Administrative Code

Virginia Administrative Code
2/22/2024

Part II. Certification Process

6VAC15-20-30. Frequency of audits.

A. All local and private correctional facilities and community residential programs affiliated with the department shall be audited every three years.

1. The regional office or facility staff shall notify the Compliance and Accreditation Unit supervisor in writing within 30 days after a new facility or program accepts the first offender.

2. The regional office staff shall conduct a preparatory audit of a new community residential program during the first six months of operation.

3. The Compliance and Accreditation Unit shall conduct a compliance audit during the second six months of operation and on a regular schedule thereafter as provided by this section.

B. The scheduled compliance audit may be postponed for up to six months due to bona fide security or emergency situations.

1. The facility or program administrator shall notify the Compliance and Accreditation Unit manager and provide details of the circumstances requiring the postponement.

2. The Compliance and Accreditation Unit supervisor shall complete a written notice of change and send copies of the approved written notice of change to the board, facility or program administrator, the appropriate regional director and the team members.

C. Any local or private correctional facility or community residential program may be scheduled for an interim compliance audit at the direction of the board. An interim audit may be scheduled for a facility or program that has:

1. Undergone renovations or additions that have resulted in additional inmate capacity or significant changes to the numbers and duties of security staff;

2. Exhibited difficulty in maintaining compliance with the board's standards;

3. Been cited for noncompliance with the board's standards as a result of Department of Corrections inspections, Department of Health inspections or informal visits made by Department of Corrections' staff; or

4. Been placed in probationary or decertified status.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.1, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

6VAC15-20-40. Preparation for audit.

A. The Compliance and Accreditation Unit supervisor shall develop an annual audit schedule.

1. The schedule shall be submitted to the Compliance and Accreditation Unit manager for review, comment and approval.

2. Upon approval, the Compliance and Accreditation Unit supervisor shall:

a. Disseminate the final schedule as appropriate, and

b. Review the schedule as necessary and make adjustments for additional audits.

3. Changes to the final audit schedule shall be agreed upon by the Compliance and Accreditation Unit manager.

4. The Compliance and Accreditation Unit supervisor shall notify the facility or program administrator of the change. Changes shall not extend the audit date beyond the established frequency limits without board approval.

B. The Compliance and Accreditation Unit manager shall appoint certification team members.

1. Team members shall have prior audit experience or have completed certification training.

2. At least one person shall be a staff member of the same type of facility or program being audited.

3. The certification team auditing local correctional facilities shall consist at minimum of a certification analyst and a local facilities manager.

4. The certification analyst shall act as team leader and shall coordinate and facilitate the audit.

C. The Compliance and Accreditation Unit shall notify the facility or program administrator in writing at least 30 days prior to a compliance audit.

D. A certification analyst should visit the facility or program administrator prior to an audit to discuss the audit process as needed. The visit shall be documented and approved by the Compliance and Accreditation Unit supervisor.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.2, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

6VAC15-20-50. On-site audit procedures.

A. The certification analyst shall, on the first day of the audit, orient the team to the audit process and afford the facility or program administrator an opportunity to brief the team on aspects of the facility or program that may have a bearing on the audit.

B. The facility or program administrator shall grant the team access to all documents, staff and areas of the facility or program that are relevant to establishing compliance.

C. A facility or community residential program with an approved variance shall provide such documentation to the certification team.

D. Data shall be collected through documentation, interview and observation.

E. The certification analyst shall brief the facility or program administrator daily on audit progress and preliminary findings. At this time, the facility or program administrator may introduce additional data having a bearing on the team's findings.

F. The entire certification team shall be included in compliance decisions.

1. When a team member finds an indication of noncompliance, the team member shall notify the entire team and provide all available information regarding the standard in question.

2. The team leader shall obtain consensus of the members to the compliance.

3. If a consensus cannot be obtained, the matter shall be referred to the Compliance and Accreditation Unit supervisor.

G. The team shall hold a final debriefing with the facility or program administrator to discuss the team's compliance audit findings.

H. At the request of the facility or program administrator, the certification team shall report compliance audit findings to facility or program staff.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.3, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

6VAC15-20-60. Audit findings.

The Compliance and Accreditation Unit shall mail the audit findings to the facility or program administrator and the regional office within five working days following the compliance audit.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.4, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007.

6VAC15-20-70. Development of a plan of action.

A. A plan of action shall be developed for all deficiencies noted in the compliance audit findings. The plan of action must identify the following:

1. The tasks required to correct a noted deficiency;

2. The personnel responsible for completing the tasks; and

3. The actual or proposed date of task completion.

B. The facility or program administrator shall submit the plan of action to the Compliance and Accreditation Unit within 10 working days of receipt of the notification of deficiencies.

C. The Compliance and Accreditation Unit manager shall

approve, amend, or return the plan of action to the facility or program administrator for revision within 10 working days of receipt.

D. The facility or program administrator shall complete any revision requested and return the plan to the Compliance and Accreditation Unit manager within 10 working days of receipt.

E. The Compliance and Accreditation Unit manager may grant one 30-day extension to a facility or program administrator for the development of a plan of action. The Compliance and Accreditation Unit manager shall notify the board of the extension and its justification. The board may grant additional extensions.

F. If a facility or program administrator fails to submit a plan of action within the time specified, the Compliance and Accreditation Unit supervisor shall submit the audit report with recommendations to the board.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.5, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

6VAC15-20-80. Variance requests.

A variance may be requested by a facility or program administrator when unable to comply with a standard.

1. Variance requests shall be submitted along with the plan of action for any deficiencies cited during the audit. Variance requests shall include:

a. The standard that cannot be met;

b. Justification for variance; and

c. The time frame for the variance.

2. Local correctional facilities and community adult residential programs shall submit the variance request directly to the board.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.6, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

6VAC15-20-90. Appeal process for audits/inspections and schedule.

A. The Board of Corrections will review appeals for locally or privately operated community facilities or community residential programs.

B. Appeals shall be submitted to the Compliance and Accreditation Unit (as noted above) along with the plan of action within 10 working days of receipt of the notification of deficiencies. The Compliance and Accreditation Unit supervisor shall submit the appeal to the board.

C. Upon completion of the board's review of the appeal, notification of the decision shall be forwarded no later than five days after the board meeting to the facility or program administrator.

D. If the appeal is ultimately denied by the board, the Compliance and Accreditation Unit will review and confirm the submitted plan of action and present a final recommendation for consideration by the board at the following board meeting.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.7, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

6VAC15-20-100. Board action on audit results.

A. The Compliance and Accreditation Unit supervisor shall submit audit reports to the board no later than 60 days after completion of the audit. Audit reports shall include:

1. A list of deficiencies;

2. Plans of corrective action and completion status;

3. Similar deficiencies from the previous audit; and

4. Recommended action for consideration by the board.

B. Based upon the audit report the board shall take one of the following actions:

1. A letter requesting corrective action on deficiencies within a specific time frame shall be issued to the facility or program.

2. A certificate of unconditional certification shall be issued to a facility or community residential program that has complied with all applicable standards.

3. A letter of probationary certification may be issued to a facility or community residential program that has not met all applicable standards if the board grants a specific period of time to correct deficiencies. The department shall provide periodic status reports to the board.

4. A letter of decertification will be issued by the board when a facility or community residential program does not meet the requirements for certification within the time limits approved by the board. The Compliance and Accreditation Unit supervisor shall provide status reports to the board during this period and notify the board when all deficiencies have been corrected.

C. A facility or community residential program's certification status shall remain in effect until subsequent board action.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.8, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

6VAC15-20-110. Notifications.

The Compliance and Accreditation Unit supervisor shall notify the facility or program administrator of the certification status immediately following the board's action. The facility or program administrator shall post the letter or certificate in a place conspicuous to the public.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.9, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007.

6VAC15-20-120. Actions that can be taken when decertified.

When a facility or community residential program is decertified the board may consider taking the following actions in compliance with statutes, policies, and procedures established by the board, the department, or other state or federal agencies:

1. Board action for facilities or community residential programs that are privately operated may include, but not be limited to, the following:

a. The facility or program administrator authorized to take action may bring about a reorganization of the facility or community residential program structure or other personnel actions deemed necessary to bring it into compliance with standards; or

b. The facility or community residential program may be closed in accordance with established procedures.

2. Board action for facilities and community residential programs that are locally operated may include, but not be limited to, the following:

a. Recommend that the facility or program administrator authorized to take action bring about a reorganization of the facility or community residential program structure or other personnel actions deemed necessary to bring it into compliance with standards;

b. Recommend that the facility or community residential program be closed or contractual agreements terminated in accordance with established procedures; or

c. Initiate proceedings for the withholding of funds under the appropriate sections of the Code of Virginia.

Statutory Authority

§ 53.1-5 of the Code of Virginia.

Historical Notes

Derived from VR230-01-003:1 § 2.10, eff. May 1, 1993; amended, Virginia Register Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 6, eff. December 21, 2011.

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