Part VIII. Crisis Services
12VAC35-105-1830. Applicability of part.
All crisis receiving centers, community-based crisis stabilization, crisis stabilization units, and REACH providers shall comply with the provisions of this part.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1840. Staffing.
A. Crisis receiving centers shall meet the following staffing requirements:
1. A licensed psychiatrist or nurse practitioner shall be available to the program, either in person or via telemedicine, 24 hours per day, seven days per week;
2. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall be available for conducting assessments;
3. Nursing services shall be provided by a registered nurse (RN) or a licensed practical nurse (LPN). Nursing staff shall be available 24 hours per day, in person. LPNs shall work directly under the supervision of a physician, nurse practitioner, or RN; and
4. Medical, psychological, psychiatric, laboratory, and toxicology services shall be available by consult or referral.
B. Community-based crisis stabilization shall meet the following staffing requirements:
1. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall conduct assessments and, for any CEPP not authored by an LMHP, review, and if the LMHP, LMHP-R, LMHP-RP, or LMHP-S agrees, sign the CEPP;
2. All staff are required to utilize a working global positioning system (GPS) enabled smart phone or GPS-enabled tablet;
3. Any time staff are dispatched for the provision of mobile crisis response, the provider shall dispatch a team that meets at least one of the following staffing composition requirements:
a. If a single person is dispatched for mobile crisis response:
(1) One licensed staff member; or
(2) One certified pre-screener.
b. If the provider dispatches a team for mobile crisis, the team shall include:
(1) One licensed staff member and one peer recovery specialist (PRS);
(2) One licensed staff member and one certified substance abuse counselor (CSAC), CSAC-supervisee, or certified substance abuse counselor assistant (CSAC-A);
(3) One licensed staff member and one QMHP (QMHP-A, QMHP-C, or QMHP-T);
(4) One PRS, and either one QMHP (QMHP-A or QMHP-C) or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;
(5) One CSAC-A, and either one QMHP (QMHP-A or QMHP-C) or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;
(6) Two QMHPs (QMHP-A, QMHP-C, or QMHP-T; however, the team shall not be two QMHP-Ts). A licensed staff member shall be required to be available via telemedicine for the assessment;
(7) Two CSACs. A licensed staff member shall be required to be available via telemedicine for the assessment; or
(8) One QMHP (QMHP-A or QMHP-C), and one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment.
C. Crisis stabilization units shall meet the following staffing requirements:
1. A licensed psychiatrist or psychiatric nurse practitioner shall be available 24 hours per day, seven days per week either in person or via telemedicine;
2. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall be available to conduct an assessment;
3. Nursing services shall be provided by either an RN or an LPN. Nursing staff shall be available in person 24 hours per day, seven days per week. LPNs shall work directly under the supervision of a physician, nurse practitioner, or an RN; and
4. Medical, psychological, psychiatric, laboratory, and toxicology services shall be available by consult or referral.
D. REACH shall meet the staffing standards specific to its licensed services. The service shall also meet the REACH standards. A REACH crisis therapeutic home shall meet both the crisis stabilization unit standards and the REACH standards.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1850. Crisis assessment.
A. The provider shall implement a written crisis assessment policy. The policy shall define how crisis assessments will be conducted and documented.
B. The provider shall actively involve the individual and the individual's authorized representative, if applicable, in the preparation of crisis assessment. In the crisis assessment, the provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.
C. The crisis assessment policy shall designate appropriately qualified employees or contractors who are responsible for conducting, obtaining, or updating assessments and medical screenings. These employees or contractors shall have experience working with the needs of individuals who are being assessed, with the crisis assessment tools being utilized and with the provision of services that the individuals may require. The crisis assessment policy shall include methods the provider will utilize to identify other appropriate services to assist individuals who are not admitted to the provider's service.
D. Assessment is an ongoing activity. The provider shall make reasonable attempts to obtain previous assessments or history relevant to the crisis. The provider shall use the individual's previous assessments or other relevant history within the course of treatment, if applicable, as noted within subsection F of this section.
E. Providers shall utilize standardized state-sanctioned or federally sanctioned crisis assessment tools as approved by the department or utilize their own crisis assessment tools that shall meet the requirements in subsection F of this section.
F. A crisis assessment shall be initiated prior to or at admission to the service. With the participation of the individual and the individual's authorized representative, if applicable, the provider shall complete or obtain information from other qualified providers in order to complete a crisis assessment detailed enough to (i) determine whether the individual qualifies for admission and (ii) initiate a safety plan or crisis ISP as required by this chapter for those individuals who are admitted to the service. The crisis assessment shall assess the individual's service, health, and safety needs and, at a minimum, include:
1. For community-based crisis stabilization providers providing the mobile crisis component of the service and crisis receiving centers:
a. Diagnosis, including current and past substance use or dependence and risk for intoxication or substance withdrawal, and co-occurring mental illness or developmental disability;
b. Risk of harm, including elements that may make an individual a danger to self or others;
c. Cognitive functional status, including the individual's ability to protect from self-harm and provide for the individual’s basic human needs;
d. Precipitating issues, including recent stressors or events;
e. Presenting needs, including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of needs. The assessor shall record:
(1) Any physical reaction to the presenting crisis if these issues are mentioned by the individual or observed during the assessment. Examples include issues with sleep, appetite, or daily activities;
(2) The individual's housing arrangements and living situation if mentioned by the individual; and
(3) Any trauma, such as sexual abuse, physical abuse, or natural disaster, if appropriate, including if a trauma is related to the current crisis or mentioned by the individual;
f. Additional current medical issues and symptoms, if applicable;
g. Current medications, including recent changes to medications. The assessor shall review current medications to the best of the individual's ability;
h. Barriers that will impact the individual's ability to seek treatment or continue to participate in services, including the individual's mood, ability, and willingness to engage in treatment, and access to transportation;
i. The individual's recovery environment and circle of support; and
j. Communication modality and language preference.
2. For crisis stabilization units and community-based crisis stabilization providing services other than mobile crisis, the assessment shall also include:
a. Relevant treatment history and health history, to include as applicable:
(1) Past prescribed medications;
(2) Hospitalizations for challenging behaviors, mental illness, or substance use;
(3) Other treatments for challenging behaviors, mental illness, or substance use;
(4) Allergies, including allergies to food and medications;
(5) Recent physical complaints and medical conditions;
(6) Nutritional needs;
(7) Chronic conditions;
(8) Communicable diseases;
(9) Restrictions on physical activities, if any;
(10) Restrictive protocols or special supervision requirements;
(11) Preferred interventions in the event behaviors or symptoms become a danger to self or others;
(12) All known contraindications to the use of seclusion, time out, or any form of physical or mechanical restraint, including medical contraindications and history of trauma;
(13) Past serious illnesses, serious injuries, and hospitalizations;
(14) Serious illnesses and chronic conditions of the individual's parents, siblings, and significant others in the same household; and
(15) Other interventions and outcomes, including interventions and outcomes that were unsuccessful. The provider should ensure previous assessments are utilized to note these interventions.
b. The individual's housing arrangements or living situation;
c. Trauma, such as sexual abuse, physical abuse, or natural disaster; and
d. Current or previous involvement in systems, such as legal, adult protective services, or child protective services.
3. If applicable to the individual's crisis, the assessment shall include:
a. The individual’s social, behavioral, developmental, and family history and supports;
b. Employment, vocational, and educational background;
c. Cultural and heritage considerations; and
d. Financial stressors, if applicable.
G. The timing for completion of the crisis assessment shall be as soon as possible after admission but no later than 24 hours after admission.
H. The provider shall retain documentation of the assessments in the individual's record for a minimum of six years following the last patient encounter, in accordance with § 54.1-2910.4 of the Code of Virginia.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1860. Safety plans and crisis individualized services plans.
A. The provider shall actively involve the individual and the individual's authorized representative, as appropriate, in the development, review, and revision of a person-centered safety plan and, if appropriate, crisis individualized services plan (crisis ISP). The individualized safety and services planning process shall be consistent with laws protecting confidentiality, privacy, human rights of individuals receiving services, and rights of minors. To the extent possible, the provider shall collaborate with the individual's crisis planning team to develop, review, revise, and implement, as appropriate, the individual's safety plan or crisis ISP.
B. Providers of developmental services shall collaborate with the individual’s support coordinator to develop or review, revise, and implement, as appropriate, a person-centered CEPP. A provisional CEPP shall be completed within 15 days of admission. An updated CEPP shall be completed within 45 days of admission. Developmental services providers may utilize a CEPP as an individual's safety plan, if appropriate. If a CEPP is to be used as a safety plan, the provider shall meet the deadline listed in subsection C of this section.
C. Providers of mental health and substance abuse services shall develop or review, revise, and implement, as appropriate, a person-centered safety plan immediately after admission that shall continue in effect until discharge from the provider’s crisis service.
D. Providers of crisis services shall develop or review, revise, and implement a crisis ISP as soon as possible after admission but no later than 48 hours after admission and prior to discharge from the provider's crisis service. This provision does not apply to the initial mobile crisis contact or to crisis receiving centers.
E. The safety plan and crisis ISP shall be developed based on the crisis assessment with the participation and informed choice of the individual receiving services.
1. To ensure the individual's participation and informed choice, the following shall be explained to the individual or the individual's authorized representative, as applicable, in a reasonable and comprehensible manner:
a. The proposed services to be delivered;
b. Any alternative services that might be advantageous for the individual; and
c. Any accompanying risks or benefits of the proposed alternative services.
2. If no alternative services are available to the individual, it shall be documented within the individual's service record that alternative services were not available and any steps taken to identify if alternative services were available.
3. Whenever there is a change to an individual's safety plan or crisis ISP, the changes shall be documented within the safety plan or crisis ISP or within documentation attached to the safety plan or crisis ISP that:
a. The individual participated in the development of or revision to the safety plan or crisis ISP;
b. The proposed and alternative services and the respective risks and benefits of those services were explained to the individual or the individual's authorized representative; and
c. The reasons the individual or the individual's authorized representative chose the option included in the safety plan or crisis ISP.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1870. Safety plan and crisis ISP requirements.
A. All individuals receiving crisis services shall have a safety plan.
1. The safety plan shall be based on the individual's immediate service, health, and safety needs identified in the crisis assessment. The safety planning process shall be an ongoing activity. The safety plan shall include:
a. Warning signs that a crisis may be developing, such as thoughts, images, mood, situation, and behavior or stressors that may trigger the individual;
b. Internal coping strategies and things the individual can do without contacting another person, such as relaxation techniques or physical activities;
c. People and social settings that the individual may turn to for distraction or support;
d. People the individual may ask for help;
e. Professionals or agencies the individual can contact during a crisis; and
f. Things the individual can do to make the individual's environment safe.
2. The safety plan may include:
a. A description of how to support the individual when pre-crisis behaviors are observed;
b. Specific instructions for the systems supporting the individual when pre-crisis behaviors are observed;
c. A description of how to support the individual when crisis behaviors are observed; and
d. Specific instructions for the systems supporting the individual during crisis.
3. In the event an individual receiving services requires medication management or seclusion, the need shall be clearly documented in an attachment to the individual's safety plan.
B. Community-based crisis stabilization and crisis stabilization unit providers shall also develop a crisis ISP. A crisis ISP shall be based on the individual's immediate service, health, and safety needs identified in the crisis assessment. The crisis ISP shall include:
1. Relevant and attainable goals, measurable objectives to inform current and future treatment, and specific strategies for addressing each need documented within the individual's crisis assessment;
2. Services, supports, and frequency of services required to accomplish the goals, including relevant psychological, mental health, substance use, behavioral, medical, rehabilitation, training, and nursing needs and supports;
3. Any use of seclusion if allowed in the service per 12VAC35-115;
4.The role of the individual and others, including the individual's family, if appropriate, in implementing the crisis ISP;
5. Identification of employees or contractors responsible for the coordination and integration of services, including employees of other agencies;
6. A behavioral support or treatment plan, if applicable; and
7. Projected discharge plan and estimated length of stay within the service.
C. In order to document agreement, both the safety plan and the crisis ISP shall be signed and dated, at a minimum, by the person responsible for implementing the safety plan or crisis ISP and the individual receiving services or the individual's authorized representative, if appropriate.
1. If the signature of the individual receiving services or the individual's authorized representative cannot be obtained, the provider shall document attempts to obtain the necessary signature and the reason why obtaining it was not possible. The provider shall continue to make attempts to obtain the necessary signature for the length of time the safety plan or crisis ISP is in effect. An attempt to obtain the necessary signature shall occur, at a minimum, each time the provider reviews the safety plan or crisis ISP.
2. The safety plan and crisis ISP shall be distributed to the individual and others authorized to receive it. The provider shall document that the safety plan and crisis ISP were distributed within the individual's service record. If the safety plan or crisis ISP cannot be distributed, the provider shall document attempts to distribute the safety plan and crisis ISP to the individual and the reason why distribution was not possible. The provider shall continue to make attempts to distribute the safety plan and crisis ISP for the length of time the safety plan and crisis ISP are in effect. An attempt to distribute the safety plan and crisis ISP shall occur, at a minimum, each time the provider reviews the safety plan or crisis ISP.
D. The provider shall have a safety plan and crisis ISP policy that designates a staff person responsible for developing, implementing, reviewing, and revising each individual's safety plan and crisis ISP, in collaboration with the individual or the individual's authorized representative, as appropriate.
E. Employees or contractors who are responsible for implementing the safety plan or crisis ISP shall (i) have access to the individual's safety plan or crisis ISP, including an individual's detailed health and safety protocols; and (ii) be competent to implement the safety plan or crisis ISP as written.
F. Whenever possible, the identified goals in the safety plan or crisis ISP shall be written in the words of the individual receiving services.
G. The provider shall use signed and dated progress notes to document the provider's efforts toward the implementation of the goals and objectives contained within the safety plan or crisis ISP.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1880. Crisis discharge planning.
A. Crisis providers are not subject to the provisions of 12VAC35-105-693.
B. Community-based crisis stabilization providers of mobile crisis response and crisis receiving center providers shall make referrals to all follow-up service providers if determined appropriate and document in accordance with the provider's crisis assessment policy. The provider shall document such arrangements, referrals, or reasons why follow-up care was not indicated within the individual's record.
C. Community-based crisis stabilization providers, when providing mobile crisis response services, and crisis receiving centers providers are not required to provide discharge planning to individuals receiving services and, therefore, are not subject to subsections D through H of this section.
D. Community-based crisis stabilization providers, crisis stabilization units, and REACH providers shall have written policies and procedures regarding the discharge or termination of individuals from the service. These policies and procedures shall include medical and clinical criteria for discharge.
E. Discharge instructions shall be provided in writing to the individual, the individual's authorized representative, and any successor provider, as applicable. Discharge instructions shall include, at a minimum, medications and dosages; names, telephone numbers, and addresses of any providers to whom the individual is referred; current medical issues or conditions; and the identity of the treating health care providers. The provider shall make appropriate referrals to all service providers identified within the individual's discharge instructions prior to the individual's scheduled discharge date.
F. The provider shall document in the individual's service record whether the individual, the individual's authorized representative, and the individual's family members, as appropriate, were involved in the discharge planning process.
G. A written discharge summary shall be completed within 30 days of discharge and shall include, at a minimum, the following:
1. The reason for the individual's admission to and discharge from the service;
2. A description of the individual's and the individual's authorized representative's participation in discharge planning and documentation of informed choice by the individual, the individual's authorized representative, or the individual's legal guardian, as applicable, in the decision to and planning for discharge;
3. The individual's current level of functioning or functioning limitations, if applicable;
4. Recommended procedures, activities, or referrals to assist the individual in maintaining or improving functioning and increased independence;
5. The status, location, and arrangements that were made for future services;
6. Progress made by the individual in achieving goals and objectives identified in the crisis ISP and summary of critical events during service provision;
7. Discharge date;
8. Any discharge medications prescribed by the provider, if applicable;
9. Dates the discharge plan was written and documented; and
10. The signature of the person who prepared the discharge plan.
H. The content of the discharge summary and the determination to discharge the individual shall be consistent with the crisis ISP and the criteria for discharge.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1890. Nursing assessment.
A. Crisis receiving centers, crisis stabilization units, and REACH CTH providers shall administer a nursing assessment within 24 hours of admission of an individual.
B. Prior to admission, each individual shall have a screening for communicable diseases, including tuberculosis, as evidenced by the completion of a screening form containing, at a minimum, the elements found on the Report of Tuberculosis Screening form published by the Virginia Department of Health. The screening shall be no older than 30 days. No screening shall be required for a new individual separated from a service with another licensed provider with a break in service of six months or less or who is transferred from another department-licensed provider.
C. A staff member shall conduct a nursing assessment. The nursing assessment shall collect information about the nonpsychiatric medical or surgical condition of an individual to determine whether there is a need for a medical assessment before a decision is made regarding continued treatment within the provider's service or transfer to a more intensive level of care. The nursing assessment shall determine if there is a current medical crisis or underlying medical condition for the individual's psychological crisis, such as any medical condition that affects the individual's psychological state, presenting behavior, or ability to receive the provider's service. The nursing assessment shall note the date of examination and have the signature of a qualified practitioner.
D. Locations designated for nursing assessments shall ensure individual privacy.
E. The provider shall review and follow up with (i) the results of the nursing assessment, including any follow-up diagnostic tests, treatments, or examinations, and (ii) documentation of the arrangements for follow-up care in the individual's record.
F. Each individual's health record shall include notations of any health or dental complaints mentioned by the individual or any injuries and shall summarize symptoms and treatment given.
G. Each individual's health record shall include or document the facility's efforts to obtain treatment summaries of ongoing psychiatric or other mental health treatment and reports.
H. The provider shall develop and implement written policies and procedures that include the use of standard precautions and address communicable and contagious medical conditions.
I. Community-based crisis stabilization providers are not required to administer nursing assessments. The provider may administer a nursing assessment if the provider has the resources to do so or may obtain a medical history or relevant information that would be a part of a medical history if the individual receiving services provides it.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1900. Vital signs for crisis services.
A. This section applies to all crisis receiving centers, crisis stabilization units, and REACH CTH providers.
B. Unless the individual refuses, the provider shall take vital signs upon admission, during the provision of services as per the medical provider's orders, and at discharge.
C. The provider shall implement written procedures regarding the collection of vital signs, including documentation of vital signs, all refusals, and all follow-up actions taken.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1910. Beds or recliners for crisis services.
A. For the purpose of this section, "clean" means freshly laundered, sanitized, and not soiled or stained.
B. Crisis receiving center providers shall arrange for each individual to have a recliner or bed. Crisis stabilization unit and REACH CTH providers shall arrange for each individual to have a bed.
C. Upon admission, the provider shall offer to launder the individual's clothes.
D. The provider shall not operate more recliners or beds at each service location than the number for which its service is licensed at that location.
E. Recliners, beds, and linens shall be clean, comfortable, and well-maintained.
F. Beds shall be equipped with a clean mattress, and recliners shall be equipped with clean cushions. Beds and recliners shall be equipped with a clean pillow, clean blankets, and clean linens. When a bed or recliner is soiled, providers shall assist individuals with bathing, as needed, and provide clean clothing and clean linens, including a clean waterproof mattress cover for a bed.
G. Providers shall change linens at least every seven days and with each new admission.
H. Providers shall provide mattresses that are fire retardant as evidenced by documentation from the manufacturer, except in buildings equipped with an automated sprinkler system as required by the Virginia Uniform Statewide Building Code (13VAC5-63).
I. Providers shall inspect each individual's recliner or bed upon discharge to (i) ensure the individual has all personal belongings and (ii) prepare the recliner or bed for cleaning.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1920. Bedrooms for crisis services.
A. This section only applies to crisis stabilization units and REACH CTH providers.
B. Bedrooms shall meet the following square footage requirements:
1. Single occupancy bedrooms shall have no less than 80 square feet of floor space.
2. Multiple occupancy bedrooms shall have no less than 60 square feet of floor space per individual.
C. No more than four individuals shall share a bedroom.
D. Bedrooms shall be free of all protrusions, sharp corners, hardware, fixtures, or other devices that may cause injury to the individual.
E. Windows in the bedrooms shall be so constructed as to minimize breakage and otherwise prevent the individual from self-harming.
F. Each individual shall have adequate private storage space accessible to the bedroom for clothing and personal belongings.
G. Each sleeping area shall have a door that can be (i) closed for privacy or quiet and (ii) readily opened in case of fire or other emergency.
H. The environment of sleeping areas shall be conducive to sleep and rest.
I. Providers of children's residential services shall provide separate sleeping areas for boys and girls four years of age or older.
J. Providers of children's residential services shall ensure beds are at least three feet apart at the head, foot, and sides, and double-decker beds shall be at least five feet apart at the head, foot, and sides.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1930. Physical environment for crisis services.
A. The physical environment, design, structure, furnishings, and lighting shall be appropriate to the individuals receiving services and the services provided.
B. The physical environment shall be accessible to individuals with physical and sensory disabilities.
C. The physical environment and furnishings shall be clean, dry, free of foul odors, safe, and well-maintained.
D. Floor surfaces and floor coverings shall promote mobility in areas used by individuals and shall promote maintenance of sanitary conditions. There shall be clear pathways through the setting, free of tripping hazards, to ensure that all individuals can move about the setting safely.
Any electrical cords, extension cords, or power strips utilized by the provider shall be properly secured and shall not be placed anywhere that the cord or strip can cause trips or falls.
E. Heat shall be evenly distributed in all rooms occupied by individuals such that a temperature no less than 68°F is maintained, unless otherwise mandated by state or federal authorities. Natural or mechanical ventilation to the outside shall be provided in all rooms used by residents. Individual or mechanical ventilating systems shall be provided in all rooms occupied by individuals when the temperature in those rooms exceeds 80°F.
F. Plumbing shall be maintained in good operational condition. Adequate hot and cold running water of a safe and appropriate temperature shall be available. Hot water accessible to individuals receiving services shall be maintained within a range of 100° to 120°F. Precautions shall be taken to prevent scalding from running water.
G. Adequate provision shall be made for the collection and legal disposal of garbage and waste materials.
H. The physical environment, structure, furnishings, and lighting shall be kept free of vermin, rodents, insects, and other pests.
I. If smoking is permitted, the provider shall make provisions for alternate smoking areas that are separate from the service environment.
J. For all program areas added after September 19, 2002, minimum room height shall be 7-1/2 feet.
K. Bedroom, bathroom, and dressing area windows and doors shall provide privacy.
L. Bathrooms intended for use by more than one individual at the same time shall provide privacy for showers and toilets.
M. The right of privacy within bathrooms includes the right to be free of cameras or audio monitors within the bathroom or angled toward a bathroom.
N. Bedrooms and bathrooms shall be free of all protrusions, sharp corners, hardware, fixtures, or other devices that may cause injury to the individual. Windows in the bathrooms shall be so constructed as to minimize breakage and otherwise prevent the individual from self-harming.
O. No required path of travel to the bathroom shall be through another bedroom. Each individual's room shall have direct access to a corridor, living area, dining area, or other common area.
P. Each provider shall make available at least one toilet, one hand basin, and a shower or bath for every four individuals. Providers of children's residential services shall:
1. Make available at least one toilet, one hand basin, and one shower or bathtub in each living unit;
2. Make available at least one bathroom equipped with a bathtub in each facility;
3. Make available at least one toilet, one hand basin, and one shower or bathtub for every eight individuals for facilities licensed before July 1, 1981;
4. Make available one toilet, one hand basin, and one shower or bathtub for every four individuals in any building constructed or structurally modified after July 1, 1981. Facilities licensed after December 28, 2007, shall comply with the one-to-four ratio; and
5. The maximum number of staff members on duty in the living unit shall be counted in determining the required number of toilets and hand basins when a separate bathroom is not provided for staff.
Q. If a provider utilizes cameras or audio monitors, the provider shall have written policies and procedures regarding audio or audio-video recordings of individuals receiving services approved by the Office of Licensing and the Office of Human Rights. The policies and procedures shall ensure and provide that:
1. The provider has obtained written consent of the individual before the individual is recorded;
2. No recording by the provider shall take place without the individual being informed;
3. The provider has postings informing individuals receiving services and others that recording is taking place; and
4. All recordings shall be used in a manner that respects the dignity and confidentiality of the individuals receiving services.
R. A provider shall develop and implement written policies and procedures approved by the Office of Licensing governing searches that shall provide that:
1. Searches shall be limited to instances where they are necessary to prohibit contraband;
2. Searches shall be conducted only by personnel who are specifically authorized to conduct searches by the written policies and procedures;
3. Searches shall be conducted in such a way to protect the individual's dignity and in the presence of one or more witnesses; and
4. The policies and procedures shall note the actions to be taken by a provider if contraband is found by a search, including methods to manage and dispose of contraband.
S. Providers who serve temporary detention orders or emergency custody orders shall ensure the program is provided in a secure facility or a secure program space.
T. Providers shall provide privacy from routine sight supervision by staff members while bathing, dressing, or conducting toileting activities. This subsection does not apply to medical personnel performing medical procedures or staff providing assistance to individuals whose physical, mental, or safety needs dictate the need for assistance with these activities as justified in the individual's record.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1940. Seclusion.
Seclusion is only allowed as permitted by 12VAC35-115 and other applicable state regulations.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.
12VAC35-105-1950. Seclusion room requirements.
The room used for seclusion of persons shall meet the following design requirements:
1. The seclusion room shall be at least six feet wide and six feet long with a minimum ceiling height of eight feet.
2. The seclusion room shall be free of all protrusions, sharp corners, hardware, fixtures, or other devices that may cause injury to the occupant.
3. Windows in the seclusion room shall be constructed to minimize breakage and otherwise prevent the occupant from self-harming.
4. Light fixtures and other electrical receptacles in the seclusion room shall be recessed or so constructed as to prevent the occupant from self-harming. Light controls shall be located outside the seclusion room.
5. Doors to the seclusion room shall be at least 32 inches wide, open outward, and shall contain observation view panels of transparent wire glass or its approved equivalent, not exceeding 120 square inches but of sufficient size for someone outside the door to see into all corners of the room.
6. The seclusion room shall contain only a mattress with a washable mattress covering designed to avoid damage by tearing.
7. The seclusion room shall maintain temperatures appropriate for the season.
8. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.
Statutory Authority
§§ 37.2-302 and 37.2-400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 22, eff. July 17, 2024.