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  4:11 pm
Commenter: Beth Dugan,Prince William County CSB

Comments on DOJ settlement regs

Prince William CS

Comments regarding Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services [12 VAC 35 ? 105]

July 22, 2020


  1. Prince William County CS continues to comply with all DBHDS regulatory requirements.  However, as DBHDS has consistently added expectations, measures, requirements, as well as reducing timelines for completion meeting these obligations have become significantly more challenging at our current staffing levels. Due to these excessive burdens Prince William CS encourages DBHDS to consider funding for additional administrative, IT and QA staff for CSB in order to meet current and future regulations.  The ever-expanding regulations have resulted in unfunded mandates from the state and impose a significant economic burden on providers that is certainly not being recouped in our current funding.
  2. The progressive actions for citations in violation of 12VAC35-105-160D.2 or 12VAC35-45-1070.c are excessively punitive and do not take leave room for human error. The standard of no less than 4 occurrences in a two-year period will be an impossible one to keep for large providers and if enforced as written could have a negative effect on the provider availability for individuals with disabilities. Nothing in this standard addresses the realities of the size of an agency, location, and programs provided.  It places an unreasonable burden on larger organizations that is almost impossible to meet.  As an agency that provides services to over 8000 clients a year an expectation that there be less than four late incident reports in a 2-year period is unreasonable.  For example, in FY20 we entered approximately 150 reports into CHRIS.  If you double that for a two year period (and that doesn’t even account for the fact that we are now required to enter all COVID-19 cases in addition to all other reports even if it doesn’t require a hospitalization) that would be 300 reports in a two year period.  If we had 4 late reports in that timeframe, we would be at 99.8% compliance, but it could still be possible to have our license moved to provisional status and/or revoked. 
  3. Paragraphs in Section 12VAC35-105-170 seem to not agree.  Section C1 states that a detailed description for the corrective action to be taken that will minimize the possibility that the violations will occur again and correct any systemic deficiencies. Section H reads that we must prevent the recurrence of a regulatory violation.  Minimize and prevent are not the same thing.  Furthermore, I agree that we should do what we can to minimize all violations, but I don’t see how it’s possible to completely prevent a situation for occurring again. Section H should remove “prevent” or remove the section entirely.
  4. 12VAC35-105-520. Risk management: Please clarify department-approved training? Is DBHDS going to provide this training? Until department-approved training is released what training would count towards meeting this regulation? In addition, please allow for qualifications of the Risk Manager to include relevant or equivalent experience and not be based solely on DBHDS training; and I suggest broadening allowable sources of training.  I would like to know how each Risk Manager's qualifications and training will be reviewed/approved. This position and its increasing responsibilities are good practice overall but are another significant unfunded requirement, that is not covered by reimbursement rates or state funding. Funding will have to be taken away from positions that provide direct care to clients in order to fund these regulations. How are smaller providers going to be able to provide quality services to their clients while also attempting to meet the demands of DBHDS?
  5. 12VAC35-105-520.F Serious injuries outside the provision of licensed services do not fall under the jurisdiction of the department and information as such will not be provided to ensure the protection of HIPAA and PHI. Accidents to staff and others fall under the purview of the County Risk Management Department and will be addressed in that manner.
  6. 12VAC35-105-520.A: Please clarify the meaning of "individual risk screenings”.  The guidance appears to indicate the risk manager will have a clinical responsibility.  While a risk manager would be looking for issues, they would not necessarily have the clinical expertise needed to conduct individual risk screenings.
  7. 12VAC35-105-520.D:  Please define triggers and threshold incidents.
CommentID: 84136