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. Providers shall comply with requirements of the Americans with Disabilities Act (42 USC § 12101 et seq.) and the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia) 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; Volume 41, Issue 18, eff. June 19, 2025.
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, 37.2-416.1, 37.2-506, 37.2-506.1, and 37.2-607 of the Code of Virginia.
B. The provider shall develop a written policy for criminal history background checks and registry searches that addresses what actions the provider must take if an applicant has certain prior convictions or a founded case of child abuse or neglect. The policy shall require, at a minimum, that the applicant disclose whether the applicant has (i) ever been convicted of or is the subject of pending charges for an offense listed in § 37.2-416, 37.2-416.1, 37.2-506, 37.2-506.1, or 37.2-607 of the Code of Virginia; or (ii) has a founded case of abuse or neglect. Any plea of nolo contendere shall be considered a conviction for purposes of this section.
C. The provider shall submit all personally descriptive applicant information necessary 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 required pursuant to subsection B of this section; and
2. Evidence that the provider submitted all information necessary to complete the criminal history background checks and registry searches, report from the Central Criminal Records Exchange, or memoranda from the department transmitting the results to the provider, as applicable, and the results from the Child Protective Registry search.
Statutory Authority
§§ 37.2-203 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 41, Issue 18, eff. June 19, 2025.
12VAC35-105-410. Job description.
Each employee or contractor shall have access to the employee's or contractor's current written job description that includes:
1. Job title;
2. Duties and responsibilities; and
3. Minimum knowledge, skills, and abilities; education or training; or experience or professional qualifications required for entry.
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 41, Issue 18, eff. June 19, 2025.
12VAC35-105-420. Qualifications of employees or contractors.
A. Each person who assumes the responsibilities of a position as an employee or a contractor shall meet the minimum qualifications of that position in accordance with the current job description.
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. Each employee or contractor shall demonstrate a working knowledge of the policies and procedures that are applicable to that employee's or contractor's 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; Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-430. Employee or contractor personnel records.
A. Employee or contractor personnel records shall include:
1. Individual identifying information;
2. Education and training history;
3. Employment history; and
4. A record of disciplinary action taken by the provider, if any.
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; Volume 41, Issue 18, eff. June 19, 2025.
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 the individual's 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. Practices of confidentiality, including access, duplication, and dissemination of any portion of an individual's record;
2. Practices that ensure an individual's rights, including orientation to human rights regulations;
3. Emergency preparedness procedures;
4. Person-centeredness;
5. Infection control practices and measures;
6. Other policies and procedures that apply to specific positions and specific duties and responsibilities; and
7. 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
§§ 37.2-203 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 41, Issue 18, eff. June 19, 2025.
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.
The provider shall keep all employees and contractors informed of policy changes that affect the employee's or contractor's performance of duties.
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 41, Issue 18, eff. June 19, 2025.
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. (Repealed.)
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; repealed, Virginia Register Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-500. (Repealed.)
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; repealed, Virginia Register Volume 41, Issue 18, eff. June 19, 2025.
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 receive tuberculosis education on an annual basis. The education shall focus on self-presentation in the event of exposure to active tuberculosis or the development of symptoms of active tuberculosis.
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 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. No employee, contractor, student, or volunteer suspected of having active tuberculosis shall 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; Volume 41, Issue 18, eff. June 19, 2025.