience; or (vii) any other licensed rehabilitation professional with one year of clinical experience.
D. The provider shall employ or contract with persons with appropriate training, as necessary, to meet the specialized needs of and to ensure the safety of individuals receiving services in residential services with medical or nursing needs; speech, language, or hearing problems; or other needs where specialized training is necessary.
E. Providers of brain injury services shall employ or contract with a neuropsychologist or licensed clinical psychologist specializing in brain injury to assist, as appropriate, with initial assessments, development of individualized services plans, crises, staff training, and service design.
F. Staff in direct care positions providing brain injury services shall have at least a high school diploma and two years of experience working with individuals with disabilities or shall have successfully completed an approved training curriculum on brain injuries within six months of employment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 19, Issue 24, eff. September 18, 2003; Volume 23, Issue 10, eff. February 21, 2007; Volume 28, Issue 5, eff. December 7, 2011; Volume 35, Issue 19, eff. June 15, 2019; Volume 36, Issue 22, eff. August 1, 2020; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-600. Nutrition.
A. A provider preparing and serving food shall:
1. Implement a written plan for the provision of food services, which ensures access to nourishing, well-balanced, varied, and healthy meals;
2. Make reasonable efforts to prepare meals that consider the cultural background, personal preferences, and food habits and that meet the dietary needs of the individuals served; and
3. Assist individuals who require assistance feeding themselves in a manner that effectively addresses any deficits.
B. Providers of residential and inpatient services shall implement a policy to monitor each individual's food consumption and nutrition for:
1. Warning signs of changes in physical or mental status related to nutrition; and
2. Compliance with any needs determined by the individualized services plan or prescribed by a physician, nutritionist, or health care professional.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-610. Community participation.
Individuals receiving residential and day support services shall be afforded opportunities to participate in community activities that are based on their personal interests or preferences. The provider shall have written documentation that such opportunities were made available to individuals served.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-620. Monitoring and evaluating service quality.
A. The provider shall develop and implement written policies and procedures for a quality improvement program sufficient to identify, monitor, and evaluate clinical and service quality and effectiveness on a systematic and ongoing basis.
B. The quality improvement program shall utilize standard quality improvement tools, including root cause analysis, and shall include a quality improvement plan.
C. The quality improvement plan shall:
1. Be reviewed and updated at least annually;
2. Define measurable goals and objectives;
3. Include and report on statewide performance measures, if applicable, as required by DBHDS;
4. Monitor implementation and effectiveness of approved corrective action plans pursuant to 12VAC35-105-170; and
5. Include ongoing monitoring and evaluation of progress toward meeting established goals and objectives.
D. The provider's policies and procedures shall include the criteria the provider will use to
1. Establish measurable goals and objectives ;
2. Update the provider's quality improvement plan; and
3. Submit revised corrective action plans to the department for approval or continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies when reviews determine that a corrective action was fully implemented but did not prevent the recurrence of the cited regulatory violation or correct a systemic deficiency pursuant to 12VAC35-105-170.
E. Input from individuals receiving services and their authorized representatives, if applicable, about services used and satisfaction level of participation in the direction of service planning shall be part of the provider's quality improvement plan. The provider shall implement improvements, when indicated.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
Article 2
Screening, Admission, Assessment, Service Planning, and Orientation
12VAC35-105-630. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; repealed, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-640. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; repealed, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-645. Initial contacts, screening, admission, assessment, service planning, orientation and discharge.
A. The provider shall implement policies and procedures for initial contacts and screening, admissions, and referral of individuals to other services and designate staff to perform these activities.
B. The provider shall maintain written documentation of an individual's initial contact and screening prior to his admission including the:
1. Date of contact;
2. Name, age, and gender of the individual;
3. Address and telephone number of the individual, if applicable;
4. Reason why the individual is requesting services; and
5. Disposition of the individual including his referral to other services for further assessment, placement on a waiting list for service, or admission to the service.
C. The provider shall assist individuals who are not admitted to identify other appropriate services.
D. The provider shall retain documentation of the individual's initial contacts and screening for six months. Documentation shall be included in the individual's record if the individual is admitted to the service.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-650. Assessment policy.
A. The provider shall implement a written assessment policy. The policy shall define how assessments will be conducted and documented.
B. The provider shall actively involve the individual and the individual's authorized representative, if applicable, in the preparation of initial and comprehensive assessments and in subsequent reassessments. In these assessments and reassessments, the provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.
C. The assessment policy shall designate employees or contractors who are responsible for conducting assessments. These employees or contractors shall have experience in working with the needs of individuals who are being assessed, the assessment tools being utilized, and the provision of services that the individuals may require.
D. Assessment is an ongoing activity. The provider shall make reasonable attempts to obtain previous assessments or relevant history.
E. An assessment shall be initiated prior to or at admission to the service. With the participation of the individual and the individual's authorized representative, if applicable, the provider shall complete an initial assessment detailed enough to determine whether the individual qualifies for admission and to initiate an ISP for those individuals who are admitted to the service. This assessment shall assess immediate service, health, and safety needs, and, at a minimum, include the individual's:
1. Diagnosis;
2. Presenting needs, including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of problems;
3. Current medical problems;
4. Current medications;
5. Current and past substance use or abuse, including co-occurring mental health and substance abuse disorders; and
6. At-risk behavior to self and others.
F. A comprehensive assessment shall update and finalize the initial assessment. The timing for completion of the comprehensive assessment shall be based upon the nature and scope of the service but shall occur no later than 30 days after admission for providers of mental health and substance abuse services and 60 days after admission for providers of developmental services. The comprehensive assessment shall address:
1. Onset and duration of problems;
2. Social, behavioral, developmental, and family history and supports;
3. Cognitive functioning, including strengths and weaknesses;
4. Employment, vocational, and educational background;
5. Previous interventions and outcomes;
6. Financial resources and benefits;
7. Health history and current medical care needs, to include:
a. Allergies;
b. Recent physical complaints and medical conditions;
c. Nutritional needs;
d. Chronic conditions;
e. Communicable diseases;
f. Restrictions on physical activities, if any;
g. Restrictive protocols or special supervision requirements;
h. Past serious illnesses, serious injuries, and hospitalizations;
i. Serious illnesses and chronic conditions of the individual's parents, siblings, and significant others in the same household; and
j. Current and past substance use, including alcohol, prescription and nonprescription medications, and illicit drugs.
8. Psychiatric and substance use issues, including current mental health or substance use needs, presence of co-occurring disorders, history of substance use or abuse, and circumstances that increase the individual's risk for mental health or substance use issues;
9. History of abuse, neglect, sexual or domestic violence, or trauma, including psychological trauma;
10. Legal status, including authorized representative, commitment, and representative payee status;
11. Relevant criminal charges or convictions and probation or parole status;
12. Daily living skills;
13. Housing arrangements;
14. Ability to access services, including transportation needs; and
15. As applicable, and in all residential services, fall risk, communication methods or needs, and mobility and adaptive equipment needs.
G. Providers of short-term intensive services, including inpatient and crisis stabilization services, shall develop policies for completing comprehensive assessments within the time frames appropriate for those services.
H. Providers of nonintensive or short-term services shall meet the requirements for the initial assessment at a minimum. Nonintensive services are services provided in jails, nursing homes, or other locations when access to records and information is limited by the location and nature of the services. Short-term services typically are provided for less than 60 days.
I. Providers may utilize standardized state or federally sanctioned assessment tools that do not meet all the criteria of this section as the initial or comprehensive assessment tools as long as the tools assess the individual's health and safety issues and substantially meet the requirements of this section.
J. Individuals who receive medication-only services shall be reassessed at least annually to determine whether there is a change in the need for additional services and the effectiveness of the medication.
K. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-660. Individualized services plan (ISP).
A. The provider shall actively involve the individual and the individual's authorized representative, as appropriate, in the development, review, and revision of a person-centered ISP. The individualized services planning process shall be consistent with laws protecting confidentiality, privacy, human rights of individuals receiving services, and rights of minors.
B. The provider shall develop and implement an initial person-centered ISP for the first 60 days for developmental services or for the first 30 days for mental health and substance abuse services. This ISP shall be developed and implemented within 24 hours of admission to address immediate service, health, and safety needs and shall continue in effect until the ISP is developed or the individual is discharged, whichever comes first.
C. The provider shall implement a person-centered comprehensive ISP as soon as possible after admission based upon the nature and scope of services but no later than 30 days after admission for providers of mental health and substance abuse services and 60 days after admission for providers of developmental services.
D. The initial ISP and the comprehensive ISP shall be developed based on the respective assessment with the participation and informed choice of the individual receiving services.
1. To ensure the individual's participation and informed choice, the following shall be explained to the individual or the individual's authorized representative, as applicable, in a reasonable and comprehensible manner:
a. The proposed services to be delivered;
b. Any alternative services that might be advantageous for the individual; and
c. Any accompanying risks or benefits of the proposed and alternative services.
2. If no alternative services are available to the individual, it shall be clearly documented within the ISP, or within documentation attached to the ISP, that alternative services were not available as well as any steps taken to identify if alternative services were available.
3. Whenever there is a change to an individual's ISP, it shall be clearly documented within the ISP, or within documentation attached to the ISP that:
a. The individual participated in the development of or revision to the ISP;
b. The proposed and alternative services and their respective risks and benefits were explained to the individual or the individual's authorized representative; and
c. The reasons the individual or the individual's authorized representative chose the option included in the ISP.
E. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 19, Issue 24, eff. September 18, 2003; Volume 23, Issue 10, eff. February 21, 2007; Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-665. ISP requirements.
A. The comprehensive ISP shall be based on the individual's needs, strengths, abilities, personal preferences, goals, and natural supports identified in the assessment. The ISP shall include:
1. Relevant and attainable goals, measurable objectives, and specific strategies for addressing each need;
2. Services and supports and frequency of services required to accomplish the goals, including relevant psychological, mental health, substance abuse, behavioral, medical, rehabilitation, training, and nursing needs and supports;
3. The role of the individual and others in implementing the service plan;
4. A communication plan for individuals with communication barriers, including language barriers;
5. A behavioral support or treatment plan, if applicable;
6. A safety plan that addresses identified risks to the individual or to others, including a fall risk plan;
7. A crisis or relapse plan, if applicable;
8. Target dates for accomplishment of goals and objectives;
9. Identification of employees or contractors responsible for coordination and integration of services, including employees of other agencies;
10. Recovery plans, if applicable; and
11. Services the individual elects to self-direct, if applicable.
B. The ISP shall be signed and dated, at a minimum, by the person responsible for implementing the plan and the individual receiving services or the individual's authorized representative in order to document agreement. If the signature of the individual receiving services or the individual's authorized representative cannot be obtained, the provider shall document attempts to obtain the necessary signature and the reason why he was unable to obtain it. The ISP shall be distributed to the individual and others authorized to receive it.
C. The provider shall designate a person who shall be responsible for developing, implementing, reviewing, and revising each individual's ISP in collaboration with the individual or individual's authorized representative, as appropriate.
D. Employees or contractors who are responsible for implementing the ISP shall demonstrate a working knowledge of the objectives and strategies contained in the individual's current ISP, including an individual's detailed health and safety protocols.
E. Providers of short-term intensive services such as inpatient and crisis services that are typically provided for less than 30 days shall implement a policy to develop an ISP within a timeframe consistent with the length of stay of individuals.
F. When a provider provides more than one service to an individual, the provider may maintain a single ISP document that contains individualized objectives and strategies for each service provided.
G. Whenever possible, the identified goals in the ISP shall be written in the words of the individual receiving services.
H. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011; amended, Virginia Register Volume 36, Issue 22, eff. August 1, 2020; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-670. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; repealed, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-675. Reassessments and ISP reviews.
A. Reassessments shall be completed at least annually and any time there is a need based on changes in the medical, psychiatric, behavioral, or other status of the individual.
B. Providers shall complete changes to the ISP as a result of the assessments.
C. The provider shall update the ISP at least annually and any time assessments identify risks, injuries, needs, or a change in status of the individual.
D. The provider shall complete quarterly reviews of the ISP at least every three months from the date of the implementation of the comprehensive ISP.
1. These reviews shall evaluate the individual's progress toward meeting the ISP's goals and objectives and the continued relevance of the ISP's objectives and strategies. The provider shall update the goals, objectives, and strategies contained in the ISP, if indicated, and implement any updates made.
2. These reviews shall document evidence of progression toward or achievement of a specific targeted outcome for each goal and objective.
3. For goals and objectives that were not accomplished by the identified target date, the provider and any appropriate treatment team members shall meet to review the reasons for lack of progress and provide the individual an opportunity to make an informed choice of how to proceed. Documentation of the quarterly review shall be added to the individual's record no later than 15 calendar days from the date the review was due to be completed, with the exception of case management services. Case management quarterly reviews shall be added to the individual's record no later than 30 calendar days from the date the review was due.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011; amended, Virginia Register Volume 35, Issue 12, eff. March 21, 2019; amended, Volume 36, Issue 22, eff. August 1, 2020; Volume 37, Issue 12, eff. March 4, 2021.
12VAC35-105-680. Progress notes or other documentation.
The provider shall use signed and dated progress notes or other documentation to document the services provided and the implementation of the goals and objectives contained in the ISP.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-690. Orientation.
A. The provider shall implement a written policy regarding the orientation of individuals and their authorized representatives, if applicable to services.
B. As appropriate to the scope and level of services the policy shall require the provision to individuals and authorized representatives the following information:
1. The mission of the provider or service;
2. Service confidentiality practices and protections for individuals receiving services;
3. Human rights policies and protections and instructions on how to report violations;
4. Opportunities for participation in services and discharge planning;
5. Fire safety and emergency preparedness procedures, if applicable;
6. The provider's grievance procedure;
7. Service guidelines including criteria for admission to and discharge or transfer from services;
8. Hours and days of operation;
9. Availability of after-hours service; and
10. Any charges or fees due from the individual.
C. In addition, individuals receiving treatment services in a correctional facility shall receive an orientation to the facility's security restrictions.
D. The provider shall document that the individual and authorized representative, if applicable, received an orientation to services.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-691. Transition of individuals among service..
A. The provider shall implement written procedures that define the process for transitioning an individual between or among services operated by the provider. At a minimum the policy shall address:
1. The process by which the provider will assure continuity of services during and following transition;
2. The participation of the individual or his authorized representative, as applicable, in the decision to move and in the planning for transfer;
3. The process and timeframe for transferring the access to individual's record and ISP to the destination location;
4. The process and timeframe for completing the transfer summary; and
5. The process and timeframe for transmitting or accessing, where applicable, discharge summaries to the destination service.
B. The transfer summary shall include at a minimum the following:
1. Reason for the individual's transfer;
2. Documentation of informed choice by the individual or his authorized representative, as applicable, in the decision to and planning for the transfer;
3. Current psychiatric and known medical conditions or issues of the individual and the identity of the individual's health care providers;
4. Updated progress of the individual in meeting goals and objectives in his ISP;
5. Emergency medical information;
6. Dosages of all currently prescribed medications and over-the-counter medications used by the individual when prescribed by the provider or known by the case manager;
7. Transfer date; and
8. Signature of employee or contractor responsible for preparing the transfer summary.
C. The transfer summary may be documented in the individual's progress notes or in information easily accessible within an electronic health record.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011; amended, Virginia Register Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-693. Discharge.
A. The provider shall have written policies and procedures regarding the discharge or termination of individuals from the service. These policies and procedures shall include medical and clinical criteria for discharge.
B. Discharge instructions shall be provided in writing to the individual, the individual's authorized representative, and the successor provider, as applicable. Discharge instructions shall include, at a minimum, medications and dosages; names, telephone numbers, and addresses of any providers to whom the individual is referred; current medical issues or conditions; and the identity of the treating health care providers.
C. The provider shall make appropriate arrangements or referrals to all service providers identified in the discharge plan prior to the individual's scheduled discharge date.
D. The content of the discharge plan and the determination to discharge the individual shall be consistent with the ISP and the criteria for discharge.
E. The provider shall document in the individual's service record that the individual, the individual's authorized representative, and the individual's family members, as appropriate, have been involved in the discharge planning process.
F. A written discharge summary shall be completed within 30 days of discharge and shall include, at a minimum, the following:
1. Reason for the individual's admission to and discharge from the service;
2. Description of the individual's or the individual's authorized representative's participation in discharge planning;
3. The individual's current level of functioning or functioning limitations, if applicable;
4. Recommended procedures, activities, or referrals to assist the individual in maintaining or improving functioning and increased independence;
5. The status, location, and arrangements that have been made for future services;
6. Progress made by the individual in achieving goals and objectives identified in the ISP and summary of critical events during service provision;
7. Discharge date;
8. Discharge medications prescribed by the provider, if applicable;
9. Date the discharge summary was actually written or documented; and
10. Signature of the person who prepared the summary.
G. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011; amended, Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
Article 3
Crisis Intervention and Emergencies
12VAC35-105-700. Written policies and procedures for crisis or emergency interventions; required elements.
A. The provider shall implement written policies and procedures for prompt intervention in the event of a crisis or a behavioral, medical, or psychiatric emergency that may occur during screening and referral, at admission, or during the period of service provision.
B. The policies and procedures shall include:
1. A definition of what constitutes a crisis or behavioral, medical, or psychiatric emergency;
2. Procedures for immediately accessing appropriate internal and external resources. This shall include a provision for obtaining physician and mental health clinical services if the provider's or service's on-call or back-up physician or mental health clinical services are not available at the time of the emergency;
3. Employee or contractor responsibilities; and
4. Location of emergency medical information for each individual receiving services, including any advance psychiatric or medical directive or crisis response plan developed by the individual, which shall be readily accessible to employees or contractors on duty in an emergency or crisis.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-710. Documenting crisis intervention and emergency services.
A. The provider shall develop a method for documenting the provision of crisis intervention and emergency services. Documentation shall include the following:
1. Date and time;
2. Description of the nature of or circumstances surrounding the crisis or emergency;
3. Name of individual;
4. Description of precipitating factors;
5. Interventions or treatment provided;
6. Names of employees or contractors responding to or consulted during the crisis or emergency; and
7. Outcome.
B. If a crisis or emergency involves an individual who is admitted into service, documentation of the crisis intervention or provision of emergency services shall become part of his record.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 4
Medical Management
12VAC35-105-720. Health care policy.
A. The provider shall implement a policy, appropriate to the scope and level of service that addresses provision of adequate and appropriate medical care. This policy shall describe how:
1. Medical care needs will be assessed including circumstances that will prompt the decision to obtain a medical assessment.
2. Individualized services plans will address any medical care needs appropriate to the scope and level of service.
3. Identified medical care needs will be addressed.
4. The provider will manage medical care needs or respond to abnormal findings.
5. The provider will communicate medical assessments and diagnostic laboratory results to the individual and authorized representative, as appropriate.
6. The provider will keep accessible to staff and contractors on duty the names, addresses, and phone numbers of the individual's medical and dental providers.
7. The provider will ensure a means for facilitating and arranging, as appropriate, transportation to medical and dental appointments and medical tests, when services cannot be provided on site.
B. The provider shall implement written policies to identify any individuals who are at risk for falls and develop and implement a fall prevention and management plan and program for each at risk individual.
C. Providers of residential or inpatient services shall provide or arrange for the provision of appropriate medical care. Providers of other services shall define instances when they shall provide or arrange for appropriate medical and dental care and instances when they shall refer the individual to appropriate medical care.
D. The provider shall implement written infection control measures including the use of universal precautions.
E. The provider shall report outbreaks of infectious diseases to the Department of Health pursuant to § 32.1-37 of the Code of Virginia.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-730. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, September 19, 2002; repealed, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-740. Physical examination for residential and inpatient services.
A. Providers of residential or inpatient services shall administer or obtain results of physical exams within 30 days of an individual's admission. The examination must have been conducted within one year of admission to the service. Providers of inpatient services shall administer physical exams within 24 hours of an individual's admission.
B. A physical examination shall include, at a minimum:
1. General physical condition (history and physical);
2. Evaluation for communicable diseases;
3. Recommendations for further diagnostic tests and treatment, if appropriate;
4. Other examinations that may be indicated; and
5. The date of examination and signature of a qualified practitioner.
C. Locations designated for physical examinations shall ensure individual privacy.
D. The provider shall review and follow up with the results of the physical examination and of any follow-up diagnostic tests, treatments, or examinations in the individual's record.
E. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-750. Emergency medical information.
A. The provider shall maintain the following emergency medical information for each individual:
1. If available, the name, address, and telephone number of:
a. The individual's physician; and
b. The authorized representative or other person to be notified;
2. Medical insurance company name and policy or Medicaid, Medicare , or CHAMPUS number, if any;
3. Currently prescribed medications and over-the-counter medications used by the individual;
4. Medication and food allergies;
5. History of substance abuse;
6. Significant medical problems or conditions;
7. Significant ambulatory or sensory problems;
8. Significant communication problems; and
9. Advance directive, if one exists.
B. Current emergency medical information shall be readily available to employees or contractors wherever program services are provided.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-760. Medical equipment.
The provider shall develop and implement a policy on maintenance and use of medical equipment, including personal medical equipment and devices.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
Article 5
Medication Management Services
12VAC35-105-770. Medication management.
A. The provider shall implement written policies addressing:
1. The safe administration, handling, storage, and disposal of medications;
2. The use of medication orders;
3. The handling of packaged medications brought by individuals from home or other residences;
4. Employees or contractors who are authorized to administer medication and training required for administration of medication;
5. The use of professional samples; and
6. The window within which medications can be given in relation to the ordered or established time of administration.
B. Medications shall be administered only by persons who are authorized to do so by state law.
C. Medications shall be administered only to the individuals for whom the medications are prescribed and shall be administered as prescribed.
D. The provider shall maintain a daily log of all medicines received and refused by each individual. This log shall identify the employee or contractor who administered the medication, the name of the medication and dosage administered or refused, and the time the medication was administered or refused.
E. If the provider administers medications or supervises self-administration of medication in a service, a current medication order for all medications the individual receives shall be maintained on site.
F. The provider shall promptly dispose of discontinued drugs, outdated drugs, and drug containers with worn, illegible, or missing labels according to the applicable regulations of the Virginia Board of Pharmacy.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-780. Medication errors and drug reactions.
In the event of a medication error or adverse drug reaction:
1. First aid shall be administered if indicated.
2. Employees or contractors shall promptly contact a poison control center, pharmacist, nurse or physician and shall take actions as directed.
3. The individual's physician shall be notified as soon as possible unless the situation is addressed in standing orders.
4. Actions taken by employees or contractors shall be documented.
5. The provider shall review medication errors at least quarterly as part of the quality assurance in 12VAC35-105-620.
6. Medication errors and adverse drug reactions shall be recorded in the individual's medication log.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-790. Medication administration and storage or pharmacy operation.
A. A provider responsible for medication administration and medication storage or pharmacy operations shall comply with:
1. The Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia);
2. The Virginia Board of Pharmacy regulations;
3. The Virginia Board of Nursing regulations; and
4. Applicable federal laws and regulations relating to controlled substances.
B. A provider responsible for medication administration and storage or pharmacy operation shall provide in-service training to employees and consultation to individuals and authorized representatives on issues of basic pharmacology including medication side effects.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 6
Behavior Interventions
12VAC35-105-800. Policies and procedures on behavior interventions and supports.
A. The provider shall implement written policies and procedures that describe the use of behavior interventions, including seclusion, restraint, and time out. The policies and procedures shall:
1. Be consistent with applicable federal and state laws and regulations;
2. Emphasize positive approaches to behavior interventions;
3. List and define behavior interventions in the order of their relative degree of intrusiveness or restrictiveness and the conditions under which they may be used in each service for each individual;
4. Protect the safety and well-being of the individual at all times, including during fire and other emergencies;
5. Specify the mechanism for monitoring the use of behavior interventions; and
6. Specify the methods for documenting the use of behavior interventions.
B. Employees and contractors trained in behavior support interventions shall implement and monitor all behavior interventions.
C. Policies and procedures related to behavior interventions shall be available to individuals, their families, authorized representatives, and advocates. Notification of policies does not need to occur in correctional facilities.
D. Individuals receiving services shall not discipline, restrain, seclude, or implement behavior interventions on other individuals receiving services.
E. Injuries resulting from or occurring during the implementation of seclusion or restraint shall be reported to the department as provided in 12VAC35-115-230 C.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 19, Issue 24, eff. September 18, 2003; Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-810. Behavioral treatment plan.
A written behavioral treatment plan may be developed as part of the individualized services plan in response to behavioral needs identified through the assessment process. A behavioral treatment plan may include restrictions only if the plan has been developed according to procedures outlined in the human rights regulations. A behavioral treatment plan shall be developed, implemented, and monitored by employees or contractors trained in behavioral treatment.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-820. Prohibited actions.
The following actions shall be prohibited:
1. Prohibition of contacts and visits with the individual's attorney, probation officer, placing agency representative, minister or chaplain;
2. Any action that is humiliating, degrading, or abusive;
3. Subjection to unsanitary living conditions;
4. Deprivation of opportunities for bathing or access to toilet facilities except as ordered by a licensed physician for a legitimate medical purpose and documented in the individual's record;
5. Deprivation of appropriate services and treatment;
6. Deprivation of health care;
7. Administration of laxatives, enemas, or emetics except as ordered by a physician or other professional acting within the scope of his license for a legitimate medical purpose and documented in the individual's record;
8. Applications of aversive stimuli except as permitted pursuant to other applicable state regulations;
9. Limitation on contacts with regulators, advocates or staff attorneys employed by the department or the Virginia Office for Protection and Advocacy.
10. Deprivation of drinking water or food necessary to meet an individual's daily nutritional needs except as ordered by a licensed physician for a legitimate medical purpose and documented in the individual's record;
11. Prohibition on contacts or visits with family or an authorized representative except as permitted by other applicable state regulations or by order of a court of competent jurisdiction;
12. Delay or withholding of incoming or outgoing mail except as permitted by other applicable state and federal regulations or by order of a court of competent jurisdiction; and
13. Deprivation of opportunities for sleep or rest except as ordered by a licensed physician for a legitimate medical purpose and documented in the individual's record.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-830. Seclusion, restraint, and time out.
A. The use of seclusion, restraint, and time out shall comply with applicable federal and state laws and regulations and be consistent with the provider's policies and procedures.
B. Devices used for mechanical restraint shall be designed specifically for emergency behavior management of human beings in clinical or therapeutic programs.
C. Application of time out, seclusion, or restraint shall be documented in the individual's record and include the following:
1. Physician's order for seclusion or mechanical restraint or chemical restraint;
2. Date and time;
3. Employees or contractors involved;
4. Circumstances and reasons for use including other emergency behavior management techniques attempted;
5. Duration;
6. Type of technique used; and
7. Outcomes, including documentation of debriefing of the individual and staff involved following the incident.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-840. Requirements for seclusion room.
A. The room used for seclusion shall meet the design requirements for buildings used for detention or seclusion of individuals.
B. The seclusion room shall be at least six feet wide and six feet long with a minimum ceiling height of eight feet.
C. The seclusion room shall be free of all protrusions, sharp corners, hardware, fixtures or other devices which may cause injury to the individual.
D. Windows in the seclusion room shall be so constructed as to minimize breakage and otherwise prevent the individual from harming himself.
E. Light fixtures and other electrical receptacles in the seclusion room shall be recessed or so constructed as to prevent the individual from harming himself. Light controls shall be located outside the seclusion room.
F. Doors to the seclusion room shall be at least 32 inches wide, shall open outward and shall contain observation view panels of transparent wire glass or its approved equivalent, not exceeding 120 square inches but of sufficient size for someone outside the door to see into all corners of the room.
G. The seclusion room shall contain only a mattress with a washable mattress covering designed to avoid damage by tearing.
H. The seclusion room shall maintain temperatures appropriate for the season.
I. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-850. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; repealed, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-860. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; repealed, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Part V
Records Management
12VAC35-105-870. Paper and electronic records management policy.
A. The provider shall implement a written records management policy that describes confidentiality, accessibility, security, and retention of paper and electronic records pertaining to individuals, including:
1. Access and limitation of access, duplication, or dissemination of individual information to persons who are authorized to access such information according to federal and state laws;
2. Storage, processing, and handling of active and closed records;
3. Storage, processing, and handling of electronic records;
4. Security measures that protect records from loss, unauthorized alteration, inadvertent or unauthorized access, disclosure of information, and transportation of records between service sites;
5. Strategies for service continuity and record recovery from interruptions that result from disasters or emergencies including contingency plans, electronic or manual back-up systems, and data retrieval systems;
6. Designation of the person responsible for records management; and
7. Disposition of records in the event that the service ceases operation. If the disposition of records involves a transfer to another provider, the provider shall have a written agreement with that provider.
B. The records management policy shall be consistent with applicable state and federal laws and regulations including:
1. Section 32.1-127.1:03 of the Code of Virginia;
2. 42 USC § 290dd;
3. 42 CFR Part 2; and
4. The Health Insurance Portability and Accountability Act (Public Law 104-191) and implementing regulations (45 CFR Parts 160, 162, and 164).
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-880. Documentation policy.
A. The provider shall define, by policy, all records it maintains that address an individual's care and treatment and what each record contains.
B. The provider shall define, by policy, and implement a system of documentation that supports appropriate service planning, coordination, and accountability. At a minimum this policy shall outline:
1. The location of the individual's record;
2. Methods of access by employees or contractors to the individual's record; and
3. Methods of updating the individual's record by employees or contractors including the frequency and format of updates.
C. Entries in the individual's record shall be current, dated, and authenticated by the persons making the entries. For paper records, errors shall be corrected by striking through and initialing the incorrect information. If records are electronic, the provider shall implement a written policy to include the identification of errors and corrections to the record.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-890. Individual's service record.
A. There shall be a separate primary record for each individual admitted for service. A separate record shall be maintained for each family member who is receiving individual treatment.
B. All individuals admitted to the service shall have identifying information readily accessible in the individual's service record. Identifying information shall include the following:
1. Identification number unique for the individual;
2. Name of individual;
3. Current residence, if known;
4. Social security number;
5. Gender;
6. Marital status;
7. Date of birth;
8. Name of authorized representative, if applicable;
9. Name, address, and telephone number for emergency contact;
10. Adjudicated legal incompetency or legal incapacity, if applicable; and
11. Date of admission to service.
C. In addition an individual's service record shall contain, at a minimum:
1. Screening documentation;
2. Assessments;
3. Medical evaluation, as applicable to the service;
4. Individualized services plans and reviews;
5. Progress notes; and
6. A discharge summary, if applicable.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-900. Record storage and security.
A. When not in use, active and closed paper records shall be stored in a locked cabinet or room.
B. Physical and data security controls shall exist to protect electronic records.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-910. Retention of individual's service records.
The provider shall retain an individual's service record for the time period specified by state or federal requirements.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-920. Review process for records.
The provider shall implement a review process to evaluate both current and closed records for completeness, accuracy, and timeliness of entries.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
Part VI
Additional Requirements for Selected Services
Article 1
Medication Assisted Treatment (Opioid Treatment Services)
12VAC35-105-925. Standards for the evaluation of new licenses for providers of services to individuals with opioid addiction.
A. Applicants requesting an initial license to provide a service for the treatment of opioid addiction through the use of methadone or any other opioid treatment medication or controlled substance shall supply information to the department that demonstrates the appropriateness of the proposed service in accordance with this section.
B. The proposed site of the service shall comply with § 37.2-406 of the Code of Virginia.
C. In jurisdictions without zoning ordinances, the department shall request that the local governing body advise it as to whether the proposed site is suitable for and compatible with use as an office and the delivery of health care services. The department shall make this request when it notifies the local governing body of a pending application.
D. Applicants shall demonstrate that the building or space to be used to provide the proposed service is suitable for the treatment of opioid addiction by submitting documentation of the following:
1. The proposed site complies with the requirements of the local building regulatory entity;
2. The proposed site complies with local zoning laws or ordinances, including any required business licenses;
3. In the absence of local zoning ordinances, the proposed site is suitable for and compatible with use as offices and the delivery of health care services;
4. In jurisdictions where there are no parking ordinances, the proposed site has sufficient off-street parking to accommodate the needs of the individuals being served and prevent the disruption of traffic flow;
5. The proposed site can accommodate individuals during periods of inclement weather;
6. The proposed site complies with the Virginia Statewide Fire Prevention Code; and
7. The applicant has a written plan to ensure security for storage of methadone at the site, which complies with regulations of the Drug Enforcement Agency (DEA), and the Virginia Board of Pharmacy.
E. Applicants shall submit information to demonstrate that there are sufficient personnel available to meet the following staffing requirements and qualifications:
1. The program sponsor means the person responsible for the operation of the opioid treatment program and who assumes responsibility for all its employees, including any practitioners, agents, or other persons providing medical, rehabilitative, or counseling at the program at any of its medication units. The program sponsor is responsible for ensuring the program is in continuous compliance with all federal, state, and local laws and regulations.
2. The program director shall be licensed or certified by the applicable Virginia health regulatory board or registered as eligible for this license or certification with relevant training, experience, or both, in the treatment of individuals with opioid addiction. The program director is responsible for the day-to-day management of the program.
3. The medical director shall be a board-certified addictionologist or have successfully completed or will complete within one year a course of study in opiate addiction that is approved by the department; and:
a. Is responsible for ensuring all medical, psychiatric, nursing, pharmacy, toxicology, and other services offered by the medication assisted opioid treatment provider are conducted in compliance with federal regulations at all times; and
b. Shall be physically present at the program for a sufficient number of hours to ensure regulatory compliance and carry out those duties specifically assigned to the medical director by regulation.
4. A minimum of one pharmacist.
5. Nurses.
6. Counselors shall be licensed or certified by the applicable Virginia health regulatory board or eligible for this license or certification.
7. Personnel to provide support services.
8. Have linkage with or access to psychological, medical, and psychiatric consultation.
9. Have access to emergency medical and psychiatric care through affiliations with more intensive levels of care.
10. Have the ability to conduct or arrange for appropriate laboratory and toxicology tests.
11. Ensure all clinical staff, whether employed by the provider or available through consultation, contract, or other means, are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
F. The applicant may provide peer recovery specialists (PRS). Peer recovery specialists shall be professionally qualified by education and experience in accordance with 12VAC35-250. A registered peer recovery specialist shall be a PRS registered with the Board of Counseling in accordance with 18VAC115-70 and provide such services as an employee or independent contractor of DBHDS, a provider licensed by the DBHDS, a practitioner licensed by or holding a permit issued from the Department of Health Professions, or a facility licensed by the Virginia Department of Health.
G. If there is a change in or loss of any staff in the positions listed or any change in the provider's ability to comply with the requirements in subsection E of this section, the provider shall formally notify the Substance Abuse and Mental Health Services Administration (SAMHSA) and DBHDS. The provider shall also submit a plan to SAMHSA and DBHDS for immediate coverage within three weeks.
H. Applicants shall submit a description for the proposed service that includes:
1. Proposed mission, philosophy, and goals of the provider;
2. Care, treatment, and services to be provided, including a comprehensive discussion of levels of care provided and alternative treatment strategies offered;
3. Proposed hours and days of operation;
4. Plans for onsite security and services adequate to ensure the safety of patients, staff, and property; and
5. A diversion control plan for dispensed medications, including policies for use of drug screens.
I. Applicants shall, in addition to the requirements of 12VAC35-105-580 C 2, provide documentation of their capability to provide the following services and support directly or by arrangement with other specified providers when such services and supports are (i) requested by an individual being served or (ii) identified as an individual need, based on the assessment conducted in accordance with 12VAC35-105-60 B and included in the individualized services plan:
1. General.
a. Psychological services;
b. Social services;
c. Vocational services;
d. Educational services, including HIV/AIDS education and other health education services; and
e. Employment services.
2. Initial medical examination services.
3. Special services for pregnant patients.
4. Initial and periodic, individualized, patient-centered assessment and treatment services.
5. Counseling services.
6. Drug abuse testing services.
7. Case management services, including medical monitoring and coordination, with onsite and offsite treatment services provided as needed.
J. Applicants shall submit documentation of contact with community services boards or behavioral health authorities in their service areas to discuss their plans for operating in the area and to develop joint agreements, as appropriate.
K. Applicants shall provide policies and procedures that shall address assessment, administration, and regulation of medication and dose levels appropriate to the individual. The policies and procedures shall at a minimum require that each individual served be assessed every six months by the treatment team to determine if that individual is appropriate for safe and voluntary medically supervised withdrawal from opioid analgesics, including methadone or buprenorphine, alternative therapies including other medication assisted treatments, or continued federally approved pharmacotherapy treatment for opioid addiction.
L. Applicants shall submit policies and procedures describing services they will provide to individuals who wish to discontinue medication assisted opioid treatment services.
M. Applicants shall provide assurances that the service will have a community liaison responsible for developing and maintaining cooperative relationships with community organizations, other service providers, local law enforcement, local government officials, and the community at large.
N. The department shall conduct announced and unannounced reviews and complaint investigations in collaboration with the Virginia Board of Pharmacy and DEA to determine compliance with the regulations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 23, Issue 20, eff. July 11, 2007; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 33, Issue 26, eff. October 6, 2017; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-930. Registration, certification, or accreditation.
A. The medication assisted opioid treatment service shall maintain current registration or certification with:
1. The federal Drug Enforcement Administration;
2. The federal Department of Health and Human Services; and
3. The Virginia Board of Pharmacy.
B. A provider of medication assisted opioid treatment services shall maintain accreditation with an entity approved under federal regulations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-935. Criteria for patient admission.
A. Before a medication assisted opioid treatment program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to (i) meet diagnostic criteria for opioid use disorder as defined within the DSM; and (ii) meet the admission criteria of Level 1.0 of ASAM. The policies shall be consistent with subsections B through E of this section.
B. A medication assisted opioid treatment program shall maintain current procedures that are designed to ensure that individuals are admitted to short-term or long-term detoxification treatment by qualified personnel, such as a program physician who determines that such treatment is appropriate for the specific individual by applying established diagnostic criteria. An individual with two or more unsuccessful detoxification episodes within a 12-month period must be assessed by the medication assisted opioid treatment program physician for other forms of treatment. A program shall not admit an individual for more than two detoxification treatment episodes in one year.
C. A medication assisted opioid treatment program shall maintain current procedures designed to ensure that individuals are admitted to maintenance treatment by qualified personnel who have determined, using accepted medical criteria, that the person is currently addicted to an opioid drug, and that the individual became addicted at least one year before admission for treatment. In addition, a program physician shall ensure that each individual voluntarily chooses maintenance treatment, that all relevant facts concerning the use of the opioid drug are clearly and adequately explained to the individual, and that each individual provides informed written consent to treatment.
D. A person younger than 18 years of age is required to have had two documented unsuccessful attempts at short-term detoxification or drug-free treatment within a 12-month period to be eligible for maintenance treatment. No individual younger than 18 years of age may be admitted to maintenance treatment unless parent, legal guardian, or responsible adult designated by the relevant state authority consents in writing to such treatment.
E. If clinically appropriate, the program physician may waive the requirement of a one-year history of addiction under subsection C of this section, for individuals released from penal institutions (within six months after release), for pregnant patients (program physician must certify pregnancy), and for previously treated individuals (up to two years after discharge).
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-940. Criteria for involuntary termination from treatment.
A. The provider shall establish criteria for involuntary termination from treatment that describe the rights of the individual receiving services and the responsibilities and rights of the provider.
B. The provider shall establish a grievance procedure as part of the rights of the individual.
C. On admission, the individual shall be given a copy of the criteria and grievance procedure and shall sign a statement acknowledging receipt of same. The signed acknowledgment shall be maintained in the individual's service record.
D. Upon admission and annually thereafter all individuals shall sign an authorization for disclosure of information to allow the provider access to the Virginia Prescription Monitoring System. Individuals who fail to sign this authorization shall be denied admission to the program.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-945. Criteria for patient discharge.
Before a medication assisted opioid treatment program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require medication assisted opioid treatment level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-950. Service operation schedule.
A. The service's days of operation shall meet the needs of the individuals served. If the service dispenses or administers a medication requiring daily dosing, the service shall operate seven days a week, 12 months a year, except for official state holidays. Prior approval from the state methadone authority shall be required for additional closed days.
B. The service may close on Sundays if all the following criteria are met:
1. The provider develops and implements policies and procedures that address recently admitted individuals receiving services, individuals not currently on a stable dose of medication, patients that present noncompliance treatment behaviors, and individuals who previously picked up take-home medications on Sundays, security of take-home medication doses, and health and safety of individuals receiving services.
2. The provider receives prior approval from the state opioid treatment authority (SOTA) for Sunday closings. Each program must have a policy that addresses medication for the newly inducted patients and those who are deemed at risk, for example, are still actively using illicit substances or medical issues that may warrant closer monitoring of medication.
3. Once approved, by the SOTA to close on Sundays, the provider shall notify individuals receiving services in writing at least 30 days in advance of their intent to close on Sundays. The notice shall address the risks to the individuals and the security of take-home medications. All individuals shall receive an orientation addressing take-home policies and procedures, and this orientation shall be documented in the individual's service record prior to receiving take-home medications.
4. The provider shall establish procedures for emergency access to dosing information 24 hours a day, seven days a week. This information may be provided via an answering service, pager, or other electronic measures. Information needed includes the individual's last dosing time and date, and dose.
C. Medication dispensing hours shall include at least two hours each day of operation outside normal working hours, that is, before 9 a.m. and after 5 p.m. The SOTA may approve an alternative schedule if the SOTA determines that schedule meets the needs of the population served by the provider.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-960. Initial and periodic assessment services.
A. The individual shall have a complete physical examination prior to admission to the service unless the individual is transferring from another licensed medication assisted opioid treatment service in Virginia. The provider shall maintain the report of the individual's physical examination in the individual's service record. The results of serology and other tests shall be available within 14 days of admission.
B. The program physician shall review a consent to treatment form with the patient and sign the form prior to the individual receiving the first dose of medication.
C. The provider shall maintain the report of the individual's physical examination in the individual's service record.
D. The program shall have a policy to ensure that coordination of care is in place with any prescribing physician.
E. The provider shall coordinate treatment services for individuals who are prescribed benzodiazepines and prescription narcotics with the treating physician. The coordination shall be the responsibility of the provider's physician and shall be documented.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-965. Special services for pregnant individuals.
The program shall ensure that every pregnant woman has the opportunity for prenatal care, prenatal education, and postpartum follow-up, either onsite or by referral to an appropriate health care provider.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-970. Counseling sessions.
The provider shall conduct face-to-face counseling sessions (either individual or group) at least every two weeks for the first year of an individual's treatment and every month in the second year of the individual's treatment. After two years, the number of face-to-face counseling sessions that an individual receives shall be based on the individual's progress in treatment. The failure of an individual to participate in counseling sessions shall be addressed as part of the overall treatment process.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-980. Drug screens.
A. The provider shall perform at least one random drug screen per month unless the conditions in subsection B of this section apply.
B. Whenever an individual's drug screen indicates continued illicit drug use or when clinically and environmentally indicated, random drug screens shall be performed weekly.
C. Drug screens shall be analyzed for opiates, methadone (if ordered), benzodiazepines, cocaine, and buprenorphine. In addition, drug screens for other drugs that have the potential for addiction shall be performed when clinically and environmentally indicated.
D. The provider shall implement a written policy on how the results of drug screens shall be used to direct treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-990. Take-home medication.
A. Prior to dispensing regularly scheduled take-home medication, the provider shall ensure the individual demonstrates a level of current lifestyle stability as evidenced by the following:
1. Regular clinic attendance, including dosing and participation in counseling or group sessions;
2. Absence of recent alcohol abuse and illicit drug use;
3. Absence of significant behavior problems;
4. Absence of recent criminal activities, charges, or convictions;
5. Stability of the individual's home environment and social relationships;
6. Length of time in treatment;
7. Ability to ensure take-home medications are safely stored; and
8. Demonstrated rehabilitative benefits of take-home medications outweigh the risks of possible diversion.
B. Determinations for the take-home approval shall be based on the clinical judgment of the physician in consultation with the treatment team and shall be documented in the individual's service record.
C. If it is determined that an individual in comprehensive maintenance treatment is appropriate for handling take-home medication, the amount of take-home medication shall not exceed:
1. A single take-home dose for one day when the clinic is closed for business, including Sundays and state or federal holidays.
2. A single dose each week during the first 90 days of treatment (beyond that in subdivision 1 of this subsection). The individual shall ingest all other doses under the supervision of a medication administration trained employee.
3. Two doses per week in the second 90 days of treatment (beyond that in subdivision 1 of this subsection).
4. Three doses per week in the third 90 days of treatment (beyond that in subdivision 1 of this subsection).
5. A maximum six-day supply of take-home doses in the remaining months of the first year of treatment.
6. A maximum two-week supply of take-home medication after one year of continuous treatment.
7. One month's supply of take-home medication after two years of continuous treatment with monthly visits made by the individual served.
D. No medication shall be dispensed to individuals in short-term detoxification treatment or interim maintenance treatment for unsupervised take-home use.
E. Medication assisted opioid treatment providers shall maintain current procedures adequate to identify the theft or diversion of take-home medications. These procedures shall require the labeling of containers with the medication assisted opioid treatment providers name, address, and telephone number. Programs shall ensure that the take-home supplies are packaged in a manner that is designed to reduce the risk of accidental ingestion, including child proof containers.
F. The provider shall educate the individual on the safe transportation and storage of take-home medication.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1000. Preventing duplication of medication services.
To prevent duplication of medication assisted opioid treatment services to an individual, prior to admission of the individual, the provider shall implement written policy and procedures for contacting every medication assisted opioid treatment service within a 50-mile radius before admitting an individual.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1010. Guests.
A. For the purpose of this section a guest is a patient of a medication assisted opioid treatment service in another state or another area of Virginia, who is traveling and is not yet eligible for take-home medication. Guest dosing shall be approved by the individual's home clinic.
B. The provider shall not dispense medication to any guest unless the guest has been receiving such medication services from another provider and documentation from that provider has been received prior to dispensing medication.
C. Guests may receive medication for up to 28 days. To continue receiving medication after 28 days, the guest must be admitted to the service. Individuals receiving guest medications as part of a residential treatment service may exceed the 28-day maximum time limit at the medication assisted opioid treatment service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1020. Detoxification prior to involuntary discharge.
The provider shall give an individual who is being involuntarily discharged an opportunity to detoxify from opioid agonist medication not less than 10 days or not more than 30 days prior to his discharge from the service, unless the state methadone authority has granted an exception.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1030. Opioid agonist medication renewal.
Physician orders for opioid agonist medication shall be reevaluated and renewed at least every six months.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-1040. Emergency preparedness plan.
The provider's emergency preparedness plan shall include provision for the continuation of opioid treatment in the event of an emergency or natural disaster.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1050. Security of opioid agonist medication supplies.
A. At a minimum, the provider shall secure opioid agonist medication supplies by restricting access to medication areas to medical or pharmacy personnel.
B. The provider shall reconcile the medication inventory monthly.
C. The provider shall keep inventory records, including the monthly reconciliation, for three years.
D. The provider shall maintain a current plan to control the diversion of medication to unprescribed or illegal uses.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 2
Medically Managed Withdrawal Services
12VAC35-105-1055. Description of level of care provided.
In the service description the provider shall describe the level of services and the medical management provided.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1060. Cooperative agreements with community agencies.
The provider shall establish cooperative agreements with other community agencies to accept referrals for treatment, including provisions for physician coverage if not provided on-site, and emergency medical care. The agreements shall clearly outline the responsibility of each party.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1070. Observation area.
The provider shall provide for designated areas for employees and contractors with unobstructed observation of individuals.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-1080. Direct-care training for providers of detoxification services.
A. The provider shall document staff training in the areas of:
1. Management of withdrawal; and
2. First responder training.
B. Untrained employees or contractors shall not be solely responsible for the care of individuals.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1090. Minimum number of employees or contractors on duty.
In detoxification service locations, at least two employees or contractors shall be on duty at all times. If the location is within or contiguous to another service location, at least one employee or contractor shall be on duty at the location with trained backup employees or contractors immediately available. In other managed withdrawal settings the number of staff on duty shall be appropriate for the services offered and individuals served.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1100. Documentation.
Employees or contractors on each shift shall document services provided and significant events in the individual's record.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1110. Admission assessments.
During the admission process, providers of medically monitored intensive inpatient services shall:
1. Identify individuals with a high-risk for medical complications or who may pose a danger to themselves or others;
2. Assess substances used and time of last use;
3. Determine time of last meal;
4. Administer a urine screen;
5. Analyze blood alcohol content or administer a breathalyzer; and
6. Record vital signs.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1120. Vital signs.
A. Unless the individual refuses, the provider shall take vital signs:
1. At admission and discharge;
2. Every four hours for the first 24 hours and every eight hours thereafter; and
3. As frequently as necessary, until signs and symptoms stabilize for individuals with a high-risk profile.
B. The provider shall have procedures to address situations when an individual refuses to have vital signs taken.
C. The provider shall document vital signs, all refusals and follow-up actions taken.
D. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1130. Light snacks and fluids.
The provider shall offer light snacks and fluids to individuals who are not in danger of aspirating.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
Article 3
Services in Department of Corrections Correctional Facilities
12VAC35-105-1140. Clinical and security coordination.
A. The provider shall have formal and informal methods of resolving procedural and programmatic issues regarding individual care arising between the clinical and security employees or contractors.
B. The provider shall demonstrate ongoing communication between clinical and security employees to ensure individual care.
C. The provider shall provide cross-training for the clinical and security employees or contractors that includes:
1. Mental health, developmental disability, and substance abuse education;
2. Use of clinical and security restraints; and
3. Channels of communication.
D. Employees or contractors shall receive periodic in-service training, and have knowledge of and be able to demonstrate the appropriate use of clinical and security restraint.
E. Security and behavioral assessments shall be completed at the time of admission to determine service eligibility and at least weekly for the safety of individuals, other persons, employees, and visitors.
F. Personal grooming and care services for individuals shall be a cooperative effort between the clinical and security employees or contractors.
G. Clinical needs and security level shall be considered when arrangements are made regarding privacy for individual contact with family and attorneys.
H. Living quarters shall be assigned on the basis of the individual's security level and clinical needs.
I. An assessment of the individual's clinical condition and needs shall be made when disciplinary action or restrictions are required for infractions of security measures.
J. Clinical services consistent with the individual's condition and plan of treatment shall be provided when security detention or isolation is imposed.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-1150. Other requirements for correctional facilities.
A. Group bathroom facilities shall be partitioned between toilets and urinals to provide privacy.
B. If uniform clothing is required, the clothing shall be properly fitted, climatically suitable, durable, and presentable.
C. Financial compensation for work performed shall be determined by the Department of Corrections. Personal housecleaning tasks may be assigned without compensation to the individual.
D. The use of audio equipment, such as televisions, radios, and record players, shall not interfere with therapeutic activities.
E. Aftercare planning for individuals nearing the end of incarceration shall include a provision for continuing medication and follow-up services with area community services to facilitate successful reintegration into the community including specific appointment provided to the inmate no later than the day of release.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 4
Sponsored Residential Homes Services
12VAC35-105-1160. Sponsored residential home information.
Providers of sponsored residential home services shall maintain the following information:
1. Names and ages of residential sponsors;
2. Date of sponsored residential home agreement;
3. The maximum number of individuals that can be placed in the home at a given time;
4. Names and ages of all other individuals who are not receiving services but are residing in a sponsored residential home;
5. Address and telephone number of the sponsored residential home; and
6. Names of all staff employed in the home, including on-call and substitute staff.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1170. Sponsored residential home agreements.
A. The provider shall maintain a written agreement with residential home sponsors. Sponsors are persons who provide the home where the service is located and are directly responsible for the provision of services. The agreement shall include the:
1. Provider's responsibilities;
2. Sponsor's responsibilities;
3. Scope of services;
4. Supervision;
5. Compensation;
6. Training; and
7. Reporting requirements and procedures.
B. The agreement shall be available for inspection by the licensing specialist and shall include a provision for granting the right of entry to state licensing specialists or human rights advocates to conduct inspections.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1180. Sponsor qualification and approval process.
A. The provider shall evaluate and certify each sponsored residential home other than his own through face-to-face interviews, home inspections, and other information documenting compliance with this section. The provider shall submit the certification form to the department before individuals are placed in the home and ensure that the following requirements are met annually.
B. The provider shall certify and document that each sponsored residential home meets the criteria for physical environment and residential services in these regulations.
C. The provider shall document the ability of the sponsored residential home staff to meet the needs of the individuals placed in the home by assessing and documenting:
1. The ability of the sponsor or any staff to communicate and understand individuals receiving services;
2. The ability of the sponsor or any staff to provide the care, treatment, training, or habilitation for individuals receiving services in the home;
3. The abilities of all members of the sponsored household to accept individuals with disabilities and their disability-related characteristics, especially the ability of children in the household to adjust to nonfamily members living with them;
4. The financial capacity of the sponsor to meet the sponsor's own expenses for up to 90 days, independent of payments received for residents living in the home; and
5. The education, qualifications, and experience of the sponsor or staff with the individuals served including Virginia Department of Motor Vehicles driving record, tuberculosis screening, first-aid and CPR certification, and completion of medication administration and behavior interventions training.
D. The provider shall obtain three job-related references, past licensing history, criminal background checks, and a search of the registry of founded complaints of child abuse and neglect maintained by the Department of Social Services for the sponsor and all staff.
E. The provider shall implement written policies for obtaining references, criminal background checks, and registry checks for all adults in the home who are neither staff nor individuals being served. The policy shall indicate what action the provider will take if the results indicate that a member of the sponsor family has been convicted of a barrier crime or fails to meet the requirements of this regulation should an ineligible result be received.
F. The sponsored residential home shall submit to the provider the results of a physical and mental health examination of family members when requested by the provider based on indications of a physical or mental health issue.
G. Sponsored residential homes shall not also operate as group homes or Department of Social Services approved homes or foster homes.
H. The provider shall submit the name, address, and certification of the sponsored residential home to the department prior to adding the home. The provider shall submit the name and address of the sponsored residential home to the department prior to closing the home. The provider shall submit a service modification when approving homes more than 100 miles from the previously approved homes.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1190. Sponsored residential home service policies.
A. The provider shall implement written policies to provide orientation and supportive services to the sponsored residential home staff specific to the needs of the individuals receiving services.
B. The provider shall implement a training plan for the sponsor staff consistent with the needs of the individuals receiving services.
C. The provider shall specify staffing arrangements in all sponsored residential homes, including on-call and substitute care arrangements.
D. The provider shall implement a written policy on managing, monitoring, and supervising sponsored residential homes. This policy shall address changes in supervision arrangements as the number of homes increase.
E. The provider shall conduct inspections of each sponsored residential home other than his own. Inspections shall be performed at least on a quarterly basis during the year with at least two being unannounced inspections.
F. On an on-going basis and at least annually, the provider shall review and document compliance by each sponsored residential home and sponsor with regulations related to sponsored residential homes.
G. The provider shall develop written policies for terminating a sponsored residential home.
H. The provider shall document that all residents or their authorized representatives are provided the opportunity to choose a new placement when the current placement ends. Prior to moving an individual to another placement the provider shall conduct and document a meeting to include the individual and his authorized representative, if applicable, case manager, the current sponsor, and a receiving placement staff, if possible.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1200. Supervision.
A. The provider shall have a supervisor for every 15 sponsored residential homes where individuals are residing.
B. A responsible adult shall be available to provide supervision to the individual as specified in the individualized service plan.
C. Any member of the sponsor family who transports individuals receiving services must have a valid driver's license and automobile liability insurance. The vehicle used to transport individuals receiving services shall have a valid registration and inspection sticker.
D. The sponsor shall inform the provider in advance of any anticipated additions or changes in the sponsored residential home or as soon as possible after an unexpected change occurs.
E. In addition to the current reporting requirements the sponsor shall report all hospitalizations of individuals being served to the provider and the individual's case manager within 24 hours.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1210. Sponsored residential home service records.
Providers of sponsored residential home services shall maintain the following records on each sponsored residential home:
1. Documentation of three references for the owner of the sponsor home;
2. Criminal background checks and results of the search of the registry of founded complaints of child abuse and neglect for all adult employees in the home;
3. Orientation and training provided by the provider to the sponsor and employees;
4. The log of provider inspections of the sponsored residential home including the date, the employee conducting the inspection, the purpose of the inspection, and a description of any significant events or findings; and
5. The daily log maintained by the sponsor of significant events related to individuals receiving services.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1220. Regulations pertaining to staff.
Providers shall certify and document compliance of sponsors with regulations pertaining to staff.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1230. Maximum number of beds or occupants in sponsored residential home.
The maximum number of individuals served in a sponsored residential home is two. The maximum number of occupants in a sponsored residential home is seven.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1235. Sponsored residential home services for children.
In addition, the following requirements shall be met for homes serving children:
1. The provider shall develop a service description based upon evidence-based practices or an accepted therapeutic model of mental health, developmental or substance abuse services, or brain injury care for children.
2. The provider shall use a treatment team model consisting of staff who provide intensive support and consultation to the sponsor parents.
3. Weekly team meetings and supervision shall be held with the sponsor parent or parents to review progress on each case, review the daily behavioral information collected, and adjust the child's individualized services plan.
4. The sponsor parent or parents shall keep a daily log of behavioral and other child specific information and be available for daily Monday through Friday contact from the provider.
5. The sponsor parent or parents shall receive 25 hours per year of in-service training pertaining to providing services for the child they serve in addition to the training otherwise required in these regulations. The sponsor parent or parents shall also participate in ongoing training at least once a quarter.
6. The provider is not considered a child placing agency. Children are placed with the provider by licensed child placing agencies, local departments of social services, or parents.
7. The sponsor parent or parents shall be at least 25 years old.
8. The sponsor parent or parents shall be able to provide care and supervision during nonschool hours.
9. The provider shall have access through directly providing it or developing agreements for 24-hour emergency mental health care for children served with serious emotional disturbances .
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 5
Case Management Services
12VAC35-105-1240. Service requirements for providers of case management services.
Providers of case management services shall document that the services below are performed consistent with the individual's assessment and ISP.
1. Enhancing community integration through increased opportunities for community access and involvement and creating opportunities to enhance community living skills to promote community adjustment including, to the maximum extent possible, the use of local community resources available to the general public;
2. Making collateral contacts with the individual's significant others with properly authorized releases to promote implementation of the individual's individualized services plan and his community adjustment;
3. Assessing needs and planning services to include developing a case management individualized services plan;
4. Linking the individual to those community supports that are most likely to promote the personal habilitative or rehabilitative and life goals of the individual as developed in the ISP;
5. Assisting the individual directly to locate, develop, or obtain needed services, resources, and appropriate public benefits;
6. Assuring the coordination of services and service planning within a provider agency, with other providers, and with other human service agencies and systems, such as local health and social services departments;
7. Monitoring service delivery through contacts with individuals receiving services and service providers and periodic site and home visits to assess the quality of care and satisfaction of the individual;
8. Providing follow up instruction, education, and counseling to guide the individual and develop a supportive relationship that promotes the ISP;
9. Advocating for individuals in response to their changing needs, based on changes in the individualized services plan;
10. Planning for transitions in the individual's life;
11. Knowing and monitoring the individual's health status, any medical conditions, and his medications and potential side effects, and assisting the individual in accessing primary care and other medical services, as needed; and
12. Understanding the capabilities of services to meet the individual's identified needs and preferences and to serve the individual without placing the individual, other participants, or staff at risk of serious harm.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1245. Case management direct assessments.
Case managers shall meet with each individual face-to-face as dictated by the individual's needs. At face-to-face meetings, the case manager shall (i) observe and assess for any previously unidentified risks, injuries, needs, or other changes in status; (ii) assess the status of previously identified risks, injuries, or needs, or other changes in status; (iii) assess whether the individual's service plan is being implemented appropriately and remains appropriate for the individual; and (iv) assess whether supports and services are being implemented consistent with the individual's strengths and preferences and in the most integrated setting appropriate to the individual's needs.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-1250. Qualifications of case management employees or contractors.
A. Employees or contractors providing case management services shall have knowledge of:
1. Services and systems available in the community including primary health care, support services, eligibility criteria and intake processes and generic community resources;
2. The nature of serious mental illness, developmental disability, substance abuse (substance use disorders), or co-occurring disorders depending on the individuals receiving services, including clinical and developmental issues;
3. Different types of assessments, including functional assessment, and their uses in service planning;
4. Treatment modalities and intervention techniques, such as behavior management, independent living skills training, supportive counseling, family education, crisis intervention, discharge planning, and service coordination;
5. Types of mental health, developmental, and substance abuse programs available in the locality;
6. The service planning process and major components of a service plan;
7. The use of medications in the care or treatment of the population served; and
8. All applicable federal and state laws and regulations and local ordinances.
B. Employees or contractors providing case management services shall have skills in:
1. Identifying and documenting an individual's need for resources, services, and other supports;
2. Using information from assessments, evaluations, observation, and interviews to develop service plans;
3. Identifying and documenting how resources, services, and natural supports such as family can be utilized to promote achievement of an individual's personal habilitative or rehabilitative and life goals; and
4. Coordinating the provision of services by diverse public and private providers.
C. Employees or contractors providing case management services shall have abilities to:
1. Work as team members, maintaining effective inter-agency and intra-agency working relationships;
2. Work independently performing position duties under general supervision; and
3. Engage in and sustain ongoing relationships with individuals receiving services.
D. Case managers serving individuals with developmental disability shall complete the DBHDS core competency-based curriculum within 30 days of hire.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020.
12VAC35-105-1255. Case manager choice.
The provider shall implement a written policy describing how individuals are assigned case managers and how they can request a change of their assigned case manager.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
Article 6
Community Gero-Psychiatric Residential Services
12VAC35-105-1260. Admission criteria.
An individual receiving community gero-psychiatric residential services shall have had a medical, psychiatric, and behavioral evaluation to determine that he cannot be appropriately cared for in a nursing home or other less intensive level of care but does not need inpatient care.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-1270. Physical environment requirements of community gero-psychiatric residential services.
A. Providers shall be responsible for ensuring safe mobility and unimpeded access to programs or services by installing and maintaining ramps, handrails, grab bars, elevators, protective surfaces, and other assistive devices or accommodations as determined by periodic review of the needs of the individuals being served. Entries, doors, halls, and program areas, including bedrooms, must have adequate room to accommodate wheelchairs and allow for proper transfer of individuals. Single bedrooms shall have at least 100 square feet and multi-bed rooms shall have at least 80 square feet per individual.
B. Floors must have resilient, nonabrasive, and slip-resistant floor surfaces and floor coverings that promote mobility in areas used by individuals and promote maintenance of sanitary conditions.
C. Temperatures shall be maintained between 70°F and 80°F throughout resident areas.
D. Bathrooms, showers, and program areas must be accessible to individuals. There must be at least one bathing unit available by lift, door, or swivel-type tub.
E. Areas must be provided for quiet and for recreation.
F. Areas must be provided for charting, storing of administrative supplies, a utility room, employee hand washing, dirty linen, clean linen storage, clothes washing, and equipment storage.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1280. Monitoring.
Employees or contractors shall regularly monitor individuals in all areas of the residence to ensure safety.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1290. Service requirements for providers of gero-psychiatric residential services.
A. Providers shall provide mental health, nursing and rehabilitative services; medical and psychiatric services; and pharmaceutical services for each individual as specified in the ISP.
B. Providers shall provide crisis stabilization services.
C. Providers shall implement written policies and procedures that support an active program of mental health and behavioral management services directed toward assisting each individual to achieve outcomes consistent with the highest level of self-care, independence, and quality of life. Programming may be on-site or at another location in the community.
D. Providers shall implement written policies and procedures that respond to the nursing needs of each individual to achieve outcomes consistent with the highest level of self-care, independence, and quality of life. Providers shall be responsible for:
1. Providing each individual services to prevent clinically avoidable complications, including: skin care, dexterity and mobility, continence, hydration, and nutrition;
2. Giving each individual proper daily personal attention and care, including skin, nail, hair, and oral hygiene, in addition to any specific care ordered by the attending physician;
3. Dressing each individual in clean clothing and encouraging each individual to wear day clothing when out of bed;
4. Providing each individual tub or shower baths as often as needed, but not less than twice weekly or a sponge bath daily if the medical condition prohibits tub or shower baths;
5. Providing each individual appropriate pain management; and
6. Ensuring that each individual has his own personal utensils, grooming items, adaptive devices, and other personal belongings including those with sentimental value.
E. Providers shall integrate behavioral and mental health care and medical and nursing care in the ISP.
F. Providers shall have available nourishment between scheduled meals.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1300. Staffing requirements for community gero-psychiatric residential services.
A. Community gero-psychiatric residential services shall be under the direction of a:
1. Program director with experience in gero-psychiatric services;
2. Medical director; and
3. Director of clinical services who is a registered nurse with experience in gero-psychiatric services.
B. Providers shall provide qualified nursing supervisors, nurses, and certified nurse aides on all shifts, seven days per week, in sufficient number to meet the assessed nursing care and behavioral management needs determined by the ISPs.
C. Providers shall provide qualified staff for behavioral, psychosocial rehabilitation, rehabilitative, mental health, or recreational programming to meet the needs determined by the ISP. These services shall be under the direction of a registered nurse, licensed psychologist, licensed clinical social worker, or licensed therapist.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1310. Interdisciplinary services planning team.
A. At a minimum, a registered nurse, a licensed psychologist, a licensed social worker, a therapist (recreational, occupational or physical therapist), a pharmacist, and a psychiatrist shall participate in the development and review of the ISP. Other employees or contractors as appropriate shall be included.
B. The interdisciplinary services planning team shall meet to develop the ISP and review it quarterly. Members of the team shall be available for consultation on an as needed basis.
C. The interdisciplinary services planning team shall review the medications prescribed at least quarterly and consult with the primary care physician as needed.
D. The interdisciplinary services planning team shall integrate medical care plans prescribed by the primary care physician into the ISP and consult with the primary care physician as needed.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1320. Employee or contractor qualifications and training.
A. A nurse aide may be employed only if he is certified by the Board of Nursing. During the initial 120 days of employment, a nurse aide may be employed if he is enrolled full-time in a nurse aide education program approved by the Virginia Board of Nursing or has completed a nurse aide education program or competency testing.
B. All nursing employees or contractors, including certified nursing assistants, must have additional competency-based training in providing mental health services to geriatric individuals, including behavior management.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
12VAC35-105-1330. Medical director.
Providers of community gero-psychiatric residential services shall employ or have a written agreement with one or more psychiatrists with training and experience in gero-psychiatric services to serve as medical director. The duties of the medical director shall include :
1. Responsibility for overall medical and psychiatric care;
2. Advising the program director and the director of clinical services on medical and psychiatric issues, including the criteria for residents to be admitted, transferred , or discharged;
3. Advising on the development, execution, and coordination of policies and procedures that have a direct effect upon the quality of medical, nursing, and psychiatric care delivered to individuals; and
4. Acting as liaison and consulting with the administrator and the primary care physician on matters regarding medical, nursing, and psychiatric care policies and procedures.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1340. Physician services and medical care.
A. Each individual in a community gero-psychiatric residential service shall be under the care of a primary care physician. Nurse practitioners and physician assistants licensed to practice in Virginia may provide care in accordance with their practice agreements. Prior to, or at the time of admission, each individual, his authorized representative, or the entity responsible for his care shall designate a primary care physician.
B. The primary care physician shall conduct a physical examination at the time of admission or within 72 hours of admission into a community gero-psychiatric residential service. The primary care physician shall develop, in coordination with the interdisciplinary services planning team, a medical care plan of treatment for an individual.
C. All physicians or other prescribers shall review all medication orders at least every 60 days or whenever there is a change in medication.
D. The provider shall have a signed agreement with a local general hospital describing back-up and emergency medical care plans.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1350. Pharmacy services for providers of community gero-psychiatric residential services.
A. The provider shall make provision for 24-hour emergency pharmacy services.
B. The provider shall have a written agreement with a qualified pharmacist to provide consultation on all aspects of the provision of pharmacy services and for regular visits, at least monthly.
C. A pharmacist licensed by the Virginia Board of Pharmacy shall review each individual's medication regimen. Any irregularities identified by the pharmacist shall be reported to the physician and the director of clinical services, and their response documented.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002.
Article 7
Assertive Community Treatment Service (Act)
12VAC35-105-1360. Admission and discharge criteria.
A. Individuals must meet the following admission criteria:
1. Diagnosis of a severe and persistent mental illness, predominantly schizophrenia, other psychotic disorder, or bipolar disorder that seriously impairs functioning in the community. Individuals with a sole diagnosis of a substance use disorder or developmental disability , personality disorder, traumatic brain injury, or an autism spectrum disorder are not the intended service recipients and should not be referred to ACT if they do not have a co-occurring psychiatric disorder.
2. Significant challenges to community integration without intensive community support including persistent or recurrent difficulty with one or more of the following:
a. Performing practical daily living tasks;
b. Maintaining employment at a self-sustaining level or consistently carrying out homemaker roles; or
c. Maintaining a safe living situation.
3. High service needs indicated due to one or more of the following:
a. Residence in a state hospital or other psychiatric hospital but clinically assessed to be able to live in a more independent situation if intensive services were provided or anticipated to require extended hospitalization, if more intensive services are not available;
b. Multiple admissions to or at least one recent long-term stay (30 days or more) in a state hospital or other acute psychiatric hospital inpatient setting within the past two years; or a recent history of more than four interventions by psychiatric emergency services per year;
c. Persistent or very recurrent severe major symptoms (e.g., affective, psychotic, suicidal);
d. Co-occurring substance addiction or abuse of significant duration (e.g., greater than six months);
e. High risk or a recent history (within the past six months) of criminal justice involvement (e.g., arrest or incarceration);
f. Ongoing difficulty meeting basic survival needs or residing in substandard housing, homeless, or at imminent risk of becoming homeless; or
g. Inability to consistently participate in traditional office-based services.
B. Individuals receiving ACT services should not be discharged for failure to comply with treatment plans or other expectations of the provider, except in certain circumstances as outlined. Individuals must meet at least one of the following criteria to be discharged:
1. Change in the individual's residence to a location out of the service area;
2. Incarceration of the individual for a period to exceed a year or long-term hospitalization (more than one year); however, the provider is expected to prioritize these individuals for ACT services upon the individual's anticipated return to the community if the individual wishes to return to services and the service level is appropriate to his needs;
3. The individual and, if appropriate, the legally responsible person, choose to withdraw from services and documented attempts by the program to re-engage the individual with the service have not been successful; or
4. The individual and team determine that ACT services are no longer needed based on the attainment of goals as identified in the person centered plan and a less intensive level of care would adequately address current goals.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1370. Treatment team and staffing plan.
A. ACT services are delivered by interdisciplinary teams.
1. ACT teams shall have sufficient staffing composition to meet the varying needs of individuals served by the team as required by this section. Each ACT team shall meet the following minimum position and staffing requirements:
a. Team leader. There shall be one full-time LMHP with three years of work experience in the provision of mental health services to adults with serious mental illness; a resident who is under the supervision of a licensed professional counselor in accordance with 18VAC115-20-10 and who is registered with the Virginia Board of Counseling with three years of experience in the provision of mental health services to adults with serious mental illness; a resident in psychology who is under supervision of a licensed clinical psychologist and is registered with the Virginia Board of Psychology in accordance with 18VAC125-20-10 and who has three years of experience in the provision of mental health services to adults with serious mental illness; a supervisee, in social work who is under the supervision of a licensed clinical social worker and who is registered with the Virginia Board of Social Work in accordance with 18VAC140-20-10 and who has three years of experience in the provision of mental health services to adults with serious mental illness; or one full-time registered QMHP-A with at least three years of experience in the provision of mental health services to adults with serious mental illness who was employed by the provider as a team leader prior to July 1, 2020. The team leader shall oversee all aspects of team operations and shall provide direct services to individuals in the community.
b. Nurses. ACT nurses shall be full-time employees or contractors with the following minimum qualifications: a registered nurse shall have one year of experience in the provision of mental health services to adults with serious mental illness, or a licensed practical nurse shall have three years of experience in the provision of mental health services to adults with serious mental illness.
(1) Small ACT teams shall have at least one full-time nurse, who shall be either an RN or an LPN;
(2) Medium ACT teams shall have at least one full-time RN and at least one additional full-time nurse who shall be an LPN or RN; and
(3) Large ACT teams shall have at least one full-time RN and at least two additional full-time nurses who shall be LPNs or RNs.
c. Vocational specialist. There shall be one or more full-time vocational specialist, who shall be a registered QMHP with demonstrated expertise in vocational services through experience or education.
d. Co-occurring disorder specialist. There shall be one or more full-time co-occurring disorder specialists, who shall be a LMHP; a resident who is under the supervision of a licensed professional counselor in accordance with 18VAC115-20-10 and who is registered with the Virginia Board of Counseling; a resident in psychology who is under supervision of a licensed clinical psychologist and is registered with the Virginia Board of Psychology in accordance with 18VAC125-20-10; a supervisee in social work who is under the supervision of a licensed clinical social worker and who is registered with the Virginia Board of Social Work in accordance with 18VAC140-20-10; registered QMHP; or certified substance abuse specialist (CSAC) with training or experience working with adults with co-occurring serious mental illness and substance use disorder.
e. ACT peer specialists. There shall be one full-time equivalent peer recovery specialists who is or has been a recipient of mental health services for severe and persistent mental illness. The peer specialist shall be certified as a peer recovery specialist in accordance with 12VAC35-250, or shall become certified in the first year of employment. The peer specialist shall be a fully integrated team member who provides peer support directly to individuals and provides leadership to other team members in understanding and supporting each individual's recovery goals.
f. Program assistant. There shall be one full-time or two part-time program assistants with skills and abilities in medical records management shall operate and coordinate the management information system, maintain accounts and budget records for individual and program expenditures, and perform administrative support activities.
g. Psychiatric care provider. There shall be one physician who is board certified in psychiatry or who is board eligible in psychiatry and is licensed to practice medicine in Virginia or a psychiatric nurse practitioner practicing within the scope of practice as defined in 18VAC90-30-120. An equivalent ratio of 16 hours of psychiatric time per 50 individuals served must be maintained. The psychiatric care provider shall be a fully integrated team member who attends team meetings and actively participates in developing and implementing each individual ISP.
h. Generalist clinical staff. There shall be additional clinical staff with the knowledge, skill, and ability required, based on the population and age of individuals being served, to carry out rehabilitation and support functions, at least 50% of whom shall be LMHPs, QMHP-As, QMHP-Ts, or QPPMHs.
(1) Small ACT teams shall have at least one generalist clinical staff;
(2) Medium ACT teams shall have at least two generalist clinical staff; and
(3) Large ACT teams shall have at least three generalist clinical staff.
2. Staff-to-individual ratios for ACT Teams:
a. Small ACT teams shall maintain a caseload of no more than 50 individuals and shall maintain at least one staff member per eight individuals, in addition to a psychiatric care provider and a program assistant.
b. Medium ACT teams shall maintain a caseload of no more than 74 individuals and shall maintain at least one staff member per nine individuals, in addition to a psychiatric care provider and a program assistant.
c. Large ACT teams shall maintain a caseload of no more than 120 individuals and shall maintain at least one staff member per nine individuals, in addition to a psychiatric care provider and a program assistant.
B. ACT teams shall be available to individuals 24 hours per day and shall operate a minimum of 12 hours each weekday and eight hours each weekend day and each holiday.
C. The ACT team shall make crisis services directly available 24 hours a day but may arrange coverage through another crisis services provider if the team coordinates with the crisis services provider daily.
D. The ACT team shall operate an after-hours on-call system and shall be available to individuals by telephone and in person when needed as determined by the team.
E. ACT teams in development may submit a transition plan to the department for approval that will allow for "start-up" when newly forming teams are not in full compliance with the ACT model relative to staffing patterns and individuals receiving services capacity. Approved transition plans shall be limited to a six-month period.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 35, Issue 19, eff. June 15, 2019; Volume 39, Issue 11, eff. February 17, 2023; Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1380. Contacts.
A. The ACT team shall provide multiple contacts per week to individuals experiencing severe symptoms or significant problems in daily living.
B. Each individual receiving ACT services shall be seen face-to-face by an employee or contractor as specified in the individual's ISP. Providers shall document all attempts to make contact, and if contact is not made, the reasons why contact was not made.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1390. ACT service daily operation and progress notes.
A. ACT teams shall conduct organizational meetings Monday through Friday at least four days per week at a regularly scheduled time to review the status of all individuals and the outcome of the most recent employee or contractor contact, assign daily and weekly tasks to employees and contractors, revise treatment plans as needed, plan for emergency and crisis situations, and to add service contacts that are identified as needed.
B. A daily log that provides a roster of individuals served in the ACT services program and documentation of services provided and contacts made with them shall be maintained and utilized in the team meeting. Daily logs shall not be considered progress notes.
C. There shall also be individual progress notes documenting services provided in accordance with the ISP each time the individual receives services, which shall be included within the individual's record. ACT teams shall also document within the individual's record attempts at outreach and engagement.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1400. ACT assessment.
The provider shall solicit the individual's own assessment of his needs, strengths, goals, preferences, and abilities to identify the need for recovery oriented treatment, rehabilitation, and support services and the status of his environmental supports within the individual's cultural context. With the participation of the individual, the provider shall assess:
1. Psychiatric history, mental status and diagnosis, including the content of an advance directive;
2. Medical, dental, and other health needs;
3. Extent and effect of drug or alcohol use;
4. Education and employment, including current daily structured use of time, school or work status, interests and preferences, and supports and barriers to educational and employment performance;
5. Social development and functioning, including childhood and family history, religious beliefs, leisure interests, and social skills;
6. Housing and daily living skills, including the support needed to obtain and maintain decent, affordable housing integrated into the broader community; the current ability to meet basic needs such as personal hygiene, food preparation, housekeeping, shopping, money management, and the use of public transportation and other community based resources;
7. Family and social network, including the current scope and strength of an individual's network of family, peers, friends, and co-workers, and their understanding and expectations of the team's services;
8. Finances and benefits, including the management of income, the need for and eligibility for benefits, and the limitations and restrictions of those benefits; and
9. Legal and criminal justice involvement, including guardianship, commitment, representative payee status, and experience as either a victim or an accused person.
Statutory Authority
§ 37.2-203 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011.
12VAC35-105-1410. Service requirements.
ACT teams shall document that the following services are provided consistent with the individual's assessment and ISP.
1. Ongoing assessment to ascertain the needs, strengths, and preferences of the individual;
2. Case management;
3. Nursing;
4. Support for wellness self-management, including the development and implementation of individual recovery plans, symptom assessment, and recovery education;
5. Psychopharmacological treatment, administration, and monitoring;
6. Co-occurring diagnosis substance use disorder services that are nonconfrontational, trauma informed, person-centered, consider interactions of mental illness and substance use, and have goals determined by the individual;
7. Empirically supported interventions and psychotherapy;
8. Psychiatric rehabilitation, which may include skill-building, coaching, and facilitating access to necessary resources to help individuals with personal care, safety skills, money management, grocery shopping, cooking, food safety and storage, purchasing and caring for clothing, household maintenance and cleaning skills, social skills, and use of transportation and other community resources;
9. Work-related services that follow evidence-based supported employment principles, such as direct assistance with job development, locating preferred jobs, assisting the individual through the application process, and communicating with employers;
10. Support for resuming education;
11. Support, education, consultation, and skill-teaching to family members , significant others, and broader natural support systems, which shall be directed exclusively to the well-being and benefit of the individual;
12. Collaboration with families and development of family and other natural supports;
13. Assistance in obtaining and maintaining safe, decent, and affordable housing that follows the individual's preferences in level of independence and location, consistent with an evidence-based supportive housing model;
14. Direct support to help individuals obtain legal and advocacy services, financial support, money-management services, medical and dental services, transportation, and natural supports in the community;
15. Crisis assessment, interventions to prevent or resolve potential crises, and admission to and discharge from psychiatric hospitals;
16. Assistance in developing and maintaining natural supports and social relationships;
17. Medication education, assistance, and support; and
18. Peer support services, such as coaching, mentoring, assistance with self-advocacy and self-direction, and modeling recovery practices.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; amended, Virginia Register Volume 28, Issue 5, eff. December 7, 2011; Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1420. (Reserved.).
Part VII
Addition Medicine Service Requirements
Article 1
Medically Managed Intensive Inpatient Level of Care 4.0
12VAC35-105-1430. Medically managed intensive inpatient Level of care 4.0 staff criteria.
A medically managed intensive inpatient program shall meet the following staff requirements:
1. Have a team of appropriately trained and credentialed professionals who provide medical management by physicians 24 hours a day, primary nursing care and observation 24 hours a day, and professional counseling services 16 hours a day;
2. Have an interdisciplinary team of appropriately credentialed clinical staff, which may include addiction-credentialed physicians, nurse practitioners, physician assistants, nurses, counselors, psychologists, and social workers, who assess and treat individuals with severe substance use disorders or addicted individuals with concomitant acute biomedical, emotional, or behavioral disorders;
3. Have staff who are knowledgeable about the biopsychosocial dimensions of addiction as well as biomedical, emotional, behavioral, and cognitive disorders;
4. Have facility-approved addiction counselors or licensed, certified, or registered addiction clinicians who administer planned interventions according to the assessed needs of the individual; and
5. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1440. Medically managed intensive inpatient Level of care 4.0 program criteria.
A medically managed intensive inpatient program shall meet the following programmatic requirements. The program shall:
1. Deliver services in a 24-hour medically managed, acute care setting and shall be available to all individuals within that setting;
2. Provide cognitive, behavioral, motivational, pharmacologic, and other therapies provided on an individual or group basis, depending on the individual's needs;
3. Provide, for the individual who has a severe biomedical disorder, physical health interventions to supplement addiction treatment;
4. Provide, for the individual who has stable psychiatric symptoms, individualized treatment activities designed to monitor the individual's mental health;
5. Provide planned clinical interventions that are designed to enhance the individual's understanding and acceptance of his addiction illness;
6. Provide family and caregiver treatment services as deemed appropriate by a licensed professional and included in an assessment and treatment plan;
7. Provide health education services;
8. Make medication assisted treatment (MAT) available for all individuals admitted to the service. MAT may be provided by facility staff or coordinated through alternative resources; and
9. Comply with 12VAC35-105-1055 through 12VAC35-105-1130.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1450. Medically managed intensive inpatient Level of care 4.0 admission criteria.
Before a medically managed intensive inpatient program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a substance use disorder or substance induced disorder as defined by the DSM; and
2. Meet the admission criteria of Level 4.0 of ASAM, including the specific criteria for adult and adolescent populations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1460. Medically managed intensive inpatient Level of care 4.0 discharge criteria.
Before a medically managed intensive inpatient program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 4.0 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Article 2
Medically Monitored Intensive Inpatient Services Level of Care 3.7
12VAC35-105-1470. Medically managed intensive inpatient Level of care 4.0 co-occurring enhanced programs.
A. Medically managed intensive inpatient co-occurring enhanced programs shall be staffed by appropriately credentialed mental health professionals who assess and treat the individual's co-occurring mental disorders. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
B. Medically managed intensive inpatient co-occurring enhanced programs shall offer individualized treatment activities designed to stabilize the individual's active psychiatric symptoms, including medication evaluation and management.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1480. Medically monitored intensive inpatient services Level of care 3.7 staff criteria.
A medically monitored intensive inpatient treatment program shall meet the following staff requirements. The program shall:
1. Have a licensed physician to oversee the treatment process and ensure quality of care. A physician, a licensed nurse practitioner, or a licensed physician assistant shall be available 24 hours a day in person or by telephone. A physician, a licensed nurse practitioner, or a licensed physician assistant shall assess the individual in person within 24 hours of admission;
2. Offer 24-hour nursing care and conduct a nursing assessment on admission. The level of nursing care must be appropriate to the severity of needs of individuals admitted to the service;
3. Have interdisciplinary staff, which may include physicians, nurses, addiction counselors, and behavioral health specialists who are able to assess and treat the individual and obtain and interpret information regarding the individual's psychiatric and substance use or addictive disorders;
4. Offer daily onsite counseling and clinical services. Clinical staff shall be knowledgeable about the biological and psychosocial dimensions of addiction and other behavioral health disorders with specialized training in behavior management techniques and evidence-based practices;
5. Have staff able to provide a planned regimen of 24-hour professionally directed evaluation, care, and treatment services;
6. Make MAT available for all individuals with opioid use disorder or alcohol use disorder. MAT may be provided by facility staff or coordinated through alternative resources; and
7. Ensure all clinical staff are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1490. Medically monitored intensive inpatient services Level of care 3.7 program criteria.
A medically monitored intensive inpatient treatment program shall meet the following programmatic requirements. The program shall:
1. Be made available to all individuals within the inpatient setting;
2. Provide a combination of individual and group therapy as deemed appropriate by a credentialed addiction treatment professional and included in an assessment and treatment plan. Such therapy shall be adapted to the individual's level of comprehension;
3. Make available medical and nursing services onsite to provide ongoing assessment and care of addiction needs;
4. Provide direct affiliations with other easily accessible levels of care or close coordination through referral to more or less intensive levels of care and other services;
5. Provide family and caregiver treatment services as deemed appropriate by a credentialed addiction treatment professional and included in an assessment and treatment plan;
6. Provide educational and informational programming adapted to individual needs. The educational and informational programming shall include materials designed to enhance the individual's understanding of addiction and may include peer recovery support services as appropriate;
7. Utilize random drug screening to monitor drug use and reinforce treatment gains;
8. Regularly monitor the individual's adherence in taking any prescribed medications; and
9. Comply with 12VAC35-105-1055 through 12VAC35-105-1130.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1500. Medically monitored intensive inpatient Level of care 3.7 admission criteria.
Before a medically monitored intensive inpatient program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a moderate or severe substance use or addictive disorder; and
2. Meet the admission criteria of Level 3.7 of ASAM, including the specific criteria for adult and adolescent populations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1510. Medically monitored intensive inpatient Level of care 3.7 discharge criteria.
A. Before a medically monitored intensive inpatient program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 3.7 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
B. Discharge planning shall occur for individuals and include realistic plans for the continuity of MAT services as indicated.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1520. Medically monitored intensive inpatient Level of care 3.7 co-occurring enhanced programs.
A. Medically monitored intensive inpatient co-occurring enhanced programs shall offer psychiatric services, medication evaluation, and laboratory services as indicated by the needs of individuals admitted to the service. A psychiatrist shall assess the individual by telephone within four hours of admission and in person with 24 hours following admission. A credentialed addiction treatment professional shall conduct a behavioral health-focused assessment at the time of admission. A registered nurse shall monitor the individual's progress and administer or monitor the individual's self-administration of psychotropic medications.
B. Medically monitored intensive inpatient co-occurring enhanced programs shall be staffed by addiction psychiatrists and appropriately credentialed behavioral health professionals who are able to assess and treat co-occurring psychiatric disorders and who have specialized training in behavior management techniques and evidence based practices. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
C. Medically monitored intensive inpatient co-occurring enhanced programs shall offer planned clinical activities designed to promote stabilization of the individual's behavioral health needs and psychiatric symptoms and to promote such stabilization, including medication education and management and motivational and engagement strategies.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Article 3
Clinically Managed High-Intensity Residential Services Level of Care 3.5
12VAC35-105-1530. Clinically managed high-intensity residential services Level of care 3.5 staff criteria.
A clinically managed high-intensity residential care program shall meet the following staff requirements. The program shall:
1. Offer telephone or in-person consultation with a physician, a licensed nurse practitioner, or a licensed physician assistant in case of emergency related to an individual's substance use disorder 24 hours a day seven days a week;
2. Offer onsite 24-hour-a-day clinical staffing by credentialed addiction treatment professionals in addition to other allied health professionals, such as peer recovery specialists, who work in an interdisciplinary team;
3. Have clinical staff knowledgeable about the biological and psychosocial dimensions of substance use and mental health disorders and their treatment. Staff shall be able to identify the signs and symptoms of acute psychiatric conditions. Staff shall have specialized training in behavior management techniques; and
4. Ensure that all clinical staff are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1540. Clinically managed high-intensity residential services Level of care 3.5 program criteria.
A clinically managed high-intensity residential care program shall meet the following programmatic requirements. The program shall:
1. Provide daily clinical services, including a range of cognitive, behavioral, and other therapies in individual or group therapy; programming; and psychoeducation as deemed appropriate by a credentialed addiction treatment professional and included in an assessment and treatment plan;
2. Provide counseling and clinical interventions to teach an individual the skills needed for daily productive activity, prosocial behavior, and reintegration into family and community;
3. Provide motivational enhancement and engagement strategies appropriate to an individual's stage of readiness to change and level of comprehension;
4. Have direct affiliations with other easily accessible levels of care or provide coordination through referral to more or less intensive levels of care and other services;
5. Provide family and caregiver treatment services as deemed appropriate by a credentialed addiction treatment professional and included in an assessment and treatment plan;
6. Provide educational, vocational, and informational programming adaptive to individual needs;
7. Utilize random drug screening to monitor progress and reinforce treatment gains as appropriate to an individual treatment plan;
8. Ensure and document that the length of an individual's stay shall be determined by the individual's condition and functioning;
9. Make a substance use treatment program available for all individuals; and
10. Make MAT available for all individuals with opioid use disorder or alcohol use disorder. Medication assisted treatment may be provided by facility staff, or coordinated through alternative resources.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1550. Clinically managed high-intensity residential services Level of care 3.5 admission criteria.
A. The individuals served by a clinically managed high-intensity residential care program are individuals who are not sufficiently stable to benefit from outpatient treatment regardless of intensity of service.
B. Before a clinically managed high-intensity residential service program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a substance use disorder or addictive disorder of moderate to high severity as defined by the DSM; and
2. Meet the admission criteria of Level 3.5 of ASAM.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1560. Clinically managed high-intensity residential services Level of care 3.5 discharge criteria.
Before a clinically managed high-intensity residential service program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 3.5 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1570. Clinically managed high-intensity residential services Level of care 3.5 co-occurring enhanced programs.
A. Clinically managed high-intensity residential services co-occurring enhanced programs shall offer psychiatric services, medication evaluation, and laboratory services. Such services shall be available by telephone within eight hours and onsite or closely coordinated offsite within 24 hours.
B. Clinically managed high-intensity residential services co-occurring enhanced programs shall be staffed by appropriately credentialed mental health professionals, including addiction psychiatrists who are able to assess and treat co-occurring mental disorders and who have specialized training in behavior management techniques. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
C. Clinically managed high-intensity residential services co-occurring enhanced programs shall offer planned clinical activities designed to stabilize the individual's mental health problems and psychiatric symptoms and to maintain such stabilization, including medication education and management and motivational and engagement strategies. Goals of therapy shall apply to both the individual's substance use disorder and any co-occurring mental disorder.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Article 4
Clinically Managed Population-Specific High Intensity Residential Services Level of Care 3.3
12VAC35-105-1580. Clinically managed population-specific high-intensity residential services Level of care 3.3 staff criteria.
A clinically managed, population-specific, high-intensity residential services program shall meet the following staff requirements. The program shall:
1. Offer telephone or in-person consultation with a physician, a licensed nurse practitioner, or a physician assistant in case of emergency related to an individual's substance use disorder 24 hours a day, seven days a week;
2. Have allied health professional staff onsite 24 hours a day. At least one clinician with competence in the treatment of substance use disorder shall be available onsite or by telephone 24 hours a day;
3. Have clinical staff knowledgeable about the biological and psychosocial dimensions of substance use and mental health disorders and their treatment and able to identify the signs and symptoms of acute psychiatric conditions. Staff shall have specialized training in behavior management techniques; and
4. Ensure all clinical staff are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1590. Clinically managed population-specific high-intensity residential services Level of care 3.3 program criteria.
A clinically managed, population-specific, high-intensity residential services program shall meet the following programmatic requirements. The program shall:
1. Provide daily clinical services that shall include a range of cognitive, behavioral, and other therapies administered on an individual and group basis, medication education and management, educational groups, and occupational or recreation activities as deemed appropriate by a credentialed addiction treatment professional and included in an assessment and treatment plan;
2. Provide daily professional addiction and mental health treatment services that may include relapse prevention, exploring interpersonal choices, peer recovery support, and development of a social network;
3. Provide services to improve the individual's ability to structure and organize the tasks of daily living and recovery. Such services shall accommodate the cognitive limitations within this population;
4. Make available medical, psychiatric, psychological, and laboratory and toxicology services through consultation or referral as indicated by the individual's condition;
5. Provide case management, including ongoing transition and continuing care planning;
6. Provide motivational interventions appropriate to the individual's stage of readiness to change and designed to address the individual's functional limitations;
7. Have direct affiliations with other easily accessible levels of care or coordinate through referral to more or less intensive levels of care and other services;
8. Provide family and caregiver treatment services as deemed appropriate by an assessment and treatment plan;
9. Utilize random drug screening to monitor progress and reinforce treatment gains;
10. Regularly monitor the individual's adherence to taking prescribed medications;
11. Make the substance use treatment program available to all individuals served by the residential care service; and
12. Make MAT available for all individuals with opioid use disorder or alcohol use disorder. Medication assisted treatment may be provided by facility staff or coordinated through alternative resources.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1600. Clinically managed population-specific high-intensity residential services Level of care 3.3 admission criteria.
Before a clinically managed, population-specific, high-intensity residential service program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a moderate or severe substance use or addictive disorder as defined by the DSM; and
2. Meet the admission criteria of Level 3.3 of ASAM.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1610. Clinically managed population-specific high-intensity residential services Level of care 3.3 discharge criteria.
A. Before a clinically managed, population-specific, high-intensity residential service program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 3.3 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
B. Discharge planning shall occur for individuals and include realistic plans for the continuity of MAT services as indicated.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1620. Clinically managed population-specific high-intensity residential services Level of care 3.3 co-occurring enhanced programs.
A. Clinically managed population-specific high-intensity residential services co-occurring enhanced programs shall offer psychiatric services, medication evaluation, and laboratory services. Such services shall be available by telephone within eight hours and onsite or closely coordinated offsite within 24 hours, as appropriate to the severity and urgency of the individual's mental condition.
B. Clinically managed population-specific high-intensity residential services co-occurring enhanced programs shall be staffed by appropriately credentialed psychiatrists and licensed mental health professionals who are able to assess and treat co-occurring mental disorders and who have specialized training in behavior management techniques. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
C. Clinically managed population-specific high-intensity residential services co-occurring enhanced programs shall offer planned clinical activities designed to stabilize the individual's mental health problems and psychiatric symptoms and to maintain such stabilization, including medication education and management and motivational and engagement strategies. Goals of therapy shall apply to both the substance use disorder and any co-occurring mental health disorder.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Article 5
Clinically Managed Low-Intensity Residential Services Level of Care 3.1
12VAC35-105-1630. Clinically managed low-intensity residential services Level of care 3.1 staff criteria.
A clinically managed low-intensity residential services program shall meet the following staff requirements. The program shall:
1. Offer telephone or in-person consultation with a physician in case of emergency related to an individual's substance use disorder, available 24 hours a day, seven days a week. The program shall also provide allied health professional staff onsite 24 hours a day;
2. Have clinical staff who are knowledgeable about the biological and psychosocial dimensions of substance use disorder and their treatment and are able to identify the signs and symptoms of acute psychiatric conditions;
3. Have a team comprised of appropriately trained and credentialed medical, addiction, and mental health professionals; and
4. Ensure all clinical staff are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1640. Clinically managed low-intensity residential services Level of care 3.1 program criteria.
A clinically managed low-intensity residential services program shall meet the following programmatic requirements. The program shall:
1. Offer a minimum of five hours a week of professionally directed treatment in addition to other treatment services offered to individuals, such as partial hospitalization or intensive outpatient treatment the focus of which is stabilizing the individual's substance use disorder. Services shall be designed to improve the individual's ability to structure and organize the tasks of daily living and recovery;
2. Ensure collaboration with care providers to develop an individual treatment plan for each individual with time-specific goals and objectives;
3. Provide counseling and clinical monitoring to support successful initial involvement in regular, productive daily activity;
4. Provide case management services;
5. Provide motivational interventions appropriate to the individual's stage of readiness to change and level of comprehension;
6. Have direct affiliations with other easily accessible levels of care or coordinate through referral to more or less intensive levels of care and other services;
7. Include the ability to arrange for needed procedures as appropriate to the severity and urgency of the individual's condition;
8. Provide family and caregiver treatment and peer recovery support services as deemed appropriate by a licensed professional and included in an assessment and treatment plan;
9. Provide addiction pharmacotherapy and the ability to arrange for pharmacotherapy for psychiatric medications;
10. Utilize random drug screening to monitor progress and reinforce treatment gains;
11. Make a substance abuse treatment program available to all individuals; and
12. Make MAT available for all individuals with opioid use disorder and alcohol use disorder. Medication assisted treatment may be provided by facility staff or coordinated through alternative resources.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1650. Clinically managed low-intensity residential services Level of care 3.1 admission criteria.
Before a clinically managed low-intensity residential service program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a moderate or severe substance use or addictive disorder as defined by the DSM; and
2. Meet the admission criteria of Level 3.1 of ASAM.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1660. Clinically managed low-intensity residential services Level of care 3.1 discharge criteria.
Before a clinically managed low-intensity residential services program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 3.1 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1670. Clinically managed low-intensity residential services Level of care 3.1 co-occurring enhanced programs.
A. Clinically managed low-intensity residential services co-occurring enhanced programs shall offer psychiatric services, including medication evaluation and laboratory services. Such services shall be provided onsite or closely coordinated offsite, as appropriate to the severity and urgency of the individual's mental condition.
B. Clinically managed low-intensity residential services co-occurring enhanced programs shall be staffed by appropriately credentialed licensed mental health professionals who are able to assess and treat co-occurring disorders with the capacity to involve addiction-trained psychiatrists. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
C. Clinically managed low-intensity residential services co-occurring enhanced programs shall offer planned clinical activities that are designed to stabilize the individual's mental health problems and psychiatric symptoms and to maintain such stabilization, including medication education and management and motivational and engagement strategies. Goals of therapy shall apply to both the substance use disorder and any co-occurring mental disorder.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Article 6
Partial Hospitalization Level of Care 2.5
12VAC35-105-1680. Substance abuse partial hospitalization services Level of care 2.5 staff criteria.
A substance abuse partial hospitalization program shall meet the following staff requirements. The program shall:
1. Have an interdisciplinary team of addiction treatment professionals, which may include counselors, psychologists, social workers, and addiction-credentialed physicians. Physicians treating individuals in this level shall have specialty training or experience in addiction medicine;
2. Have staff able to obtain and interpret information regarding the individual's biopsychosocial needs;
3. Have staff trained to understand the signs and symptoms of mental disorders and to understand and be able to explain the uses of psychotropic medications and their interactions with substance-related disorders; and
4. Ensure all clinical staff are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1690. Substance abuse partial hospitalization services Level of care 2.5 program criteria.
A substance abuse partial hospitalization program shall meet the following programmatic requirements. The program shall:
1. Offer no fewer than 20 hours of skilled treatment services per week in a structured program. Services may include individual and group counseling, medication management, family therapy, peer recovery support services, educational groups, or occupational and recreational therapy;
2. Provide a combination of individual and group therapy as deemed appropriate by a licensed professional and included in an assessment and treatment plan;
3. Provide medical and nursing services as deemed appropriate by a licensed professional and included in an assessment and treatment plan;
4. Provide motivational enhancement and engagement strategies appropriate to an individual's stage of readiness to change and level of comprehension;
5. Have direct affiliations with other easily accessible levels of care or coordinate through referral to more or less intensive levels of care and other services;
6. Provide family and caregiver treatment services as deemed appropriate by a licensed professional and included in an assessment and treatment plan;
7. Provide educational and informational programming adaptable to individual needs;
8. Ensure and document that the length of service shall be determined by the individual's condition and functioning;
9. Make emergency services available by telephone 24 hours a day, seven days a week when the program is not in session; and
10. Make MAT available for all individuals with opioid use disorder or alcohol use disorder. MAT may be provided by facility staff or coordinated through alternative resources.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1700. Substance abuse partial hospitalization Level of care 2.5 admission criteria.
Before a substance abuse partial hospitalization program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a substance use disorder or addictive disorder as defined by the DSM; and
2. Meet the admission criteria of Level 2.5 of ASAM, including the specific criteria for adult and adolescent populations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1710. Substance abuse partial hospitalization Level of care 2.5 discharge criteria.
Before a substance abuse partial hospitalization program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 2.5 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1720. Substance abuse partial hospitalization Level of care 2.5 co-occurring enhanced programs.
A. Substance abuse partial hospitalization co-occurring enhanced programs shall offer psychiatric services appropriate to the individual's mental health condition. Such services shall be available by telephone and onsite or closely coordinated offsite, within a shorter time than in a co-occurring capable program.
B. Substance abuse partial hospitalization co-occurring enhanced programs shall be staffed by appropriately credentialed mental health professionals who assess and treat co-occurring mental disorders. Intensive case management shall be delivered by cross-trained, interdisciplinary staff through mobile outreach and shall involve engagement-oriented addiction treatment and psychiatric programming. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
C. Substance abuse partial hospitalization co-occurring enhanced programs shall offer intensive case management, assertive community treatment, medication management, and psychotherapy.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Article 7
Intensive Outpatient Services Level of Care 2.1
12VAC35-105-1730. Substance abuse intensive outpatient services Level of care 2.1 staff criteria.
A substance abuse intensive outpatient services program shall meet the following staff requirements. The program shall:
1. Be staffed by interdisciplinary team of appropriately credentialed addiction treatment professionals, which may include counselors, psychologists, social workers, and addiction-credentialed physicians. Physicians shall have specialty training or experience in addiction medicine or addiction psychiatry;
2. Have program staff that are able to obtain and interpret information regarding the individual's biopsychosocial needs;
3. Have program staff trained to understand the signs and symptoms of mental disorders and to understand and be able to explain the uses of psychotropic medications and their interactions with substance use and other addictive disorders; and
4. Ensure all clinical staff are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1740. Substance abuse intensive outpatient services Level of care 2.1 program criteria.
A substance abuse intensive outpatient services program shall meet the following programmatic requirements. The program shall:
1. Offer a minimum of three service hours per service day to achieve no fewer than nine hours and no more than 19 hours of programming per week in a structured environment;
2. Ensure psychiatric and other medical consultation shall be available within 24 hours by telephone and within 72 hours in person;
3. Offer consultation in case of emergency related to an individual's substance use disorder by telephone 24 hours a day, seven days a week when the treatment program is not in session;
4. Provide a combination of individual and group therapy as deemed appropriate by a licensed professional and included in an assessment and treatment plan;
5. Have direct affiliations with other easily accessible levels of care or coordinate through referral to more or less intensive levels of care and other services;
6. Provide family and caregiver treatment and peer recovery support services as deemed appropriate by a licensed professional and included in an assessment and treatment plan;
7. Provide education and informational programming adaptable to individual needs and developmental status;
8. Ensure and document that the length of service shall be determined by the individual's condition and functioning; and
9. Make MAT available for all individuals with opioid use disorder and alcohol use disorder. MAT may be provided by facility staff or coordinated through alternative resources.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1750. Substance abuse intensive outpatient services Level of care 2.1 admission criteria.
Before a substance abuse intensive outpatient services program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a substance use disorder or addictive disorder as defined by the DSM; and
2. Meet the admission criteria of Level 2.1 of ASAM, including the specific criteria for adult and adolescent populations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1760. Substance abuse intensive outpatient services Level of care 2.1 discharge criteria.
Before a substance abuse intensive outpatient services program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 2.1 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1770. Substance abuse intensive outpatient services Level of care 2.1 co-occurring enhanced programs.
A. Substance abuse intensive outpatient services co-occurring enhanced programs shall offer psychiatric services appropriate to the individual's mental health condition. Such services shall be available by telephone and onsite or closely coordinated offsite, within a shorter time than in a co-occurring capable program.
B. Substance abuse intensive outpatient services co-occurring enhanced programs shall be staffed by appropriately credential mental health professionals who assess and treat co-occurring mental disorders. Capacity to consult with an addiction psychiatrist shall be available. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
C. Substance abuse intensive outpatient services co-occurring enhanced programs shall offer intensive case management, assertive community treatment, medication management, and psychotherapy.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Article 8
Substance Abuse Outpatient Services Level of Care 1.0
12VAC35-105-1780. Substance abuse outpatient services Level of care 1.0 staff criteria.
Substance abuse outpatient services programs shall meet the following staff requirements. The program shall:
1. Have appropriately credentialed or licensed treatment professionals who assess and treat substance-related mental and addictive disorders;
2. Have program staff who are capable of monitoring stabilized mental health problems and recognizing any instability of individuals with co-occurring mental health conditions;
3. Provide medication management services by a licensed independent practitioner with prescribing authority; and
4. Ensure all clinical staff are qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1790. Substance abuse outpatient services Level of care 1.0 program criteria.
Substance abuse outpatient services programs shall meet the following programmatic requirements. The program shall:
1. Offer no more than nine hours of programming a week;
2. Ensure emergency services shall be available by telephone 24 hours a day, seven days a week;
3. Provide individual or group counseling, motivational enhancement, family therapy, educational groups, occupational and recreational therapy, psychotherapy, addiction, and pharmacotherapy as indicated by each individual's needs;
4. For individuals with mental illness, ensure the use of psychotropic medication, mental health treatment and that the individual's relationship to substance abuse disorders shall be addressed as the need arises;
5. Provide medical, psychiatric, psychological, laboratory, and toxicology services onsite or through consultation or referral. Medical and psychiatric consultation shall be available within 24 hours by telephone, or if in person, within a timeframe appropriate to the severity and urgency of the consultation requested;
6. Have direct affiliations with other easily accessible levels of care or coordinate through referral to more or less intensive levels of care and other services; and
7. Ensure through documentation that the duration of treatment varies with the severity of the individual's illness and response to treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1800. Substance abuse outpatient services Level of care 1.0 admission criteria.
Before a substance abuse outpatient services program may admit an individual, the individual shall meet the criteria for admission as defined by the provider's policies. The provider's policy regarding admission shall at a minimum require the individual to:
1. Meet diagnostic criteria for a substance use disorder or addictive disorder as defined by the DSM; and
2. Meet the admission criteria of Level 1.0 of ASAM, including the specific criteria for adult and adolescent populations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1810. Substance abuse outpatient services Level of care 1.0 discharge criteria.
Before a substance abuse outpatient services program may discharge or transfer an individual, the individual shall meet the criteria for discharge or transfer as defined by the provider's policies, which shall include provisions for the discharge or transfer of individuals who have:
1. Achieved the goals of the treatment services and no longer require ASAM 1.0 level of care;
2. Been unable to achieve the goals of the individual's treatment but could achieve the individual's goals with a different type of treatment; or
3. Achieved the individual's original treatment goals but have developed new treatment challenges that can only be adequately addressed in a different type of treatment.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
12VAC35-105-1820. Substance abuse outpatient services Level of care 1.0 co-occurring enhanced programs.
A. Substance abuse outpatient services co-occurring enhanced programs shall offer ongoing intensive case management for highly crisis-prone individuals with co-occurring disorders.
B. Substance abuse outpatient services co-occurring enhanced programs shall include credentialed mental health trained personnel who are able to assess, monitor, and manage the types of severe and chronic mental disorders seen in a level 1 setting as well as other psychiatric disorders that are mildly unstable. Staff shall be knowledgeable about management of co-occurring mental and substance-related disorders, including assessment of the individual's stage of readiness to change and engagement of individuals who have co-occurring mental disorders. All clinical staff shall be qualified by training and experience and appropriately licensed, certified, or registered by the appropriate health regulatory board to serve individuals admitted to the service.
C. Substance abuse outpatient services co-occurring enhanced programs shall offer therapies to actively address, monitor, and manage psychotropic medication, mental health treatment, and interaction with substance-related and addictive disorders.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 39, Issue 11, eff. February 17, 2023.
Part VIII
Crisis Services
12VAC35-105-1830. Applicability of part.
All crisis receiving centers, community-based crisis stabilization, crisis stabilization units, and REACH providers shall comply with the provisions of this part.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1840. Staffing.
A. Crisis receiving centers shall meet the following staffing requirements:
1. A licensed psychiatrist or nurse practitioner shall be available to the program, either in person or via telemedicine, 24 hours per day, seven days per week;
2. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall be available for conducting assessments;
3. Nursing services shall be provided by a registered nurse (RN) or a licensed practical nurse (LPN). Nursing staff shall be available 24 hours per day, in person. LPNs shall work directly under the supervision of a physician, nurse practitioner, or RN; and
4. Medical, psychological, psychiatric, laboratory, and toxicology services shall be available by consult or referral.
B. Community-based crisis stabilization shall meet the following staffing requirements:
1. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall conduct assessments and, for any CEPP not authored by an LMHP, review, and if the LMHP, LMHP-R, LMHP-RP, or LMHP-S agrees, sign the CEPP;
2. All staff are required to utilize a working global positioning system (GPS) enabled smart phone or GPS-enabled tablet;
3. Any time staff are dispatched for the provision of mobile crisis response, the provider shall dispatch a team that meets at least one of the following staffing composition requirements:
a. If a single person is dispatched for mobile crisis response:
(1) One licensed staff member; or
(2) One certified pre-screener.
b. If the provider dispatches a team for mobile crisis, the team shall include:
(1) One licensed staff member and one peer recovery specialist (PRS);
(2) One licensed staff member and one certified substance abuse counselor (CSAC), CSAC-supervisee, or certified substance abuse counselor assistant (CSAC-A);
(3) One licensed staff member and one QMHP (QMHP-A, QMHP-C, or QMHP-T);
(4) One PRS, and either one QMHP (QMHP-A or QMHP-C) or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;
(5) One CSAC-A, and either one QMHP (QMHP-A or QMHP-C) or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;
(6) Two QMHPs (QMHP-A, QMHP-C, or QMHP-T; however, the team shall not be two QMHP-Ts). A licensed staff member shall be required to be available via telemedicine for the assessment;
(7) Two CSACs. A licensed staff member shall be required to be available via telemedicine for the assessment; or
(8) One QMHP (QMHP-A or QMHP-C), and one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment.
C. Crisis stabilization units shall meet the following staffing requirements:
1. A licensed psychiatrist or psychiatric nurse practitioner shall be available 24 hours per day, seven days per week either in person or via telemedicine;
2. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall be available to conduct an assessment;
3. Nursing services shall be provided by either an RN or an LPN. Nursing staff shall be available in person 24 hours per day, seven days per week. LPNs shall work directly under the supervision of a physician, nurse practitioner, or an RN; and
4. Medical, psychological, psychiatric, laboratory, and toxicology services shall be available by consult or referral.
D. REACH shall meet the staffing standards specific to its licensed services. The service shall also meet the REACH standards. A REACH crisis therapeutic home shall meet both the crisis stabilization unit standards and the REACH standards.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1850. Crisis assessment.
A. The provider shall implement a written crisis assessment policy. The policy shall define how crisis assessments will be conducted and documented.
B. The provider shall actively involve the individual and the individual's authorized representative, if applicable, in the preparation of crisis assessment. In the crisis assessment, the provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.
C. The crisis assessment policy shall designate appropriately qualified employees or contractors who are responsible for conducting, obtaining, or updating assessments and medical screenings. These employees or contractors shall have experience working with the needs of individuals who are being assessed, with the crisis assessment tools being utilized and with the provision of services that the individuals may require. The crisis assessment policy shall include methods the provider will utilize to identify other appropriate services to assist individuals who are not admitted to the provider's service.
D. Assessment is an ongoing activity. The provider shall make reasonable attempts to obtain previous assessments or history relevant to the crisis. The provider shall use the individual's previous assessments or other relevant history within the course of treatment, if applicable, as noted within subsection F of this section.
E. Providers shall utilize standardized state-sanctioned or federally sanctioned crisis assessment tools as approved by the department or utilize their own crisis assessment tools that shall meet the requirements in subsection F of this section.
F. A crisis assessment shall be initiated prior to or at admission to the service. With the participation of the individual and the individual's authorized representative, if applicable, the provider shall complete or obtain information from other qualified providers in order to complete a crisis assessment detailed enough to (i) determine whether the individual qualifies for admission and (ii) initiate a safety plan or crisis ISP as required by this chapter for those individuals who are admitted to the service. The crisis assessment shall assess the individual's service, health, and safety needs and, at a minimum, include:
1. For community-based crisis stabilization providers providing the mobile crisis component of the service and crisis receiving centers:
a. Diagnosis, including current and past substance use or dependence and risk for intoxication or substance withdrawal, and co-occurring mental illness or developmental disability;
b. Risk of harm, including elements that may make an individual a danger to self or others;
c. Cognitive functional status, including the individual's ability to protect from self-harm and provide for the individual’s basic human needs;
d. Precipitating issues, including recent stressors or events;
e. Presenting needs, including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of needs. The assessor shall record:
(1) Any physical reaction to the presenting crisis if these issues are mentioned by the individual or observed during the assessment. Examples include issues with sleep, appetite, or daily activities;
(2) The individual's housing arrangements and living situation if mentioned by the individual; and
(3) Any trauma, such as sexual abuse, physical abuse, or natural disaster, if appropriate, including if a trauma is related to the current crisis or mentioned by the individual;
f. Additional current medical issues and symptoms, if applicable;
g. Current medications, including recent changes to medications. The assessor shall review current medications to the best of the individual's ability;
h. Barriers that will impact the individual's ability to seek treatment or continue to participate in services, including the individual's mood, ability, and willingness to engage in treatment, and access to transportation;
i. The individual's recovery environment and circle of support; and
j. Communication modality and language preference.
2. For crisis stabilization units and community-based crisis stabilization providing services other than mobile crisis, the assessment shall also include:
a. Relevant treatment history and health history, to include as applicable:
(1) Past prescribed medications;
(2) Hospitalizations for challenging behaviors, mental illness, or substance use;
(3) Other treatments for challenging behaviors, mental illness, or substance use;
(4) Allergies, including allergies to food and medications;
(5) Recent physical complaints and medical conditions;
(6) Nutritional needs;
(7) Chronic conditions;
(8) Communicable diseases;
(9) Restrictions on physical activities, if any;
(10) Restrictive protocols or special supervision requirements;
(11) Preferred interventions in the event behaviors or symptoms become a danger to self or others;
(12) All known contraindications to the use of seclusion, time out, or any form of physical or mechanical restraint, including medical contraindications and history of trauma;
(13) Past serious illnesses, serious injuries, and hospitalizations;
(14) Serious illnesses and chronic conditions of the individual's parents, siblings, and significant others in the same household; and
(15) Other interventions and outcomes, including interventions and outcomes that were unsuccessful. The provider should ensure previous assessments are utilized to note these interventions.
b. The individual's housing arrangements or living situation;
c. Trauma, such as sexual abuse, physical abuse, or natural disaster; and
d. Current or previous involvement in systems, such as legal, adult protective services, or child protective services.
3. If applicable to the individual's crisis, the assessment shall include:
a. The individual’s social, behavioral, developmental, and family history and supports;
b. Employment, vocational, and educational background;
c. Cultural and heritage considerations; and
d. Financial stressors, if applicable.
G. The timing for completion of the crisis assessment shall be as soon as possible after admission but no later than 24 hours after admission.
H. The provider shall retain documentation of the assessments in the individual's record for a minimum of six years following the last patient encounter, in accordance with § 54.1-2910.4 of the Code of Virginia.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1860. Safety plans and crisis individualized services plans.
A. The provider shall actively involve the individual and the individual's authorized representative, as appropriate, in the development, review, and revision of a person-centered safety plan and, if appropriate, crisis individualized services plan (crisis ISP). The individualized safety and services planning process shall be consistent with laws protecting confidentiality, privacy, human rights of individuals receiving services, and rights of minors. To the extent possible, the provider shall collaborate with the individual's crisis planning team to develop, review, revise, and implement, as appropriate, the individual's safety plan or crisis ISP.
B. Providers of developmental services shall collaborate with the individual’s support coordinator to develop or review, revise, and implement, as appropriate, a person-centered CEPP. A provisional CEPP shall be completed within 15 days of admission. An updated CEPP shall be completed within 45 days of admission. Developmental services providers may utilize a CEPP as an individual's safety plan, if appropriate. If a CEPP is to be used as a safety plan, the provider shall meet the deadline listed in subsection C of this section.
C. Providers of mental health and substance abuse services shall develop or review, revise, and implement, as appropriate, a person-centered safety plan immediately after admission that shall continue in effect until discharge from the provider’s crisis service.
D. Providers of crisis services shall develop or review, revise, and implement a crisis ISP as soon as possible after admission but no later than 48 hours after admission and prior to discharge from the provider's crisis service. This provision does not apply to the initial mobile crisis contact or to crisis receiving centers.
E. The safety plan and crisis ISP shall be developed based on the crisis assessment with the participation and informed choice of the individual receiving services.
1. To ensure the individual's participation and informed choice, the following shall be explained to the individual or the individual's authorized representative, as applicable, in a reasonable and comprehensible manner:
a. The proposed services to be delivered;
b. Any alternative services that might be advantageous for the individual; and
c. Any accompanying risks or benefits of the proposed alternative services.
2. If no alternative services are available to the individual, it shall be documented within the individual's service record that alternative services were not available and any steps taken to identify if alternative services were available.
3. Whenever there is a change to an individual's safety plan or crisis ISP, the changes shall be documented within the safety plan or crisis ISP or within documentation attached to the safety plan or crisis ISP that:
a. The individual participated in the development of or revision to the safety plan or crisis ISP;
b. The proposed and alternative services and the respective risks and benefits of those services were explained to the individual or the individual's authorized representative; and
c. The reasons the individual or the individual's authorized representative chose the option included in the safety plan or crisis ISP.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1870. Safety plan and crisis ISP requirements.
A. All individuals receiving crisis services shall have a safety plan.
1. The safety plan shall be based on the individual's immediate service, health, and safety needs identified in the crisis assessment. The safety planning process shall be an ongoing activity. The safety plan shall include:
a. Warning signs that a crisis may be developing, such as thoughts, images, mood, situation, and behavior or stressors that may trigger the individual;
b. Internal coping strategies and things the individual can do without contacting another person, such as relaxation techniques or physical activities;
c. People and social settings that the individual may turn to for distraction or support;
d. People the individual may ask for help;
e. Professionals or agencies the individual can contact during a crisis; and
f. Things the individual can do to make the individual's environment safe.
2. The safety plan may include:
a. A description of how to support the individual when pre-crisis behaviors are observed;
b. Specific instructions for the systems supporting the individual when pre-crisis behaviors are observed;
c. A description of how to support the individual when crisis behaviors are observed; and
d. Specific instructions for the systems supporting the individual during crisis.
3. In the event an individual receiving services requires medication management or seclusion, the need shall be clearly documented in an attachment to the individual's safety plan.
B. Community-based crisis stabilization and crisis stabilization unit providers shall also develop a crisis ISP. A crisis ISP shall be based on the individual's immediate service, health, and safety needs identified in the crisis assessment. The crisis ISP shall include:
1. Relevant and attainable goals, measurable objectives to inform current and future treatment, and specific strategies for addressing each need documented within the individual's crisis assessment;
2. Services, supports, and frequency of services required to accomplish the goals, including relevant psychological, mental health, substance use, behavioral, medical, rehabilitation, training, and nursing needs and supports;
3. Any use of seclusion if allowed in the service per 12VAC35-115;
4.The role of the individual and others, including the individual's family, if appropriate, in implementing the crisis ISP;
5. Identification of employees or contractors responsible for the coordination and integration of services, including employees of other agencies;
6. A behavioral support or treatment plan, if applicable; and
7. Projected discharge plan and estimated length of stay within the service.
C. In order to document agreement, both the safety plan and the crisis ISP shall be signed and dated, at a minimum, by the person responsible for implementing the safety plan or crisis ISP and the individual receiving services or the individual's authorized representative, if appropriate.
1. If the signature of the individual receiving services or the individual's authorized representative cannot be obtained, the provider shall document attempts to obtain the necessary signature and the reason why obtaining it was not possible. The provider shall continue to make attempts to obtain the necessary signature for the length of time the safety plan or crisis ISP is in effect. An attempt to obtain the necessary signature shall occur, at a minimum, each time the provider reviews the safety plan or crisis ISP.
2. The safety plan and crisis ISP shall be distributed to the individual and others authorized to receive it. The provider shall document that the safety plan and crisis ISP were distributed within the individual's service record. If the safety plan or crisis ISP cannot be distributed, the provider shall document attempts to distribute the safety plan and crisis ISP to the individual and the reason why distribution was not possible. The provider shall continue to make attempts to distribute the safety plan and crisis ISP for the length of time the safety plan and crisis ISP are in effect. An attempt to distribute the safety plan and crisis ISP shall occur, at a minimum, each time the provider reviews the safety plan or crisis ISP.
D. The provider shall have a safety plan and crisis ISP policy that designates a staff person responsible for developing, implementing, reviewing, and revising each individual's safety plan and crisis ISP, in collaboration with the individual or the individual's authorized representative, as appropriate.
E. Employees or contractors who are responsible for implementing the safety plan or crisis ISP shall (i) have access to the individual's safety plan or crisis ISP, including an individual's detailed health and safety protocols; and (ii) be competent to implement the safety plan or crisis ISP as written.
F. Whenever possible, the identified goals in the safety plan or crisis ISP shall be written in the words of the individual receiving services.
G. The provider shall use signed and dated progress notes to document the provider's efforts toward the implementation of the goals and objectives contained within the safety plan or crisis ISP.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1880. Crisis discharge planning.
A. Crisis providers are not subject to the provisions of 12VAC35-105-693.
B. Community-based crisis stabilization providers of mobile crisis response and crisis receiving center providers shall make referrals to all follow-up service providers if determined appropriate and document in accordance with the provider's crisis assessment policy. The provider shall document such arrangements, referrals, or reasons why follow-up care was not indicated within the individual's record.
C. Community-based crisis stabilization providers, when providing mobile crisis response services, and crisis receiving centers providers are not required to provide discharge planning to individuals receiving services and, therefore, are not subject to subsections D through H of this section.
D. Community-based crisis stabilization providers, crisis stabilization units, and REACH providers shall have written policies and procedures regarding the discharge or termination of individuals from the service. These policies and procedures shall include medical and clinical criteria for discharge.
E. Discharge instructions shall be provided in writing to the individual, the individual's authorized representative, and any successor provider, as applicable. Discharge instructions shall include, at a minimum, medications and dosages; names, telephone numbers, and addresses of any providers to whom the individual is referred; current medical issues or conditions; and the identity of the treating health care providers. The provider shall make appropriate referrals to all service providers identified within the individual's discharge instructions prior to the individual's scheduled discharge date.
F. The provider shall document in the individual's service record whether the individual, the individual's authorized representative, and the individual's family members, as appropriate, were involved in the discharge planning process.
G. A written discharge summary shall be completed within 30 days of discharge and shall include, at a minimum, the following:
1. The reason for the individual's admission to and discharge from the service;
2. A description of the individual's and the individual's authorized representative's participation in discharge planning and documentation of informed choice by the individual, the individual's authorized representative, or the individual's legal guardian, as applicable, in the decision to and planning for discharge;
3. The individual's current level of functioning or functioning limitations, if applicable;
4. Recommended procedures, activities, or referrals to assist the individual in maintaining or improving functioning and increased independence;
5. The status, location, and arrangements that were made for future services;
6. Progress made by the individual in achieving goals and objectives identified in the crisis ISP and summary of critical events during service provision;
7. Discharge date;
8. Any discharge medications prescribed by the provider, if applicable;
9. Dates the discharge plan was written and documented; and
10. The signature of the person who prepared the discharge plan.
H. The content of the discharge summary and the determination to discharge the individual shall be consistent with the crisis ISP and the criteria for discharge.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1890. Nursing assessment.
A. Crisis receiving centers, crisis stabilization units, and REACH CTH providers shall administer a nursing assessment within 24 hours of admission of an individual.
B. Prior to admission, each individual shall have a screening for communicable diseases, including tuberculosis, as evidenced by the completion of a screening form containing, at a minimum, the elements found on the Report of Tuberculosis Screening form published by the Virginia Department of Health. The screening shall be no older than 30 days. No screening shall be required for a new individual separated from a service with another licensed provider with a break in service of six months or less or who is transferred from another department-licensed provider.
C. A staff member shall conduct a nursing assessment. The nursing assessment shall collect information about the nonpsychiatric medical or surgical condition of an individual to determine whether there is a need for a medical assessment before a decision is made regarding continued treatment within the provider's service or transfer to a more intensive level of care. The nursing assessment shall determine if there is a current medical crisis or underlying medical condition for the individual's psychological crisis, such as any medical condition that affects the individual's psychological state, presenting behavior, or ability to receive the provider's service. The nursing assessment shall note the date of examination and have the signature of a qualified practitioner.
D. Locations designated for nursing assessments shall ensure individual privacy.
E. The provider shall review and follow up with (i) the results of the nursing assessment, including any follow-up diagnostic tests, treatments, or examinations, and (ii) documentation of the arrangements for follow-up care in the individual's record.
F. Each individual's health record shall include notations of any health or dental complaints mentioned by the individual or any injuries and shall summarize symptoms and treatment given.
G. Each individual's health record shall include or document the facility's efforts to obtain treatment summaries of ongoing psychiatric or other mental health treatment and reports.
H. The provider shall develop and implement written policies and procedures that include the use of standard precautions and address communicable and contagious medical conditions.
I. Community-based crisis stabilization providers are not required to administer nursing assessments. The provider may administer a nursing assessment if the provider has the resources to do so or may obtain a medical history or relevant information that would be a part of a medical history if the individual receiving services provides it.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1900. Vital signs for crisis services.
A. This section applies to all crisis receiving centers, crisis stabilization units, and REACH CTH providers.
B. Unless the individual refuses, the provider shall take vital signs upon admission, during the provision of services as per the medical provider's orders, and at discharge.
C. The provider shall implement written procedures regarding the collection of vital signs, including documentation of vital signs, all refusals, and all follow-up actions taken.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1910. Beds or recliners for crisis services.
A. For the purpose of this section, "clean" means freshly laundered, sanitized, and not soiled or stained.
B. Crisis receiving center providers shall arrange for each individual to have a recliner or bed. Crisis stabilization unit and REACH CTH providers shall arrange for each individual to have a bed.
C. Upon admission, the provider shall offer to launder the individual's clothes.
D. The provider shall not operate more recliners or beds at each service location than the number for which its service is licensed at that location.
E. Recliners, beds, and linens shall be clean, comfortable, and well-maintained.
F. Beds shall be equipped with a clean mattress, and recliners shall be equipped with clean cushions. Beds and recliners shall be equipped with a clean pillow, clean blankets, and clean linens. When a bed or recliner is soiled, providers shall assist individuals with bathing, as needed, and provide clean clothing and clean linens, including a clean waterproof mattress cover for a bed.
G. Providers shall change linens at least every seven days and with each new admission.
H. Providers shall provide mattresses that are fire retardant as evidenced by documentation from the manufacturer, except in buildings equipped with an automated sprinkler system as required by the Virginia Uniform Statewide Building Code (13VAC5-63).
I. Providers shall inspect each individual's recliner or bed upon discharge to (i) ensure the individual has all personal belongings and (ii) prepare the recliner or bed for cleaning.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1920. Bedrooms for crisis services.
A. This section only applies to crisis stabilization units and REACH CTH providers.
B. Bedrooms shall meet the following square footage requirements:
1. Single occupancy bedrooms shall have no less than 80 square feet of floor space.
2. Multiple occupancy bedrooms shall have no less than 60 square feet of floor space per individual.
C. No more than four individuals shall share a bedroom.
D. Bedrooms shall be free of all protrusions, sharp corners, hardware, fixtures, or other devices that may cause injury to the individual.
E. Windows in the bedrooms shall be so constructed as to minimize breakage and otherwise prevent the individual from self-harming.
F. Each individual shall have adequate private storage space accessible to the bedroom for clothing and personal belongings.
G. Each sleeping area shall have a door that can be (i) closed for privacy or quiet and (ii) readily opened in case of fire or other emergency.
H. The environment of sleeping areas shall be conducive to sleep and rest.
I. Providers of children's residential services shall provide separate sleeping areas for boys and girls four years of age or older.
J. Providers of children's residential services shall ensure beds are at least three feet apart at the head, foot, and sides, and double-decker beds shall be at least five feet apart at the head, foot, and sides.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1930. Physical environment for crisis services.
A. The physical environment, design, structure, furnishings, and lighting shall be appropriate to the individuals receiving services and the services provided.
B. The physical environment shall be accessible to individuals with physical and sensory disabilities.
C. The physical environment and furnishings shall be clean, dry, free of foul odors, safe, and well-maintained.
D. Floor surfaces and floor coverings shall promote mobility in areas used by individuals and shall promote maintenance of sanitary conditions. There shall be clear pathways through the setting, free of tripping hazards, to ensure that all individuals can move about the setting safely.
Any electrical cords, extension cords, or power strips utilized by the provider shall be properly secured and shall not be placed anywhere that the cord or strip can cause trips or falls.
E. Heat shall be evenly distributed in all rooms occupied by individuals such that a temperature no less than 68°F is maintained, unless otherwise mandated by state or federal authorities. Natural or mechanical ventilation to the outside shall be provided in all rooms used by residents. Individual or mechanical ventilating systems shall be provided in all rooms occupied by individuals when the temperature in those rooms exceeds 80°F.
F. Plumbing shall be maintained in good operational condition. Adequate hot and cold running water of a safe and appropriate temperature shall be available. Hot water accessible to individuals receiving services shall be maintained within a range of 100° to 120°F. Precautions shall be taken to prevent scalding from running water.
G. Adequate provision shall be made for the collection and legal disposal of garbage and waste materials.
H. The physical environment, structure, furnishings, and lighting shall be kept free of vermin, rodents, insects, and other pests.
I. If smoking is permitted, the provider shall make provisions for alternate smoking areas that are separate from the service environment.
J. For all program areas added after September 19, 2002, minimum room height shall be 7-1/2 feet.
K. Bedroom, bathroom, and dressing area windows and doors shall provide privacy.
L. Bathrooms intended for use by more than one individual at the same time shall provide privacy for showers and toilets.
M. The right of privacy within bathrooms includes the right to be free of cameras or audio monitors within the bathroom or angled toward a bathroom.
N. Bedrooms and bathrooms shall be free of all protrusions, sharp corners, hardware, fixtures, or other devices that may cause injury to the individual. Windows in the bathrooms shall be so constructed as to minimize breakage and otherwise prevent the individual from self-harming.
O. No required path of travel to the bathroom shall be through another bedroom. Each individual's room shall have direct access to a corridor, living area, dining area, or other common area.
P. Each provider shall make available at least one toilet, one hand basin, and a shower or bath for every four individuals. Providers of children's residential services shall:
1. Make available at least one toilet, one hand basin, and one shower or bathtub in each living unit;
2. Make available at least one bathroom equipped with a bathtub in each facility;
3. Make available at least one toilet, one hand basin, and one shower or bathtub for every eight individuals for facilities licensed before July 1, 1981;
4. Make available one toilet, one hand basin, and one shower or bathtub for every four individuals in any building constructed or structurally modified after July 1, 1981. Facilities licensed after December 28, 2007, shall comply with the one-to-four ratio; and
5. The maximum number of staff members on duty in the living unit shall be counted in determining the required number of toilets and hand basins when a separate bathroom is not provided for staff.
Q. If a provider utilizes cameras or audio monitors, the provider shall have written policies and procedures regarding audio or audio-video recordings of individuals receiving services approved by the Office of Licensing and the Office of Human Rights. The policies and procedures shall ensure and provide that:
1. The provider has obtained written consent of the individual before the individual is recorded;
2. No recording by the provider shall take place without the individual being informed;
3. The provider has postings informing individuals receiving services and others that recording is taking place; and
4. All recordings shall be used in a manner that respects the dignity and confidentiality of the individuals receiving services.
R. A provider shall develop and implement written policies and procedures approved by the Office of Licensing governing searches that shall provide that:
1. Searches shall be limited to instances where they are necessary to prohibit contraband;
2. Searches shall be conducted only by personnel who are specifically authorized to conduct searches by the written policies and procedures;
3. Searches shall be conducted in such a way to protect the individual's dignity and in the presence of one or more witnesses; and
4. The policies and procedures shall note the actions to be taken by a provider if contraband is found by a search, including methods to manage and dispose of contraband.
S. Providers who serve temporary detention orders or emergency custody orders shall ensure the program is provided in a secure facility or a secure program space.
T. Providers shall provide privacy from routine sight supervision by staff members while bathing, dressing, or conducting toileting activities. This subsection does not apply to medical personnel performing medical procedures or staff providing assistance to individuals whose physical, mental, or safety needs dictate the need for assistance with these activities as justified in the individual's record.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1940. Seclusion.
Seclusion is only allowed as permitted by 12VAC35-115 and other applicable state regulations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1950. Seclusion room requirements.
The room used for seclusion of persons shall meet the following design requirements:
1. The seclusion room shall be at least six feet wide and six feet long with a minimum ceiling height of eight feet.
2. The seclusion room shall be free of all protrusions, sharp corners, hardware, fixtures, or other devices that may cause injury to the occupant.
3. Windows in the seclusion room shall be constructed to minimize breakage and otherwise prevent the occupant from self-harming.
4. Light fixtures and other electrical receptacles in the seclusion room shall be recessed or so constructed as to prevent the occupant from self-harming. Light controls shall be located outside the seclusion room.
5. Doors to the seclusion room shall be at least 32 inches wide, open outward, and shall contain observation view panels of transparent wire glass or its approved equivalent, not exceeding 120 square inches but of sufficient size for someone outside the door to see into all corners of the room.
6. The seclusion room shall contain only a mattress with a washable mattress covering designed to avoid damage by tearing.
7. The seclusion room shall maintain temperatures appropriate for the season.
8. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
Forms (12VAC35-105)
Initial Provider Application For Licensing (rev.1/10).
Renewal Provider Application For Licensing (rev. 2/09).
Service Modification - Provider Request, DMH 966E 1140 (rev. 1/09).
Documents Incorporated by Reference (12VAC35-105)
The ASAM: Treatment for Addictive, Substance-Related and Co-Occurring Conditions, Third Edition, American Society of Addiction Medicine, Address, asam.org.
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. DSM-5, American Psychiatric Association, 800 Maine Avenue, S.W., Suite 900 Washington, DC 20024, psychiatry.org