Virginia Regulatory Town Hall
Department of Behavioral Health and Developmental Services
State Board of Behavioral Health and Developmental Services
Rules and Regulations For Licensing Providers by the Department of Behavioral Health and Developmental Services [12 VAC 35 ‑ 105]
Action Compliance with Virginia’s Settlement Agreement with US DOJ
Stage Final
Comment Period Ended on 7/22/2020
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7/22/20  1:32 pm
Commenter: Lorie Horton, Highlands Community Services

Regulation Changes

 12VAC35-105-20. Definitions

"Level III serious incident" means a serious incident whether or not the incident occurs while in the provision of a service or on the provider's premises and results in:

1. Any death of an individual;

2. A sexual assault of an individual;

HCS objects to the inclusion of sexual assault as Level III serious incident, as by definition it would require all assaults whether related to the provision of service or not, be reported. Reporting incidents outside of service provision would create an unnecessary intrusion into the individual’s privacy and possible negatively impact the individual’s willingness to discuss in therapy.  It would require an RCA, which will result in needless additional trauma with no clinical or legal gain and is in direct contradiction to DBHDS’ prioritization of trauma training for providers as part of its STEP-VA outpatient requirements.  Providers have no control or authority over incidents that occur outside service provision, therefore no corrective process could reasonably have impact.  Sexual assaults if they occur as part of service provision, are already required to be reported as part of the Human Rights Regulations.

12VAC35-105-530. Emergency preparedness and response plan

A. 9. Schedule for testing the implementation of the plan and conducting emergency preparedness drills.  Fire and evacuation drills shall be conducted at least monthly.

HCS objects to requiring all services/locations to conduct fire drills at the same frequency. For some locations and services, this creates a needless interruption in the provision of care without demonstrative improvement in preparedness.  This would be particularly true for outpatient services and crisis services.  HCS would recommend that agencies be held accountable to conduct drills as prescribed in their policies and procedures with a requirement that day and residential programs such as PSR, Day Support, Non-School based TDT, crisis stabilization be required to conduct drills quarterly. 

L. All provider locations shall maintain a floor plan identifying location of:

1. Exits;

2. Primary and secondary evacuation routes;

3. Accessible egress routes;

4. Portable fire extinguishers; and

5. Flashlights 


HCS recommends the addition of the phrase or emergency lighting be added to item 5.  For larger, multi-story buildings flashlights are not an optimal option for emergency lighting.


12VAC35-105-660. Individualized services plan (ISP).

D. The initial ISP and the comprehensive ISP shall be developed based on the respective 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 and alternative services.

HCS requests that DBHDS clarify/define what is meant by “alternative services.”

CommentID: 84085