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.).