Part IV. Services and Supports
Article 1
Service Description and Staffing
12VAC35-105-570. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 18, Issue 18, eff. September 19, 2002; repealed, Virginia Register Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-580. Service description requirements.
A. The provider shall develop and implement descriptions of services offered 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 individual's physical and emotional needs; provide protection, guidance, and supervision; and meet the objectives of any required individualized services plan.
C. Elements of each service description required by subsection A of this section 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 not implement services that are inconsistent with its most current service description.
E. The provider shall admit only those individuals whose service needs are consistent with the service description, for whom services are available, and for whom staffing levels and types meet the needs of the individual receiving services.
F. 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.
G. The service description for substance abuse treatment services shall address the timely and appropriate treatment of pregnant women with substance abuse (substance use disorders).
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.
12VAC35-105-590. 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 staffing plan shall not include volunteers or students and shall not rely on students or volunteers to supplant direct care positions.
C. The provider shall develop a written transition staffing plan for new services, added locations, and changes in capacity.
D. The provider shall meet the following staffing requirements related to supervision.
1. The provider shall describe how employees and contractors will be supervised in the staffing plan and how that supervision will be documented.
2. Supervision of employees and contractors 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 collaborative behavioral 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 (i) a registered QMHP who has practiced for three years and completed the supervisor training required by the Department of Health Professions; (ii) a licensed mental health professional who has completed the supervisor training required by the Department of Health Professions; or (iii) a person under supervision who is license-eligible, registered with the Board of Counseling, Board of Psychology, or Board of Social Work, and has completed the supervisor training required by the Department of Health Professions. A registered QMHP who meets these requirements may supervise activities within the QMHP's scope. This supervision must occur under the broader required direction of and in collaboration with the LMHP or licensed eligible mental health professional.
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 who 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 (e.g., 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.
E. 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.
F. 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.
G. 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
§§ 37.2-203 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 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; Volume 41, Issue 20, eff. June 18, 2025; Volume 41, Issue 18, eff. June 19, 2025.
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, and admission.
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 each individual's initial contact and screening, 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 referral to other services for further assessment, placement on a waiting list for service, or admission to the service.
C. Providers of crisis or case management services shall assist individuals who are not admitted to identify other appropriate services.
D. For individuals who are not admitted, the provider shall retain documentation of the individual's initial contact and screening referenced in subsection B of this section for a period of six months.
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 41, Issue 18, eff. June 19, 2025.
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 of individuals and authorized representatives.
A. The provider shall implement a written policy regarding the orientation to services for individuals and authorized representatives, if applicable.
B. As appropriate to the scope and level of services, the policy shall require the provision to individuals and authorized representatives, if applicable, the following information:
1. Confidentiality practices and protections for individuals receiving services;
2. Human rights policies and protections and instructions on how to report violations;
3. Opportunities for participation in services and discharge planning;
4. Fire safety and emergency preparedness procedures, if applicable;
5. The provider's complaint procedure;
6. Service guidelines, including criteria for admission and discharge or transfer;
7. Hours and days of operation;
8. Availability of after-hours service; and
9. Any charges or fees due from the individual.
C. In addition to the provisions of subsection B of this section, orientation for individuals receiving treatment services in a correctional facility shall cover 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; Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-691. Transition of individuals among services by the same provider.
A. Except when transfer is ordered by a court of competent jurisdiction, the receiving service shall obtain from the sending service at the time of transfer:
1. Documentation of:
a. Informed choice by the individual or authorized representative, as applicable, in the decision to and planning for the transfer;
b. Notification to the family, if appropriate; and
c. Signature of the employee or contractor responsible for preparing the transfer summary and transfer date;
2. A written summary of the individual's progress while at the facility, justification for the transfer, and the individual's current strengths and needs; and
3. The individual's record, including emergency medical information.
B. The sending service shall retain a copy of the face sheet and a written summary of the individual's progress while within the service and shall document the date of transfer and the name of the service to which the individual was transferred.
Statutory Authority
§§ 37.2-203 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 41, Issue 18, eff. June 19, 2025.
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. At a minimum, discharge instructions shall include medications and dosages, if applicable; names, telephone numbers, and addresses of any successor providers to whom the individual is referred; current medical issues or conditions; and the identity of the individual's treating health care practitioners.
C. The provider shall make appropriate arrangements or referrals to all services or successor 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 complete a written discharge summary within 30 days of discharge that includes, at a minimum, the following:
1. Reason for the individual's admission to and discharge from the service;
2. Description of participation by the individual or the individual's authorized representative 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 were made for future services;
6. Progress made by the individual in achieving goals and objectives identified in the ISP and a summary of critical events during service provision;
7. Date of discharge and when the discharge summary was actually written or documented; and
8. Signature of the provider's employee or contractor responsible for preparing the discharge summary.
F. 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; Volume 41, Issue 18, eff. June 19, 2025.
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, as defined in 12VAC35-105-20, 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 service-specific working definition of what constitutes a behavioral, medical, or psychiatric emergency;
2. Employee or contractor responsibilities; and
3. 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; Volume 41, Issue 18, eff. June 19, 2025.
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 offered, 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 telephone 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. The provider shall implement written infection control measures, including the use of universal precautions.
D. The provider shall report outbreaks of infectious diseases to the Virginia 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; Volume 41, Issue 18, eff. June 19, 2025.
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. Within 30 days of an individual's admission, providers of residential or inpatient services shall either administer a physical examination or obtain results of an examination conducted within the previous 12 months. Providers of inpatient services shall administer physical exams within 24 hours of an individual's admission.
B. A physical examination shall include the date of examination and signature of a qualified practitioner.
C. 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.
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 28, Issue 5, eff. December 7, 2011; Volume 40, Issue 22, eff. July 17, 2024; Volume 41, Issue 18, eff. June 19, 2025.
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 outside the facility;
4. Training requirements necessary for employees or contractors who are authorized to administer medication; and
5. 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 authorized to do so by the Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia).
C. Medications shall be administered as prescribed and only to the individuals for whom the medications are 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; Volume 41, Issue 18, eff. June 19, 2025.
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. (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.
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 conditions for the use of behavior interventions that comply with the requirements of 12VAC35-115, including seclusion, restraint, and time out. The policies and procedures shall:
1. List and define behavior interventions in the order of relative degree of intrusiveness or restrictiveness and the conditions under which each intervention may be used in accordance with each individual's ISP;
2. Protect the safety and well-being of the individual at all times, including during fire and other emergencies; and
3. Specify the mechanism for monitoring and 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, families, authorized representatives, and advocates. Notification of policies does not need to occur in correctional facilities.
D. No individual receiving services shall 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
§§ 37.2-203 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 19, Issue 24, eff. September 18, 2003; Volume 28, Issue 5, eff. December 7, 2011; Volume 36, Issue 22, eff. August 1, 2020; Volume 41, Issue 18, eff. June 19, 2025.
12VAC35-105-810. 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.