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 (Repealed.)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 September 19, 2002; repealed, Virginia Register Volume 41, Issue 18, eff.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.