Administrative Code

Virginia Administrative Code
8/9/2022

Part II. Administration

12VAC35-46-170. Governing body.

A. The provider shall clearly identify the corporation, association, partnership, individual, or public agency that is the licensee.

B. The provider shall clearly identify any governing board, body, entity, or person to whom it delegates the legal responsibilities and duties of the provider.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-180. Responsibilities of the provider.

A. The provider shall appoint a qualified chief administrative officer to whom it delegates, in writing, the authority and responsibility for administrative direction of the facility.

B. The provider shall develop and implement a written decision-making plan that shall provide for a staff person with the qualifications of the chief administrative officer or program director to be designated to assume the temporary responsibility for the operation of the facility. Each plan shall include an organizational chart.

C. The provider shall develop a written statement of the objectives of the facility including a description of the target population and the programs to be offered.

D. The provider shall develop and implement written policies and procedures to monitor and evaluate service quality and effectiveness on a systematic and on-going basis. The provider shall implement improvements when indicated.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-190. Fiscal accountability.

A. Facilities operated by corporations, unincorporated organizations or associations, individuals, or partnerships shall prepare at the end of each fiscal year:

1. An operating statement showing revenue and expenses for the fiscal year just ended;

2. A working budget showing projected revenue and expenses for the next fiscal year that gives evidence that there are sufficient funds to operate; and

3. A balance sheet showing assets and liabilities for the fiscal year just ended.

B. There shall be a system of financial recordkeeping that shows a separation of the facility's accounts from all other records.

C. The provider shall develop and implement written policies and procedures that address the day-to-day handling of facility funds to include:

1. Handling of deposits;

2. Writing of checks; and

3. Handling of petty cash.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-200. Insurance.

A. The provider shall maintain liability insurance covering the premises and the facility's operations.

B. The provider shall provide documentation that all vehicles used to transport residents are insured, including vehicles owned by staff.

C. The members of the governing body and staff who have been authorized to handle the facility's or residents' funds shall be bonded or otherwise indemnified against employee dishonesty.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-210. Fundraising.

The provider shall not use residents in its fundraising activities without written permission of the legal guardian and the permission of residents 14 years or older.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-220. Weapons.

The provider shall develop and implement written policies and procedures governing the possession and use of firearms, pellet guns, air guns, and other weapons on the facility's premises and during facility-related activities. The policy shall provide that no firearms, pellet guns, air guns, or other weapons shall be permitted on the premises or at facility-sponsored activities unless the weapons are:

1. In the possession of licensed security personnel or law-enforcement officers;

2. Kept securely under lock and key; or

3. Used by a resident with the legal guardian's permission under the supervision of a responsible adult in accord with policies and procedures developed by the facility for the weapons' lawful and safe use.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-230. Relationship to the department.

A. The provider shall submit or make available to the department such reports and information as the department may require to establish compliance with these regulations and other applicable regulations and statutes.

B. The governing body or its official representative shall notify the department within five working days of any change in administrative structure or newly hired chief administrative officer or program director.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-240. Facilities serving persons over the age of 17 years.

Facilities that are approved to serve persons over the age of 17 years shall comply with these regulations for all occupants regardless of age, except when it is determined by the department that housing, programs, services, and supervision for such persons are provided separately from those for the other residents.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-250. Health information.

A. Health information required by this section shall be maintained for each staff member and for each individual who resides in a building occupied by residents, including each person who is not a staff member or resident of the facility. Health information shall be handled, maintained, and stored in a fashion that maintains confidentiality of the information at all times.

B. Tuberculosis evaluation.

1. At the time of hire or residency at the facility, each individual shall submit the results of a screening assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of a form containing, at a minimum, the elements of a current screening form published by the Virginia Department of Health. The screening assessment shall be no older than 30 days.

2. Each individual shall annually submit the results of a screening assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of a form containing, at a minimum, the elements of a current screening form published by the Virginia Department of Health.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-260. Physical or mental health of personnel.

A. The provider or the department may require a report of examination by a licensed physician or mental health professional when there are indications that an individual's physical, mental, or emotional health may jeopardize the care of residents.

B. An individual who is determined by a licensed physician or mental health professional to show an indication of a physical or mental condition that may jeopardize the safety of residents or that would prevent the performance of duties shall be removed immediately from contact with residents and food served to residents until the condition is cleared as evidenced by a signed statement from the physician or mental health professional.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-270. Qualifications.

A. Regulations establishing minimum position qualifications shall be applicable to all providers. In lieu of the minimum position qualifications contained in this chapter, providers subject to (i) the rules and regulations of the Virginia Department of Human Resource Management or (ii) the rules and regulations of a local government personnel office may develop written minimum entry-level qualifications in accord with the rules and regulations of the supervising personnel authority.

B. A person who assumes or is designated to assume the responsibilities of a position or any combination of positions described in these regulations after December 28, 2007, shall:

1. Meet the qualifications of the position or positions;

2. Fully comply with all applicable regulations for each function; and

3. Demonstrate a working knowledge of the policies and procedures that are applicable to his specific position or positions.

C. When services or consultations are obtained on a contractual basis they shall be provided by professionally qualified personnel.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-280. Job descriptions.

A. There shall be a written job description for each position that, at a minimum, includes the:

1. Job title;

2. Duties and responsibilities of the incumbent;

3. Job title of the immediate supervisor; and

4. Minimum education, experience, knowledge, skills, and abilities required for entry-level performance of the job.

B. A copy of the job description shall be given to each person assigned to a position at the time of employment or assignment.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-290. Written personnel policies and procedures.

A. The provider shall have and implement provider approved written personnel policies and make its written personnel policies readily accessible to each staff member.

B. The provider shall develop and implement written policies and procedures to assure that persons employed in or designated to assume the responsibilities of each position possess the education, experience, knowledge, skills, and abilities specified in the job description for the position.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-300. Personnel records.

A. Separate up-to-date written or automated personnel records shall be maintained for each employee, student/intern, volunteer, and contractual service provider for whom background investigations are required by Virginia statute. Content of personnel records of volunteers, students/interns, and contractual service providers may be limited to documentation of compliance with requirements of Virginia laws regarding child protective services and criminal history background investigations.

B. The records of each employee shall include:

1. A completed employment application form or other written material providing the individual's name, address, phone number, and social security number or other unique identifier;

2. Educational background and employment history;

3. Written references or notations of oral references;

4. Reports of required health examinations;

5. Annual performance evaluations;

6. Date of employment for each position held and separation;

7. Documentation of compliance with requirements of Virginia laws regarding child protective services and criminal history background investigations;

8. Documentation of educational degrees and of professional certification or licensure;

9. Documentation of all training required by these regulations and any other training received by individual staff; and

10. A current job description.

C. Personnel records, including separate health records, shall be retained in their entirety for at least three years after separation from employment, contractual service, student/intern, or volunteer service.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-310. Staff development.

A. Required initial training.

1. Within seven days following their begin date, each staff member responsible for supervision of children shall receive basic orientation to the facility's behavior intervention policies, procedures, and techniques regarding less restrictive interventions, timeout, and physical restraint.

2. Within 14 days following an individual's begin date, and before an individual is alone supervising children, the provider shall conduct emergency preparedness and response training that shall include:

a. Alerting emergency personnel and sounding alarms;

b. Implementing evacuation procedures, including evacuation of residents with special needs (i.e., deaf, blind, nonambulatory);

c. Using, maintaining, and operating emergency equipment;

d. Accessing emergency information for residents including medical information; and

e. Utilizing community support services.

3. Within 14 days following their begin date, new employees, employees transferring from other facilities operated by the same provider, relief staff, volunteers, and students/interns shall be given orientation and training regarding:

a. The objectives of the facility;

b. Practices of confidentiality;

c. The decision-making plan;

d. These regulations including the prohibited actions as outlined in this regulation; and

e. Other policies and procedures that are applicable to their positions, duties, and responsibilities.

4. Within 30 days following their begin date, all staff working with residents shall be enrolled in a standard first aid class and in a cardiopulmonary resuscitation class facilitated by the American Red Cross or other recognized authority, unless the individual is currently certified in first aid and cardiopulmonary resuscitation.

5. Within 30 days following their begin date, all staff working with residents shall be trained in child abuse and neglect, mandatory reporting, maintaining appropriate professional relationships, and interaction among staff and residents, and suicide prevention.

6. Within 30 days following their begin date, all staff shall be trained on the facility's policies and procedures regarding standard precautions.

7. Within 30 days following their begin date, all staff shall be trained on appropriate siting of children's residential facilities, and good neighbor policies and community relations.

8. Before administering medication, all staff responsible for medication administration shall have successfully completed a medication training program approved by the Board of Nursing or be licensed by the Commonwealth of Virginia to administer medications.

9. All staff shall be trained in any area of quality improvement as identified from the results of the quality improvement plan.

B. Required annual retraining.

1. All employees, contractors, students/interns, and volunteers shall complete an annual refresher emergency preparedness and response training that shall include:

a. Alerting emergency personnel and sounding alarms;

b. Implementing evacuation procedures, including evacuation of residents with special needs (i.e., deaf, blind, nonambulatory);

c. Using, maintaining, and operating emergency equipment;

d. Accessing emergency information for residents including medical information; and

e. Utilizing community support services.

2. All staff who administer medication shall complete annual refresher medication training.

3. All child care staff shall receive annual retraining on the provider's behavior supports and timeout policies and procedures.

4. All staff working with residents shall receive annual retraining in child abuse and neglect, mandatory reporting, maintaining appropriate professional relationships, and interaction among staff and residents, and suicide prevention.

5. All staff shall receive annual retraining on the provider's policies and procedures regarding standard precautions.

C. Each full-time staff person who works with residents shall complete an additional 15 hours of annual training applicable to their job duties.

D. Providers shall develop and implement written policies and procedures to ensure that part-time staff receive training applicable to their positions.

E. Training provided shall be comprehensive and based on the needs of the population served to ensure that staff have the competencies to perform their jobs.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-320. Staff supervision.

The provider shall develop and implement written policies and procedures regarding the supervision of employees, volunteers, contractors, and students/interns. These policies and procedures shall include:

1. Type of supervision;

2. Frequency of supervision; and

3. How the supervision will be documented.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-330. The applicant.

As a condition of initial licensure and, if appropriate, license renewal, each applicant shall:

1. Provide documentation that they have been trained on appropriate siting of children's residential facilities, and good neighbor policies and community relations;

2. Be interviewed in person by the department to determine the qualifications of the owner or operator as set out in these regulations. Should the applicant not be qualified to perform the duties of the chief administrative officer, the applicant shall hire an individual with the qualifications, as set out in these regulations, to perform the duties of the chief administrative officer; and

3. Provide evidence of having relevant prior experience.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-340. The chief administrative officer.

A. The chief administrative officer shall have the following responsibilities:

1. Responsibility for compliance with these regulations and other applicable regulations;

2. Responsibility for all personnel;

3. Responsibility for overseeing the facility operation in its entirety, including the approval of the design of the structured program of care and its implementation; and

4. Responsibility for the facility's financial integrity.

B. A chief administrative officer appointed after December 28, 2007, shall have at least:

1. A master's degree in social work, psychology, counseling, nursing, or administration and a combination of two years professional experience working with children and in administration and supervision;

2. A baccalaureate degree in social work, psychology, counseling, nursing, or administration and three years of combined professional experience with children, and in administration and supervision; or

3. A baccalaureate degree and a combination of four years professional experience in a children's residential facility and in administration and supervision.

C. Any applicant for the chief administrative officer position shall submit the following to demonstrate compliance with the qualifications required by this regulation for the chief administrative officer:

1. Official transcripts from the accredited college or university of attendance within 30 days of hire; and

2. Documentation of prior relevant experience.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-350. Program director.

A. The facility's program shall be directed by one or more qualified persons.

B. Persons directing programs shall be responsible for the development and implementation of the programs and services offered by the facility, including overseeing assessments, service planning, staff scheduling, and supervision.

C. Persons directing programs of a facility licensed to care for 13 or more residents shall be full-time, qualified staff members.

D. A person appointed after December 28, 2007, to direct programs shall have at least:

1. A master's degree in social work, psychology, counseling, or nursing and a combination of two years professional experience with children in a children's residential facility and in administration or supervision;

2. A baccalaureate degree in social work, psychology, counseling, or nursing and a combination of three years professional experience with children in a children's residential facility and in administration or supervision;

3. A baccalaureate degree and a combination of four years of professional experience with children in a children's residential facility and in administration or supervision; or

4. A license issued by the Commonwealth of Virginia as a drug or alcoholism counselor/worker if the facility's purpose is to treat drug abuse or alcoholism.

E. For services providing brain injury services, a person appointed to direct programs shall have a master's degree in psychology, or be a nurse licensed in Virginia, a rehabilitation professional licensed in Virginia, or a Certified Brain Injury Specialist with at least one year of clinical experience working with individuals with brain injury. Program directors who hold a bachelor's degree in the field of institutional management, social work, education, or other allied discipline shall have a minimum of two years of experience working with individuals with brain injury.

F. Any applicant for the program director position shall submit the following to demonstrate compliance with the qualifications required by this regulation for the program director:

1. Official transcripts from the accredited college or university of attendance within 30 days of hire; and

2. Documentation of prior relevant experience.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-360. Case manager.

A. Case managers shall have the responsibility for coordination of all services offered to each resident.

B. Case managers shall have:

1. A master's degree in social work, psychology, or counseling;

2. A baccalaureate degree in social work or psychology with documented field work experience and shall be supervised by the program director or other staff employed by the provider with the same qualifications; or

3. A baccalaureate degree and three years of professional experience working with children.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-370. Child care supervisor.

A. Child care supervisors shall have responsibility for the:

1. Development of the daily living program within each child care unit; and

2. Orientation, training, and supervision of direct care workers.

B. Child care supervisors shall have:

1. A baccalaureate degree in social work or psychology and two years of professional experience working with children one year of which must have been in a residential facility for children;

2. A high school diploma or a General Education Development Certificate (G.E.D.) and a minimum of five years professional experience working with children with at least two years in a residential facility for children; or

3. A combination of education and experience working with children as approved by the department.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-380. Child care staff.

A. The child care worker shall have responsibility for guidance and supervision of the children to whom he is assigned including:

1. Overseeing physical care;

2. Development of acceptable habits and attitudes;

3. Management of resident behavior; and

4. Helping to meet the goals and objectives of any required individualized service plan.

B. A child care worker and a relief child care worker shall:

1. Have a baccalaureate degree in human services;

2. Have an associates degree and three months experience working with children; or

3. Be a high school graduate or have a G.E.D. and have six months of experience working with children.

C. Child care staff with a high school diploma or G.E.D. with no experience working with children may not work alone, but may be employed as long as they are working directly with the chief administrative officer, program director, case manager, child care supervisor, or a child care worker with one or more years of professional experience working with children.

D. Child care staff in brain injury residential services shall have two years experience working with children with disabilities.

E. An individual hired, promoted, demoted, or transferred to a child care worker's position after August 6, 2009, shall be at least 21 years old, except as provided in 12VAC35-46-270 A.

F. The provider shall not be dependent on temporary contract workers to provide resident care.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-390. Relief staff.

Qualified relief staff shall be employed as necessary to meet the needs of the programs and services offered and to maintain a structured program of care in accordance with these regulations.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-395. Additional requirements for residential facilities for individuals with brain injury.

The provider of brain injury services shall employ or contract with a neuropsychologist or licensed clinical psychologist specializing in brain injury to assist, as appropriate, with initial assessments, development of individualized service plans, crises, staff training, and service design.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-400. Volunteers and student/interns.

A. A facility that uses volunteers or students/interns shall develop and implement written policies and procedures governing their selection and use.

B. The facility shall not be dependent upon volunteers or students/interns to provide basic services.

C. Responsibilities of volunteers and students/interns shall be clearly defined in writing.

D. Volunteers and students/interns shall have qualifications appropriate to the services they render.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

12VAC35-46-410. Support functions.

A. Child care workers and other staff responsible for child care may assume the duties of nonchild care personnel only when these duties do not interfere with their child care responsibilities.

B. Residents shall not be solely responsible for support functions including, but not necessarily limited to, food service, maintenance of building and grounds, and housekeeping.

Statutory Authority

§§ 37.2-408 and 37.2-203 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. August 6, 2009.

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