Final Text
CHAPTER 105
RULES AND REGULATIONS FOR THE LICENSING OF PROVIDERS OF MENTAL
HEALTH, MENTAL RETARDATION, SUBSTANCE ABUSE, THE INDIVIDUAL AND FAMILY
DEVELOPMENTAL DISABILITIES SUPPORT WAIVER, AND RESIDENTIAL BRAIN INJURY BY
THE DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES
Part I
General Provisions
Article 1
Authority and Applicability
12VAC35-105-10. Authority and applicability.
A. Section 37.1-179.1 37.2-404 of the Code of Virginia
authorizes the commissioner to license providers subject to rules and
regulations promulgated adopted by the State Mental Health,
Mental Retardation and Substance Abuse Services Board of Behavioral
Health and Developmental Services.
B. No provider shall establish, maintain, conduct [ , ]
or operate any service for persons with mental illness or mental retardation
or persons with substance addiction or abuse without first receiving a
license from the commissioner.
Article 2.
Definitions
12VAC35-105-20. Definitions.
The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:
"Abuse" (§ 37.2-100 of the Code of Virginia) means
any act or failure to act by an employee or other person responsible for the
care of an individual receiving services in a facility or program
operated, licensed, or funded by the department, excluding those operated by
the Virginia Department of Corrections, that was performed or was failed to
be performed knowingly, recklessly, or intentionally, and that caused or might
have caused physical or psychological harm, injury, or death to an
individual a person receiving services care or treatment
for mental illness, mental retardation (intellectual disability), or substance
abuse (substance use [ disorder disorders ] ).
Examples of abuse include, but are not limited to, the following acts
such as:
1. Rape, sexual assault, or other criminal sexual behavior;
2. Assault or battery;
3. Use of language that demeans, threatens, intimidates, or humiliates the person;
4. Misuse or misappropriation of the person's assets, goods, or property;
5. Use of excessive force when placing a person in physical or mechanical restraint;
6. Use of physical or mechanical restraints on a person that is
not in compliance with federal and state laws, regulations, and policies,
professional accepted standards of practice, or the person's individual
service individualized services plan;
7. Use of more restrictive or intensive services or denial of
services to punish the person or that is not consistent with his individual
service individualized services plan.
"Activities of daily living" or "ADLs"
means personal care activities and [ include includes ]
bathing, dressing, transferring, toileting, grooming, hygiene, feeding, and
eating. An individual's degree of independence in performing these activities
is part of determining the appropriate level of care and services.
"Admission" means the process of acceptance into a
service that includes orientation to service goals, rules and requirements,
and assignment to appropriate employees as defined by the provider's
policies [ . ]
"Authorized representative" means a person
permitted by law or [ the Rules and Regulations to Assure Rights
of Individuals Receiving Services from Providers Licensed, Funded, or Operated
by the Department of Behavioral Health and Developmental Services ( ]
12VAC35-115 [ ) ] to authorize the disclosure
of information or consent to treatment and services or [ the ]
participation in human research.
"Behavior management intervention"
means those principles and methods employed by a provider to help an individual
receiving services [ to ] achieve a positive outcome and to
address [ and correct inappropriate ] challenging
behavior in a constructive and safe manner. Behavior management intervention
principles and methods must be employed in accordance with the individualized service
services plan and written policies and procedures governing service
expectations, treatment goals, safety, and security.
"Behavioral treatment" or "positive behavior
support program" means any set of documented procedures that are an
integral part of the interdisciplinary treatment plan and are developed on the
basis of a systemic data collection such as a functional assessment for the
purpose of assisting an individual receiving services to achieve any or all of
the following: (i) improved behavioral functioning and effectiveness; (ii)
alleviation of the symptoms of psychopathology; or (iii) reduction of serious
behaviors. A behavioral treatment program can also be referred to as a
behavioral treatment plan or behavioral support plan.
"Behavioral treatment plan," "functional plan," or "behavioral support plan" means any set of documented procedures that are an integral part of the individualized services plan and are developed on the basis of a systematic data collection, such as a functional assessment, for the purpose of assisting individuals to achieve [ the following ]:
1. Improved behavioral functioning and effectiveness;
2. Alleviation of symptoms of psychopathology; or
3. Reduction of challenging behaviors.
"Brain injury" means any injury to the brain that
occurs after birth, but before age 65, that is acquired through traumatic or
nontraumatic insults. Nontraumatic insults may include [ , but are not
limited to, ] anoxia, hypoxia, aneurysm, toxic exposure,
encephalopathy, surgical interventions, tumor, and stroke. Brain injury does
not include hereditary, congenital, or degenerative brain disorders [ , ]
or injuries induced by birth trauma.
[ "Brain Injury Waiver" means a Virginia
Medicaid home and community-based waiver for persons with brain injury approved
by the Centers for Medicare and Medicaid Services. ]
"Care" or "treatment" means a set of
individually planned interventions, training, habilitation, or supports that
help an individual obtain or maintain an optimal level of functioning, reduce
the effects of disability or discomfort, or ameliorate symptoms, undesirable
changes or conditions specific to physical, mental, behavioral, cognitive, or
social functioning the individually planned [ , sound,
and ] therapeutic interventions that conform to current
acceptable professional practice and that are intended to improve or maintain
functioning of an individual receiving services delivered by a provider.
"Case management service" means assisting
[ services that can include ] assistance to individuals
and their families to access family members in assessing needed
services and supports that are essential to meeting their basic needs
identified in their individualized service plan, which include not only
accessing needed mental health, mental retardation and substance abuse
services, but also any medical, nutritional, social, educational, vocational
and employment, housing, economic assistance, transportation, leisure and
recreational, legal, and advocacy services and supports that the individual
needs to function in a community setting responsive to the person's
individual needs. Case management services include: identifying [ and
reaching out to ] potential users of the service; assessing
needs and planning services; linking the individual to services and supports;
assisting the individual directly to locate, develop, or obtain needed services
and resources; coordinating services with other providers; enhancing community
integration; making collateral contacts; monitoring service delivery; discharge
planning; and advocating for individuals in response to their changing needs.
Maintaining waiting lists for services, case management tracking and
periodically contacting individuals for the purpose of determining the
potential need for services shall be considered screening and referral and not
admission into licensed case management. [ The term "case
"Case ] management service" does not include maintaining
service waiting lists or periodically contacting or tracking individuals to
determine potential service needs.
[ "Clubhouse service" means the provision of
recovery-oriented psychosocial rehabilitation services in a nonresidential
setting on a regular basis not less than two hours per day, five days per week,
in which clubhouse members and employees work together in the development and
implementation of structured activities involved in the day-to-day operation of
the clubhouse facilities and in other social and employment opportunities
through skills training, peer support, vocational rehabilitation, and community
resource development.
"Clinical experience" means providing direct services to individuals with mental illness or the provision of direct geriatric services or special education services. Experience may include supervised internships, practicums, and field experience. ]
"Commissioner" means the Commissioner of the
Department of Mental Behavioral Health, Mental Retardation
and Substance Abuse Services or his authorized agent Developmental
Services.
"Community gero-psychiatric residential services"
means 24-hour nonacute care in conjunction with treatment provided
to individuals with mental illness, behavioral problems, and concomitant health
problems who are usually age 65 or older in a geriatric setting that
provides is less intensive services than a psychiatric
hospital, but more intensive mental health services than a
nursing home or group home. Individuals with mental illness, behavioral
problems, and concomitant health problems (usually age 65 and older),
appropriately treated in a geriatric setting, are provided Services
include assessment and individualized services planning by an interdisciplinary
services team, intense supervision, psychiatric care, behavioral treatment
planning and [ behavioral behavior ] interventions,
nursing, and other health related services. An Interdisciplinary Services
Team assesses the individual and develops the services plan.
"Community intermediate care facility/mental retardation
(ICF/MR)" means a service residential facility licensed
by the Department of Mental Health, Mental Retardation, and Substance Abuse
Services in which care is provided in which care is provided to
individuals who have mental retardation (intellectual disability) or a
developmental disability due to brain injury [ who are not in
need of nursing care, but ] who need more intensive training and
supervision than may be available in an assisted living facility or group home.
Such facilities must shall comply with Title XIX of the Social
Security Act standards and federal certification requirements, provide
health or rehabilitative services, and provide active treatment to individuals receiving
services toward the achievement of a more independent level of functioning or
an improved quality of life.
"Complaint" means an allegation brought to the
attention of the department that a licensed provider violated of a violation
of these regulations or a provider's policies and procedures related to
these regulations.
"Co-occurring disorders" means the presence of
more than one and often several of the following disorders that are identified
independently of one another and are not simply a cluster of symptoms resulting
from a single disorder: mental illness, mental retardation (intellectual
disability), or substance [ abuse (substance ] use
[ disorder disorders) ]; brain injury; or
developmental disability.
"Co-occurring services" means individually
planned [ , sound, and ] therapeutic treatment
that addresses in an integrated concurrent manner the service needs of
individuals who have co-occurring disorders [ who have an
established diagnosis in one domain such as mental illness, mental retardation
(intellectual disability), substance abuse disorder, developmental disability,
or brain injury and signs or symptoms of an evolving disorder in another
domain; or who present acute signs or symptoms of a co-occurring condition ].
"Consumer service plan" or "CSP" means
that document addressing all needs of recipients of home and community-based
care developmental disability services (IFDDS Waiver), in all life areas.
Supporting documentation developed by service providers is to be incorporated
in the CSP by the support coordinator. Factors to be considered when these
plans are developed may include, but are not limited to, recipient ages, level
of functioning, and preferences.
"Corrective action plan" means the provider's pledged
corrective action in response to noncompliances cited areas of
noncompliance documented by the regulatory authority. A corrective action
plan must be completed within a specified time.
"Correctional facility" means a facility operated under the management and control of the Virginia Department of Corrections.
[ "Corporal punishment" means punishment
administered through the intentional inflicting of pain or discomfort to the an
individual's body (i) through actions such as, but not limited to, striking
or hitting the individual with any part of the body or with an
implement; (ii) through pinching, pulling or shaking; or (iii) through any
similar action that normally inflicts pain or discomfort to the individual. ]
"Crisis" means a [ deteriorating or unstable ]
situation [ often developing suddenly or rapidly ] in
which an individual presents an immediate danger to self or others or is at
risk of serious mental or physical health deterioration that produces [ acute,
heightened, ] emotional, mental, physical, medical, or behavioral
distress [ or challenges ]; or any
situation or circumstance in which the individual perceives or experiences a
sudden loss of his ability to use effective problem-solving and coping skills.
"Crisis stabilization" means direct, intensive intervention
to individuals who are experiencing serious psychiatric or behavioral problems,
or both, that jeopardize their current community living situation. This service
shall include temporary intensive services and supports that avert emergency
psychiatric hospitalization or institutional placement or prevent out-of-home
placement. This service shall be designed to stabilize recipients and
strengthen the current living situations so that individuals can be maintained
in the community during and beyond the crisis period nonresidential [ ambulatory ]
or residential direct care and treatment to nonhospitalized individuals
experiencing an acute crisis that may jeopardize their current community living
situation. Crisis stabilization is intended to avert hospitalization or
rehospitalization; provide normative environments with a high assurance of
safety and security for crisis intervention; stabilize individuals in crisis;
and mobilize the resources of the community support system, family members, and
others for ongoing rehabilitation and recovery.
"Day support service" means the provision of
individualized planned activities, supports, training, supervision, and
transportation to individuals with mental retardation or related conditions, or
brain injury, to improve functioning or maintain an optimal level of
functioning structured programs of [ treatment, ]
activity [ , ] or training services [ for
adults with an intellectual disability or a developmental disability, ] generally
in clusters of two or more continuous hours per day provided to groups or
individuals in nonresidential [ (center-based) settings or
in the community (noncenter-based) community-based ] settings.
Services may Day support services may provide opportunities for peer
interaction and community integration and are designed to enhance the
following skills: self-care and hygiene, eating, toileting, task
learning, community resource utilization, environmental and behavioral skills,
social skills, medication management, prevocational skills, and
transportation skills. Services provide opportunities for peer
interaction and community integration. Services may be provided in a facility
(center based) or provided out in the community (noncenter based). Services are
provided for two or more consecutive hours per day. The term "day
support service" does not include services in which the primary function
is to provide extended sheltered or competitive employment, supported or
transitional employment-related services, general education educational
services, or general recreational services, or outpatient services
licensed pursuant to this chapter.
[ "Day treatment services" means ] the
provision of coordinated, intensive, comprehensive, and multidisciplinary
treatment to individuals through a combination of diagnostic, medical,
psychiatric, case management, psychosocial rehabilitation, prevocational and
educational services. Services are provided for two or more consecutive hours
per day [ treatment that includes the major diagnostic, medical,
psychiatric, psychosocial, and prevocational and educational treatment
modalities designed for adults with serious mental illnesses or substance use
or co-occurring disorders who require coordinated, intensive, comprehensive,
and multidisciplinary treatment that is not provided in outpatient services.
Partial hospitalization is a type of day treatment service. See definitions of
"therapeutic day treatment services for children and adolescents" and
"partial hospitalization." ]
"Department" means the Virginia Department of Mental
Health, Mental Retardation Behavioral Health and Substance Abuse
Developmental Services.
[ "Developmental disabilities" means autism or a severe, chronic disability that meets all of the following conditions identified in 42 CFR 435.1009:
1. Attributable to cerebral palsy, epilepsy, or any other condition, other than mental illness, that is found to be closely related to mental retardation (intellectual disability) because this condition results in impairment of general intellectual functioning or adaptive behavior similar to behavior of individuals with mental retardation (intellectual disability) and requires treatment or services similar to those required for these individuals;
2. Manifested before the individual reaches age 18;
3. Likely to continue indefinitely; and
4. Results in substantial functional limitations in three or more of the following areas of major life activity:
a. Self-care;
b. Understanding and use of language;
c. Learning;
d. Mobility;
e. Self-direction; or
f. Capacity for independent living. ]
"Discharge" means the process by which the
individual's active involvement with a [ provider service ]
is terminated by the provider [ or, ] individual
[ , or authorized representative ].
"Discharge plan" means the written plan that
establishes the criteria for an individual's discharge from a service and identifies
and coordinates planning for aftercare delivery of any
services needed after discharge.
"Dispense" means to deliver a drug to an ultimate user by or pursuant to the lawful order of a practitioner, including the prescribing and administering, packaging, labeling or compounding necessary to prepare the substance for that delivery. (§ 54.1-3400 et seq. of the Code of Virginia.)
"Emergency service" means mental health, mental
retardation or substance abuse services available unscheduled and
sometimes scheduled crisis intervention, stabilization, and referral assistance
provided over the telephone or face-to-face, if indicated, [ available ]
24 hours a day and seven days per week that provide crisis intervention,
stabilization, and referral assistance over the telephone or face-to-face for
individuals seeking services for themselves or others. Emergency services also
may include walk-ins, home visits, jail interventions, pre-admission
screenings, [ and ] preadmission [ and ]
other screening activities designed to stabilize an individual
within the setting most appropriate to the individual's current condition associated
with [ judicial admission to a state hospital, inpatient or
crisis stabilization unit, training center, or other activities associated with ]
the judicial [ admission ] process
[ , such as mandatory outpatient treatment orders ].
"Group home or community residential service"
means a congregate residential service providing 24-hour supervision in
a community-based [ , home-like dwelling home having eight or
fewer residents ]. These services are provided for individuals
needing assistance Services include supervision, supports, counseling,
and training in activities of daily living or for individuals
whose [ service individualized services ] plan
identifies the need for the specific type types of supervision
or counseling services available in this setting. [ Section
15.2-2291 of the Code of Virginia defines group homes for zoning purposes as
having eight or fewer residents. ]
"Home and noncenter based" means that a service is
provided in the individual's home or other noncenter-based setting. This
includes [ but is not limited to ] noncenter-based day
support, supportive in-home, and intensive in-home services.
"IFDDS Waiver" means the Individual and Family Developmental Disabilities Support Waiver.
"Individual" or "individual receiving
services" means a person receiving care or treatment or other
services from a provider that are licensed under this chapter
whether that person is referred to as a patient, consumer, client,
resident, student, individual, recipient, family member, relative, or other
term. When the term is used, the requirement applies to every individual
receiving [ licensed ] services [ of from ]
the provider.
"Individualized services plan" or "ISP"
means a comprehensive and regularly updated written plan of action to meet
the needs and preferences of an individual that describes the
individual's needs, the measurable goals and objectives to address those needs,
and strategies to reach the individual's goals. An ISP is
person-centered, empowers the individual, and is designed to meet the needs and
preferences of the individual. The ISP is developed through a partnership
between the individual and the provider and includes an individual's treatment
plan, habilitation plan, person-centered plan, or plan of care [ ,
which are all considered individualized service plans ].
"Initial assessment" means an assessment conducted prior to or at admission to determine whether the individual meets the service's admission criteria; what the individual's immediate service, health, and safety needs are; and whether the provider has the capability and staffing to provide the needed services.
"Inpatient psychiatric service" means a intensive
24-hour intensive medical, nursing care, and treatment services
provided for to individuals with mental [ illness illnesses ]
or problems with substance [ abuse (substance ] use
disorders [ ) ] in a hospital as defined in § 32.1-123 of
the Code of Virginia or in a special unit of such a hospital.
"Instrumental activities of daily living" or "IADLs" means meal preparation, housekeeping, laundry, and managing money. A person's degree of independence in performing these activities is part of determining appropriate level of care and services.
"Intensive Community Treatment (ICT) service" means a self-contained interdisciplinary team of at least five full-time equivalent clinical staff, a program assistant, and a full-time psychiatrist that:
1. Assumes responsibility for directly providing needed
treatment, rehabilitation, and support services to identified individuals with
severe and persistent mental [ illnesses illness ] especially
those who have severe symptoms that are not effectively remedied by available
treatments or who because of reasons related to their mental illness resist or
avoid involvement with mental health services;
2. Minimally refers individuals to outside service providers;
3. Provides services on a long-term care basis with continuity of caregivers over time;
4. Delivers 75% or more of the services outside program offices; and
5. Emphasizes outreach, relationship building, and individualization of services.
The individuals to be served by ICT are individuals who
have severe symptoms and impairments not effectively remedied by available
treatments or who, because of reasons related to their mental illness, resist
or avoid involvement with mental health services.
"Intensive in-home service" means family
preservation interventions for children and adolescents who have or are at-risk
of serious emotional disturbance, including such individuals who also have
a diagnosis of mental retardation (intellectual disability). Services
are Intensive in-home service is usually time-limited and
is provided typically in the residence of an individual who is at risk of
being moved to out-of-home placement or who is being transitioned back home
from an out-of-home placement. These services include The service
includes 24-hour per day emergency response; crisis treatment; individual
and family counseling; life, parenting, and communication skills; and
case management activities and coordination with other services; and
emergency response.
[ "Intensive outpatient service" means
treatment provided in a concentrated manner ] (involving multiple
outpatient visits per week) [ over a period of time for individuals
requiring intensive outpatient stabilization. ] These
services usually [ Intensive outpatient services include
multiple group therapy sessions during the week, individual and family therapy,
individual monitoring, and case management. ]
"Investigation" means a detailed inquiry or
systematic examination of the operations of a provider or its services
regarding [ a an alleged ] violation of
regulations or law. An investigation may be undertaken as a result of a
complaint, an incident report [ , ] or other information that
comes to the attention of the department.
"Legally authorized representative" means a
person permitted by law to give informed consent for disclosure of information
and give informed consent to treatment, including medical treatment, and
participation in human research for an individual who lacks the mental capacity
to make these decisions.
"Licensed mental health professional (LMHP)" means a
physician, licensed clinical psychologist, licensed professional counselor,
licensed clinical social worker, licensed substance abuse treatment
practitioner, licensed marriage and family [ counselor
therapist ], or certification as a certified psychiatric
clinical nurse specialist.
"Location" means a place where services are or could be provided.
[ "Managed "Medically managed ]
withdrawal services" means detoxification services to eliminate or
reduce the effects of alcohol or other drugs in the individual's body.
"Mandatory outpatient treatment order" means an
order issued by [ the a ] court
pursuant to § 37.2-817 [ D ] of the Code of
Virginia.
"Medical detoxification" means a service provided in
a hospital or other 24-hour care facility [ , ] under
the supervision of medical personnel using medication to systematically
eliminate or reduce effects of alcohol or other drugs in the individual's
body.
"Medical evaluation" means the process of assessing an individual's health status that includes a medical history and a physical examination of an individual conducted by a licensed medical practitioner operating within the scope of his license.
"Medication" means prescribed or over-the-counter drugs or both.
"Medication administration" means the direct
application of medications by injection, inhalation, [ or ]
ingestion [ , ] or any other means to an individual receiving
services by (i) persons legally permitted to administer medications or (ii) the
individual at the direction and in the presence of persons legally permitted to
administer medications.
[ "Medication assisted treatment (Opioid treatment service)" means an intervention strategy that combines outpatient treatment with the administering or dispensing of synthetic narcotics, such as methadone or buprenorphine (suboxone), approved by the federal Food and Drug Administration for the purpose of replacing the use of and reducing the craving for opioid substances, such as heroin or other narcotic drugs. ]
"Medication error" means that an error has
been made in administering a medication to an individual [ and
includes ] when any of the following occur: (i) the wrong medication
is given to an individual [ , such as ] (ii) the wrong
individual is given the medication, (iii) the wrong dosage is given to an
individual, (iv) medication is given to an individual at the wrong time or not
at all, or (v) the [ proper wrong ] method
is [ not ] used to give the medication to the individual.
"Medication storage" means any area where medications are maintained by the provider, including a locked cabinet, locked room, or locked box.
"Mental Health Community Support Service (MHCSS)"
means the provision of recovery-oriented [ psychosocial rehabilitation ]
services to individuals with long-term, severe [ psychiatric
disabilities mental illness ] including. MHCSS [ include
includes ] skills training and assistance in accessing and effectively
utilizing services and supports that are essential to meeting the needs
identified in their the individualized service services
plan and development of environmental supports necessary to sustain active
community living as independently as possible. MHCSS Services are may
be provided in any setting in which the individual's needs can be
addressed, skills training applied, and recovery experienced.
"Mental illness" means a disorder of thought, mood, emotion, perception, or orientation that significantly impairs judgment, behavior, capacity to recognize reality, or ability to address basic life necessities and requires care and treatment for the health, safety, or recovery of the individual or for the safety of others.
"Mental retardation (intellectual disability)"
means substantial a disability originating before the age of 18 years
characterized concurrently by (i) significantly subaverage general
intellectual functioning as demonstrated by performance on a standardized
measure of intellectual functioning administered in conformity with accepted
professional practice that is at least two standard deviations below the mean;
and (ii) that originates during the development period and is associated
with impairment significant limitations in adaptive behavior as
expressed in conceptual, social, and practical adaptive skills (§ 37.2-100
of the Code of Virginia). It exists concurrently with related
limitations in two or more of the following applicable adaptive skill areas:
communication, self-care, home living, social skills, community use,
self-direction, health and safety, functional academics, leisure, and work.
[ According to the American Association on Intellectual and
Developmental Disabilities (AAIDD) definition, these impairments should be
assessed in the context of the individual's environment, considering cultural
and linguistic diversity as well as differences in communication and sensory
motor and behavioral factors. Within an individual, limitations often coexist
with strengths. The purpose of describing limitations is to develop a profile
of needed supports. With personalized supports over a sustained period, the
functioning of an individual will improve. In some organizations, the term "intellectual
disability" is used instead of "mental retardation." ]
"Mentally ill" means any person afflicted with
mental disease to such an extent that for his own welfare or the welfare of
others he requires care and treatment, or with mental disorder or functioning
classifiable under the diagnostic criteria from the Diagnostic and Statistical
Manual of Mental Disorders of the American Psychiatric Association, Fourth
Edition, 1994, that affects the well-being or behavior of an individual.
"Neglect" means the failure by an individual or provider
responsible for providing services to provide nourishment, treatment, care,
goods, or services necessary to the health, safety or welfare of a person
receiving care or treatment for mental illness, mental retardation or substance
abuse (§ 37.2-100 of the Code of Virginia). This definition of neglect also
applies to individuals receiving in-home support, crisis stabilization, and day
support under the IFDDS or Brain Injury Waiver and individuals receiving
residential brain injury services a program or facility operated,
licensed, or funded by the department, excluding those operated by the
Department of Corrections, responsible for providing services to do so,
including nourishment, treatment, care, goods, or services necessary to the
health, safety, or welfare of a person receiving care or treatment for mental
illness, mental retardation (intellectual disability), or substance abuse
[ (substance use disorders) ].
"Neurobehavioral services" means the assessment, evaluation, and treatment of cognitive, perceptual, behavioral, and other impairments caused by brain injury that affect an individual's ability to function successfully in the community.
[ "Opioid treatment service" means an
intervention strategy that combines treatment with the administering or
dispensing of opioid agonist treatment medication. An individual-specific,
physician-ordered dose of medication is administered or dispensed either for
detoxification or maintenance treatment. ]
"Outpatient service" means a variety of
treatment interventions generally provided to individuals, groups or
families on an hourly schedule, on an individual, group, or family
basis, and usually in a clinic or similar facility or in another location.
Outpatient services may include, but are not limited to, emergency
services, crisis intervention services, diagnosis and evaluation, intake and
screening, counseling, psychotherapy, behavior management, psychological
testing and assessment, chemotherapy and medication management services, and
jail based services diagnosis and evaluation, screening and intake,
counseling, psychotherapy, behavior management, psychological testing and
assessment, laboratory and other ancillary services, medical services, [ and ]
medication services [ , and, jail and detention-based
services ]. "Outpatient service" specifically includes:
1. Services operated by a community services board [ or a behavioral health authority ] established pursuant to Chapter 5 (§ 37.2-500 et seq.) [ or Chapter 6 (§ 37.2-600 et seq.) ] of Title 37.2 of the Code of Virginia;
2. Services [ funded wholly or in part, directly
or indirectly, contracted ] by a community services board or
a behavioral health authority established pursuant to Chapter 5 (§ 37.2-500
et seq.) or Chapter 6 (§ 37.2-600 et seq.) of Title 37.2 of the Code of
Virginia; or
3. Services that are owned, operated, or controlled by a corporation organized pursuant to the provisions of either Chapter 9 (§ 13.1-601 et seq.) or Chapter 10 (§ 13.1-801 et seq.) of Title 13.1 of the Code of Virginia.
"Partial hospitalization service" means [ the
provision within a medically supervised setting of day treatment services that
are ] time-limited active treatment interventions [ ,
that are ] more intensive than outpatient services, designed to
stabilize and ameliorate acute symptoms, and serve as an alternative to
inpatient hospitalization or to reduce the length of a hospital stay. Partial
hospitalization is focused on individuals [ with serious
mental illness, substance abuse (substance use disorders), or co-occurring
disorders ] at risk of hospitalization or who have been recently
discharged from an inpatient setting.
"Person-centered" means focusing on the needs and preferences of the individual; empowering and supporting the individual in defining the direction for his life; and promoting self-determination, community involvement, and recovery.
[ "Plan of care" means a document
addressing all needs of recipients of home and community-based care developmental
disability services (IFDDS Waiver) in all life areas. It includes supporting
documentation developed by service providers. Factors considered in developing
this plan may include recipient ages, level of functioning, and preferences. ]
"Program of Assertive Community Treatment (PACT) service" means a self-contained interdisciplinary team of at least 10 full-time equivalent clinical staff, a program assistant, and a full- or part-time psychiatrist that:
1. Assumes responsibility for directly providing needed
treatment, rehabilitation, and support services to identified individuals with
severe and persistent mental illnesses;, [ especially
including ] those who have severe symptoms that are not effectively
remedied by available treatments or who because of reasons related to their
mental illness resist or avoid involvement with mental health services;
2. Minimally refers individuals to outside service providers;
3. Provides services on a long-term care basis with continuity of caregivers over time;
4. Delivers 75% or more of the services outside program offices; and
5. Emphasizes outreach, relationship building, and individualization of services.
The individuals to be served by PACT are individuals who
have severe symptoms and impairments not effectively remedied by available
treatments or who, because of reasons related to their mental illness, resist
or avoid involvement with mental health services.
"Provider" means any person, entity [ , ]
or organization, excluding an agency of the federal government by whatever name
or designation, that delivers (i) services to [ persons individuals ]
with mental illness, mental retardation (intellectual disability), or
substance abuse [ (substance use disorders) ];,
(ii) services to [ persons individuals ] who receive
day support, in-home support, or crisis stabilization services funded through
the IFDDS Waiver;, [ (iii) services to persons under the
Brain Injury Waiver; ] or [ (iv) (iii) ]
residential services for [ persons individuals ] with
brain injury. The person, entity [ , ] or organization shall
include a hospital as defined in § 32.1-123 of the Code of Virginia, community
services board, behavioral health authority, private provider, and any other
similar or related person, entity [ , ] or organization. It
shall not include any individual practitioner who holds a license issued by a
health regulatory board of the Department of Health Professions or who is
exempt from licensing pursuant to §§ 54.1-2901, 54.1-3001, 54.1-3501, 54.1-3601
and 54.1-3701 of the Code of Virginia.
"Psychosocial rehabilitation [ service ]"
means [ a program of two or more consecutive hours per day provided to
groups of adults in a nonresidential setting. Individuals must demonstrate a
clinical need for the service arising from a condition due to mental,
behavioral, or emotional illness that results in significant functional
impairments in major life activities. This service provides education to teach
the individual about mental illness, substance abuse, and appropriate medication
to avoid complication and relapse and opportunities to learn and use
independent skills and to enhance social and interpersonal skills within a
consistent program structure and environment. ] care or treatment
for individuals with long-term, severe psychiatric disabilities, which is
designed to improve their quality of life by assisting them to assume
responsibility over their lives and to function as actively and independently
in society as possible, through the strengthening of individual skills and the
development of environmental supports necessary to sustain community living
[ the process of providing assessment, medication education,
opportunities to learn and use independent living skills and enhance social and
interpersonal skills, opportunities for vocational and other education, family
support and education, and advocacy in a supportive community environment
focusing on normalization. It emphasizes strengthening the individual's ability
to deal with everyday life rather than focusing on the treatment of
pathological conditions. ] Psychosocial rehabilitation includes
skills training, peer support, vocational rehabilitation, and community
resource development oriented toward empowerment, recovery, and competency.
"Qualified Brain Injury Professional (QBIP)"
means a clinician in the health professions who is trained and experienced in
providing brain injury services to individuals who have a brain injury
diagnosis including a (i) physician: a doctor of medicine or osteopathy; (ii)
psychiatrist: a doctor of medicine or osteopathy, specializing in psychiatry
and licensed in Virginia; (iii) psychologist: a person with a master's degree
in psychology from a college or university with at least one year of clinical
experience; (iv) social worker: a person with at least a bachelor's degree in
human services or related field (social work, psychology, psychiatric
rehabilitation, sociology, counseling, vocational rehabilitation, human
services counseling, or other degree deemed equivalent to those described) from
an accredited college, with at least two years of clinical experience providing
direct services to individuals with a diagnosis of brain injury; (v) certified
brain injury specialist; (vi) registered nurse licensed in Virginia with at
least one year of clinical experience; or (vii) any other licensed
rehabilitation professional with one year of clinical experience.
"Qualified Developmental Disabilities Professional
(QDDP)" means an individual possessing at least one year of documented
experience working directly with individuals who have related conditions and is
one of the following: a doctor of medicine or osteopathy, a registered nurse,
or an individual holding at least a bachelor's degree in a human service field
including, but not limited to, sociology, social work, special education,
rehabilitation counseling, or psychology.
"Qualified Mental Health [ Professional
(QMHP)" Professional-Adult (QMHP-A)" ] means a
clinician in the health professions a person [ working
in a PACT or ICT in the human services field ] who is
trained and experienced in providing psychiatric or mental health services to
individuals who have a [ psychiatric diagnosis mental
illness ]; including [ a ] (i) [ physician: ]
a doctor of medicine or osteopathy [ licensed in Virginia ];
(ii) [ psychiatrist: ] a doctor of medicine or osteopathy,
specializing in psychiatry and licensed in Virginia; (iii) [ psychologist: ]
an individual with a master's degree in psychology from [ a an
accredited ] college or university with at least one year of clinical
experience; (iv) [ a ] social worker: an individual with at
least a bachelor's degree in human services or related field (social work,
psychology, psychiatric rehabilitation, sociology, counseling, vocational
rehabilitation, human services counseling or other degree deemed equivalent to
those described) from an accredited college and with at least one year of
clinical experience providing direct services to [ persons individuals ]
with a diagnosis of mental illness; (v) [ Registered a person
with at least a bachelor's degree from an accredited college in an unrelated
field that includes at least 15 semester credits (or equivalent) in a human
services field and who has at least three years of clinical experience; (vi) a
Certified ] Psychiatric Rehabilitation Provider [ (RPRP) (CPRP) ]
registered with the International Association of Psychosocial Rehabilitation
Services (IAPSRS) United States Psychiatric Rehabilitation Association
(USPRA); [ (vi) (vii) a ] registered nurse licensed in the
Commonwealth of Virginia with at least one year of clinical experience; or
[ (vii) (viii) ] any other licensed mental health
professional.
[ "Qualified Mental Health Professional-Child (QMHP-C)" means a person in the human services field who is trained and experienced in providing psychiatric or mental health services to children who have a mental illness. To qualify as a QMHP-C, the individual must have the designated clinical experience and must either (i) be a doctor of medicine or osteopathy licensed in Virginia; (ii) have a master's degree in psychology from an accredited college or university with at least one year of clinical experience with children and adolescents; (iii) have a social work bachelor's or master's degree from an accredited college or university with at least one year of documented clinical experience with children or adolescents; (iv) be a registered nurse with at least one year of clinical experience with children and adolescents; (v) have at least a bachelor's degree in a human services field or in special education from an accredited college with at least one year of clinical experience with children and adolescents, or (vi) be a licensed mental health professional.
"Qualified Mental Health Professional-Eligible (QMHP-E)" means a person who has: (i) at least a bachelor's degree in a human service field or special education from an accredited college without one year of clinical experience or (ii) at least a bachelor's degree in a nonrelated field and is enrolled in a master's or doctoral clinical program, taking the equivalent of at least three credit hours per semester and is employed by a provider that has a triennial license issued by the department and has a department and DMAS-approved supervision training program.
"Qualified Mental Retardation Professional (QMRP)" means a person who possesses at least one year of documented experience working directly with individuals who have mental retardation (intellectual disability) or other developmental disabilities and one of the following credentials: (i) a doctor of medicine or osteopathy licensed in Virginia, (ii) a registered nurse licensed in Virginia, or (iii) completion of at least a bachelor's degree in a human services field, including, but not limited to sociology, social work, special education, rehabilitation counseling, or psychology. ]
"Qualified Mental Retardation Professional
(QMRP)" means an individual possessing at least one year of documented
experience working directly with individuals who have mental retardation or
other developmental disabilities and is one of the following: a doctor of
medicine or osteopathy, a registered nurse, or holds at least a bachelor's
degree in a human services field including, but not limited to, sociology,
social work, special education, rehabilitation counseling, and psychology.
"Qualified Paraprofessional in Brain Injury
(QPPBI)" means an individual with at least a high school diploma and two
years experience working with individuals with disabilities.
"Qualified Paraprofessional in Mental Health
(QPPMH)" means an individual a person who must, at a
minimum, meet one of the following criteria: (i) registered with the [ International
Association of Psychosocial Rehabilitation Services (IAPSRS) United
States Psychiatric Association (USPRA) ] as an Associate Psychiatric
Rehabilitation Provider (APRP); (ii) [ has ] an [ Associate's
Degree associate's degree ] in a related field (social work,
psychology, psychiatric rehabilitation, sociology, counseling, vocational
rehabilitation, human services counseling) and at least one year of experience
providing direct services to [ persons individuals ]
with a diagnosis of mental illness; or (iii) [ has ] a minimum
of 90 hours classroom training and 12 weeks of experience under the direct
personal supervision of a [ QMHP QMHP-Adult ] providing
services to [ persons individuals ] with mental
illness and at least one year of experience (including the 12 weeks of
supervised experience).
"Recovery" means a journey of healing and
transformation enabling an individual with a mental illness to live a
meaningful life in a community of his choice while striving to achieve his full
potential. For individuals with substance [ abuse (substance ]
use disorders [ ) ], recovery is an incremental
process leading to positive social change and a full return to biological,
psychological, and social functioning. For individuals with mental retardation
(intellectual disability), the concept of recovery does not apply in the sense
that [ persons individuals ] with
mental retardation (intellectual disability) will need supports throughout
their entire [ life lives ] although
these may change over time. With supports, individuals with mental retardation
(intellectual disability) are capable of living lives that are fulfilling and
satisfying and that bring meaning to themselves and others [ that
whom ] they know.
"Referral" means the process of directing an applicant or an individual to a provider or service that is designed to provide the assistance needed.
[ "Related conditions" or
"developmental disabilities" means autism or a severe, chronic
disability that meets all of the following conditions identified in 42 CFR
435.1009:
1. Attributable to cerebral palsy, epilepsy or any other
condition, other than mental illness, that is found to be closely related to
mental retardation (intellectual disability) because this condition
results in impairment of general intellectual functioning or adaptive behavior
similar to behavior of persons with mental retardation (intellectual
disability) ,and requires treatment or services similar to those required
for these persons;
2. Manifested before the person reaches age 22;
3. Likely to continue indefinitely; and
4. Results in substantial functional limitations in three or
more of the following areas of major life activity:
a. Self-care;
b. Understanding and use of language;
c. Learning;
d. Mobility;
e. Self-direction; or
f. Capacity for independent living. ]
"Residential crisis stabilization service" means (i) providing short-term, intensive treatment to [ nonhospitalized ] individuals who require multidisciplinary treatment in order to stabilize acute psychiatric symptoms and prevent admission to a psychiatric inpatient unit; (ii) providing normative environments with a high assurance of safety and security for crisis intervention; and (iii) mobilizing the resources of the community support system, family members, and others for ongoing rehabilitation and recovery.
"Residential service" means a category of service
providing 24-hour care support in conjunction with care and
treatment or a training program in a setting other than a hospital or
training center. Residential services provide a range of living arrangements
from highly structured and intensively supervised to relatively independent
requiring a modest amount of staff support and monitoring. Residential services
include, but are not limited to: residential treatment, group or
community homes, supervised living, residential crisis stabilization,
community gero-psychiatric residential, community intermediate care
facility-MR, sponsored residential homes, medical and social detoxification,
neurobehavioral services, and substance abuse residential treatment for women
and children.
"Residential treatment service" means providing an intensive and highly structured mental health, substance abuse, or neurobehavioral service, or services for co-occurring disorders in a residential setting, other than an inpatient service.
"Respite care service" means providing for a
short-term, time limited period of care of an individual for the purpose of
providing relief to the individual's family, guardian, or regular care giver.
[ Individuals Persons ] providing respite care are
recruited, trained, and supervised by a licensed provider. These services may
be provided in a variety of settings including residential, day support,
in-home, or [ in ] a sponsored residential home.
"Restraint" means the use of an approved a
mechanical device, medication, physical intervention, or hands-on
hold, or pharmacologic agent to involuntarily prevent an
individual receiving services from moving his body to engage in a behavior that
places him or others at imminent risk. This term includes restraints
used for behavioral, medical, or protective purposes. There are three
kinds of restraints:
1. A restraint used for "behavioral" purposes
means the use of an approved physical hold, a psychotropic medication, or a
mechanical device that is used for the purpose of controlling behavior or
involuntarily restricting the freedom of movement of the individual in an
instance in which there is an imminent risk of an individual harming himself or
others, including staff; when nonphysical interventions are not viable; and
safety issues require an immediate response.
2. A restraint used for "medical" purposes means
the use of an approved mechanical or physical hold to limit the mobility of the
individual for medical, diagnostic, or surgical purposes and the related
post-procedure care processes, when the use of such a device is not a standard
practice for the individual's condition.
3. A restraint used for "protective" purposes
means the use of a mechanical device to compensate for a physical deficit, when
the individual does not have the option to remove the device. The device may
limit an individual's movement and prevent possible harm to the individual
(e.g., bed rail or gerichair) or it may create a passive barrier to protect the
individual (e.g., helmet).
4. A "mechanical restraint" means the use of an
approved mechanical device that involuntarily restricts the freedom of movement
or voluntary functioning of a limb or a portion of a person's body as a means
to control his physical activities, and the individual receiving services does
not have the ability to remove the device.
5. A "pharmacological restraint" means a drug that
is given involuntarily for the emergency control of behavior when it is not
standard treatment for the individual's medical or psychiatric condition.
6. A "physical restraint" (also referred to
"manual hold") means the use of approved physical interventions or
"hands-on" holds to prevent an individual from moving his body to
engage in a behavior that places him or others at risk of physical harm.
Physical restraint does not include the use of "hands-on" approaches
that occur for extremely brief periods of time and never exceed more than a few
seconds duration and are used for the following purposes: (i) to intervene in
or redirect a potentially dangerous encounter in which the individual may
voluntarily move away from the situation or hands-on approach or (ii) to
quickly de-escalate a dangerous situation that could cause harm to the
individual or others.
1. Mechanical restraint means the use of a mechanical device that cannot be removed by the individual to restrict the individual's freedom of movement or functioning of a limb or portion of an individual's body when that behavior places him or others at imminent risk.
2. Pharmacological restraint means the use of a medication that is administered involuntarily for the emergency control of an individual's behavior when that individual's behavior places him or others at imminent risk and the administered medication is not a standard treatment for the individual's medical or psychiatric condition.
3. Physical restraint, also referred to as manual hold, means the use of a physical intervention or hands-on hold to prevent an individual from moving his body when that individual's behavior places him or others at imminent risk.
"Restraints for behavioral purposes" means using a physical hold, medication, or a mechanical device to control behavior or involuntary restrict the freedom of movement of an individual in an instance when all of the following conditions are met: (i) there is an emergency; (ii) nonphysical interventions are not viable; and (iii) safety issues require an immediate response.
"Restraints for medical purposes" means using a physical hold, medication, or mechanical device to limit the mobility of an individual for medical, diagnostic, or surgical purposes, such as routine dental care or radiological procedures and related post-procedure care processes, when use of the restraint is not the accepted clinical practice for treating the individual's condition.
"Restraints for protective purposes" means using a mechanical device to compensate for a physical or cognitive deficit when the individual does not have the option to remove the device. The device may limit an individual's movement, for example, bed rails or a gerichair, and prevent possible harm to the individual or it may create a passive barrier, such as a helmet to protect the individual.
"Restriction" means anything that limits or prevents an individual from freely exercising his rights and privileges.
"Screening" means the preliminary assessment of
an individual's appropriateness for admission or readmission to a service process
or procedure for determining whether the individual meets the minimum criteria
for admission.
"Seclusion" means the involuntary placement of an
individual receiving services alone, in a locked room or
secured area from which he is physically prevented from leaving an area
secured by a door that is locked or held shut by a staff person [ , ]
by physically blocking the door, or by any other physical [ or
verbal ] means so that the individual cannot leave it.
"Serious injury" means any injury resulting in
bodily [ hurt, ] damage, harm [ , ] or loss
that requires medical attention by a licensed physician, doctor of
osteopathic medicine, physician assistant, or nurse practitioner while the
individual is supervised by or involved in services [ ; or
injuries related to the individual's diagnosis wherever they occur ],
such as [ , ] attempted suicides, medication
overdoses, [ or ] reactions from medications
administered or prescribed by the service [ , and when the
injuries require medical attention by a licensed physician, doctor of
osteopathic medicine, physician assistant, or nurse practitioner ].
"Service" or "services" means (i) planned
individualized interventions intended to reduce or ameliorate mental illness,
mental retardation (intellectual disability), or substance abuse [ (substance
use disorders) ] through care, treatment, training, habilitation,
or other supports that are delivered by a provider to individuals with mental
illness, mental retardation (intellectual disability), or substance
abuse [ (substance use disorders) ]. Services include outpatient
services, intensive in-home services, opioid treatment services, inpatient
psychiatric hospitalization, community gero-psychiatric residential services,
assertive community treatment and other clinical services; day support, day
treatment, partial hospitalization, psychosocial rehabilitation, and
habilitation services; case management services; and supportive residential,
[ special school, ] halfway house, and other residential
services; (ii) day support, in [ - ] home support, and crisis
stabilization services provided to individuals under the IFDDS Waiver; and
(iii) planned individualized interventions intended to reduce or ameliorate the
effects of brain injury through care, treatment, or other supports [ provided
under the Brain Injury Waiver ] or in residential services for persons
with brain injury.
"Shall" means an obligation to act is imposed.
"Shall not" means an obligation not to act is imposed.
"Skills training" means systematic skill building through curriculum-based psychoeducational and cognitive-behavioral interventions. These interventions break down complex objectives for role performance into simpler components, including basic cognitive skills such as attention, to facilitate learning and competency.
"Social detoxification service" means providing
nonmedical supervised care for the individual's natural process of
withdrawal from [ excessive ] use of alcohol or other drugs.
"Sponsored residential home" means a service where
providers arrange for, supervise [ , ] and provide programmatic,
financial, and service support to families or individuals persons
(sponsors) providing care or treatment in their own homes for [ adults
individuals receiving services ].
"State board" means the State Board of Behavioral Health and Developmental Services. The board has statutory responsibility for adopting regulations that may be necessary to carry out the provisions of Title 37.2 of the Code of Virginia and other laws of the Commonwealth administered by the commissioner or the department.
"State methadone authority" means the
[ Virginia Department of Mental [ Behavioral ]
Health, Mental Retardation and Substance Abuse Services [ department and
Developmental Services ] that is authorized by the federal Center for
Substance Abuse Treatment to exercise the responsibility and authority for
governing the treatment of opiate addiction with an opioid drug. This is
the agency designated by the Governor to exercise the responsibility and
authority for governing the treatment of opiate addiction with an opioid drug.
"Substance abuse [ " or "
( ] substance use [ disorder) disorders)
]" means the use, of drugs enumerated in the Virginia
Drug Control Act (§ 54.1-3400 et seq.) without a compelling medical
reason, of or alcohol and other drugs which that (i)
results in psychological or physiological dependency dependence
or danger to self or others as a function of continued and compulsive
use in such a manner as to induce or (ii) results in mental,
emotional [ , ] or physical impairment and cause that
causes socially dysfunctional or socially disordering behavior; and
(iii) [ , ] because of such substance abuse [ , ]
requires care and treatment for the health of the individual. This care and
treatment may include counseling, rehabilitation, or medical or psychiatric
care.
[ "Substance abuse intensive outpatient service" means treatment provided in a concentrated manner for two or more consecutive hours per day to groups of individuals in a nonresidential setting. This service is provided over a period of time for individuals requiring more intensive services than an outpatient service can provide. Substance abuse intensive outpatient services include multiple group therapy sessions during the week, individual and family therapy, individual monitoring, and case management. ]
"Substance abuse residential treatment for women with children service" means a 24-hour residential service providing an intensive and highly structured substance abuse service for women with children who live in the same facility.
"Supervised living residential service" means the provision of significant direct supervision and community support services to individuals living in apartments or other residential settings. These services differ from supportive in-home service because the provider assumes responsibility for management of the physical environment of the residence, and staff supervision and monitoring are daily and available on a 24-hour basis. Services are provided based on the needs of the individual in areas such as food preparation, housekeeping, medication administration, personal hygiene, [ treatment, counseling, ] and budgeting.
"Supportive in-home service" (formerly supportive
residential) means the provision of community support services and other
structured services to assist individuals. Services, to
strengthen individual skills, and [ to that ]
provide environmental supports necessary to attain and sustain independent
community residential living. They Services include, but are
not limited to, drop-in or friendly-visitor support and counseling to more
intensive support, monitoring, training, in-home support, respite care,
and family support services. Services are based on the needs of the individual
and include training and assistance. These services normally do not involve
overnight care by the provider; however, due to the flexible nature of these
services, overnight care may be provided on an occasional basis.
[ "Systemic corrective action" means the
provider's plans to address any cited violation of these regulations that will
significantly reduce the probability that the violation will re-occur. ]
"Therapeutic day treatment for children and adolescents" means a treatment program that serves (i) children and adolescents from birth through age 17 [ and under certain circumstances up to 21 ] with serious emotional disturbances, substance use, or co-occurring disorders or (ii) children from birth through age seven who are at risk of serious emotional disturbance, in order to combine psychotherapeutic interventions with education and mental health or substance abuse treatment. Services include: evaluation; medication education and management; opportunities to learn and use daily living skills and to enhance social and interpersonal skills; and individual, group, and family counseling.
"Time out" means assisting an individual to
regain emotional control by removing the individual from his immediate
environment to a different, open location until he is calm or the problem
behavior has subsided the involuntary removal of an individual by a
staff person from a source of reinforcement to a different, open
location for a specified period of time or until the problem behavior has
subsided to discontinue or reduce the frequency of problematic behavior.
"Volunteer" means a person who, without financial remuneration, provides services to individuals on behalf of the provider.
Part II
Licensing Process
12VAC35-105-30. Licenses.
A. Licenses are issued to providers who offer services to one
or a combination of the following disability groups: persons with individuals
who have mental illness, persons with mental retardation (intellectual
disability), persons with or substance addiction or
[ abuse ] problems; persons with related conditions [ (substance ]
use [ disorder) disorders) ]; have
developmental disability and are served under the IFDDS Waiver,;
or persons with have brain injury and are [ receiving
served in ] residential [ services settings
or under the Brain Injury Waiver ] or in a residential
service.
B. Providers shall be licensed to provide specific services as defined in this chapter or as determined by the commissioner. These services include:
1. Case management;
2. Clubhouse;
3. 2. Community gero-psychiatric residential;
4. 3. Community intermediate care facility-MR;
5. Crisis 4. Residential crisis stabilization (residential
and nonresidential);
5. Nonresidential crisis stabilization;
6. Day support;
7. Day treatment, includes [ club house
and ] therapeutic day treatment for children and adolescents;
8. Group home and community residential;
9. Inpatient psychiatric;
10. Intensive Community Treatment (ICT);
11. Intensive in-home;
[ 12. Intensive outpatient;
13. 12. ] Medical detoxification
Managed withdrawal, including medical detoxification and social
detoxification;
[ 14. 13. ] Mental health community
support;
[ 15. 14. ] Opioid treatment [ /medication
assisted treatment ];
[ 16. 15. ] Emergency;
[ 16. 17. ] Outpatient;
[ 17. 18. ] Partial hospitalization;
[ 18. 19. ] Program of assertive
community treatment (PACT);
[ 19. 20. ] Psychosocial
rehabilitation;
[ 20. 21. ] Residential treatment;
[ 21. 22. ] Respite care;
22. Social detoxification;
[ 23. 22. ] Sponsored residential home;
[ 24. 23. ] Substance abuse residential
treatment for women with children;
[ 24. Substance abuse intensive outpatient; ]
25. Supervised living residential; and
26. Supportive in-home.
C. A license addendum describes shall describe
the services licensed, the population disabilities of individuals who
may be served, the specific locations where services are to be
provided or organized administered, and the terms, and
conditions for each service offered by a licensed provider. For residential and
inpatient services, the license identifies the number of beds individuals
each residential location may serve at a given time.
12VAC35-105-40. Application requirements.
A. All providers that are not currently licensed shall be
required to apply for a license using the application designated by the
commissioner. Providers applying for a license must shall submit:
1. A working budget showing projected revenue and expenses for the first year of operation, including a revenue plan.
2. Documentation of working capital to include:
a. Funds or a line of credit sufficient to cover at least 90 days of operating expenses if the provider is a corporation, unincorporated organization or association, a sole proprietor, or a partnership.
b. Appropriated revenue if the provider is a state or local government agency, board or commission.
3. Documentation of authority to conduct business in the Commonwealth of Virginia.
4. A disclosure statement identifying the legal names and
dates of any services licensed [ to in Virginia or
other states that ] the applicant [ in other states
or in Virginia holds or has held ], previous
sanctions or negative actions against any license to provide services that the
applicant holds or has held in any other state or in Virginia, [ and ]
the names and dates of any disciplinary actions involving the applicant's
current or past licensed services [ , and any criminal
convictions and conviction dates involving the applicant.owners of the
organization ].
B. Providers must shall submit an application
listing each service to be provided and submit the following items for each
service:
1. A staffing plan;
2. Employee credentials or and job descriptions
containing all the elements outlined in 12VAC35-105-410 A;
3. A service description containing all the elements outlined in 12VAC35-105-580 C; and
4. Records management policy containing all the elements
outlined in 12VAC35-105-390 and 12VAC35-105-870 A; and.
5. A certificate of occupancy, floor plan (with dimensions),
and any required inspections for all service locations.
C. The provider shall confirm his intent to renew the license prior to the expiration date of the license and notify the department in advance of any changes in service or location.
12VAC35-105-50. Issuance of licenses.
A. The commissioner issues may issue the following
types of licenses [ .:
B. 1. ] A conditional license shall be
issued to a new provider or service for services that demonstrates
compliance with administrative and policy regulations but has not demonstrated
compliance with all the regulations.
[ 1. a. ] A conditional license shall
not exceed six months.
[ 2. b. ] A conditional license may be
renewed if the provider is not able to demonstrate compliance with all the
regulations at the end of the license period. A conditional license and any
renewals shall not exceed 12 successive months for all conditional licenses and
renewals combined.
[ 3. c. ] A provider [ or service ] holding
a conditional license [ for a service ] shall demonstrate
progress toward compliance.
[ 4. d. ] A provider holding
a conditional license shall not add services or locations during the
conditional period.
[ 5. e. ] A group home or
community residential service provider shall [ not serve
more than four individuals in a single location during the conditional period.
be limited to providing services in a single location, serving no more than
four individuals during the conditional period. ]
[ C. 2. ] A provisional license may be
issued to a provider or for a service that has demonstrated an
inability to maintain compliance with regulations, has violations of human
rights or licensing regulations that pose a threat to the health or safety of
individuals being served, has multiple violations of human rights or licensing
regulations, or has failed to comply with a previous corrective action plan.
[ 1. a. ] A provisional license may be
issued at any time.
[ 2. b. ] The term of a provisional
license [ may shall ] not exceed six months.
[ 3. c. ] A provisional license may be
renewed; but a provisional license and any renewals shall not exceed 12
successive months for all provisional licenses and renewals combined.
[ 4. d. ] A provider [ or
service ] holding a provisional license [ for a service ]
shall demonstrate progress toward compliance.
[ 5. e. ] A provider
[ for a service ] holding a provisional license [ for
a service ] shall not increase its services or locations or expand
the capacity of the service.
5. [ 6. f. ] A
provisional license for a service shall be noted as a stipulation on the
provider license. The stipulation shall also indicate the violations to be
corrected and the expiration date of the provisional license.
[ D. 3. ] A full license shall be
issued after a provider or service demonstrates compliance with all the
applicable regulations.
[ 1. a. ] A full license may be
granted to a provider for service for up to three years. The length of
the license shall be in the sole discretion of the commissioner.
[ 2. b. ] If a full license is granted
for three years, it shall be referred to as a triennial license. A triennial
license shall be granted to providers for services who that
have had no noncompliances or only violations that did not pose a threat to
the health of safety of individuals being served during the previous license
period demonstrated compliance with the regulations. The
commissioner may waive this limitation if the provider has demonstrated
consistent compliance for more than a year or that sufficient provider
oversight is in place issue a triennial license to a provider for
service that had violations during the previous license period if those
violations did not pose a threat to the health or safety of individuals being
served and the provider or service has demonstrated consistent compliance for
more than a year and has a process [ in place ] that
provides sufficient oversight to maintain compliance [ in place ].
[ 3. c. ] If a full license is granted
for one year, it shall be referred to as an annual license.
[ 4. d. ] The term of the first full
renewal license after the expiration of a conditional or provisional license may
shall not exceed one year.
[ E. B. ] The license may bear
stipulations. [ Stipulations ] may be limitations on
the provider or may impose additional requirements. Terms of any such
stipulations on licenses issued to the provider shall be specified on the
provider license. [ 1. Stipulations may be added to the license
issued to the provider to The commissioner may add stipulations on a
license issued to a provider that may ] place limits on the
provider or to impose additional requirements on the provider. [ Terms
of any such stipulations shall be specified on the provider license.
2. Stipulations may also recognize the expertise of the
provider as defined and approved by the department to serve individuals with
specialized needs. ]
[ F. C. ] A license shall not be
transferred or assigned to another provider. A new application shall be made
and a new license issued when there is a change in ownership.
[ G. D. ] A license shall not be
issued or renewed unless the provider is affiliated with a local human rights
committee.
[ H. E. ] No service may shall
be issued a license with an expiration date that is after the expiration
date of the provider license.
[ I. F. ] A license continues shall
continue in effect after the expiration date if the provider has submitted
a renewal application before the date of expiration and there are no grounds to
deny the application. The department shall issue a letter stating the
provider or service license shall be effective for six additional months if the [ renewed ]
license is not issued before the date of expiration.
12VAC35-105-60. Modification.
A. Upon written request by the provider, the license may be
modified during the term of the license with respect to the populations A
provider shall submit a written service modification application at least 45
days in advance of a proposed modification to its license. The modification may
address the characteristics of individuals served (disability, age, [ and
or ] gender), the services offered, the locations where services
are provided, existing stipulations and the, or the
maximum number of beds. Approval of such request shall be at the sole
discretion of the commissioner individuals served under the provider
[ or service ] license.
B. A change requiring a modification of the license shall
not be implemented prior to approval by the commissioner. The department may
give approval to implement a modification pending the issuance of the modified
license based on guidelines determined by the commissioner Upon receipt
of the completed service modification application, the commissioner may revise
the provider [ or service ] license. Approval of
such request shall be at the sole discretion of the commissioner.
C. A change requiring a modification of the license shall not be implemented prior to approval by the commissioner. The department may send the provider a letter approving implementation of the modification pending the issuance of the modified license.
12VAC35-105-70. Onsite reviews.
A. The department shall conduct an announced or unannounced onsite review of all new providers and services to determine compliance with this chapter.
B. The department shall conduct unannounced onsite reviews of
licensed providers and each of its services service at any time
and at least annually to determine compliance with these regulations. The
annual unannounced onsite reviews shall be focused on preventing specific risks
to individuals, including an evaluation of the physical facilities in which the
services are provided.
C. The department may conduct announced and unannounced onsite reviews at any time as part of the investigations of complaints or incidents to determine if there is a violation of this chapter.
12VAC35-105-90. Compliance.
A. The department shall determine the level of compliance with each regulation as follows:
1. "Compliance" (C) means the provider is
clearly in compliance with [ acts in accordance with
meets the requirements of ] a regulation.
2. "Noncompliance" (NC) means the provider is
clearly in noncompliance with [ violates or ] fails
to meet [ or violates ] part or all of a
regulation.
3. "Not Determined" (ND) means that the provider must provide additional information to determine compliance with a regulation.
4. "Not Applicable" (NA) means the provider is specifically
exempted from or not required to demonstrate compliance with the provisions
of a regulation at the time.
B. The provider, including its employees, contract service providers, student interns [ , ] and volunteers, shall comply with all applicable regulations.
12VAC35-105-100. Sanctions.
A. The commissioner may invoke the sanctions enumerated in §
37.1-185.1 § 37.2-419 of the Code of Virginia upon receipt of information
that a licensed provider is:
1. In violation of the provisions of §§ 37.1-84.1 and
37.1-179 through 37.1-189.1 §§ 37.2-400 through 37.2-422 of the
Code of Virginia, these regulations, or the provisions of the Rules and
Regulations to Assure the Rights of Individuals Receiving Services from
Providers of Mental Health, Mental Retardation and Substance Abuse Services
Licensed, Funded, or Operated by the Department of [ Mental
Health, Mental Retardation Behavioral Health ] and
[ Substance Abuse Developmental ] Services
(12VAC35-115); and
2. Such violation adversely impacts affects the
human rights of individuals, or poses an imminent and substantial threat to the
health, safety or welfare of individuals.
The commissioner shall notify the provider in writing of the
specific violations found [ , ] and of his intention to
convene an informal conference pursuant to § 2.2-4019 of the Code of Virginia
at which the presiding officer will be asked to recommend issuance of a special
order.
B. The sanctions contained in the special order shall remain in effect during the pendency of any appeal of the special order.
12VAC35-105-110. Denial, revocation or suspension of a license.
A. An application for a license or license renewal may be denied and a full, conditional, or provisional license may be revoked or suspended for one or more of the following reasons:
1. The provider [ or applicant ] has violated
any provisions of Chapter 8 (§ 37.1-179 et seq.) of Title 37.1 Article
2 (§ 37.2-403 et seq.) of Chapter 4 of Title 37.2 of the Code of
Virginia or these licensing regulations;
2. The provider's [ or applicant's ] conduct
or practices are detrimental to the welfare of any individual receiving
services or in violation of human rights identified in § 37.1-84.1 § 37.2-400
of the Code of Virginia or the human rights regulations (12VAC35-115);
3. The provider [ or applicant ] permits, aids, or abets the commission of an illegal act;
4. The provider [ or applicant ] fails or refuses to submit reports or to make records available as requested by the department;
5. The provider [ or applicant ] refuses
to admit a representative of the department [ who displays a
state-issued photo identification ] to the premises; or
6. The provider [ or applicant ] fails to
submit or implement an adequate corrective action plan.; or
7. The provider [ or applicant ] submits [ substantively
any ] misleading or false information to the department.
B. A provider shall be notified in writing of the department's intent to deny, revoke [ , ] or suspend a License; the reasons for the action; the right to appeal; and the appeal process. The provider has the right to appeal the department's decision under the provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia).
12VAC35-105-115. Summary suspension.
A. In conjunction with any proceeding for revocation, denial
[ , ] or other action, when conditions or practices exist that
pose an immediate and substantial threat to the health, safety, and welfare of
the residents individuals living there, the commissioner may
issue an order of summary suspension of the license to operate any group home
or residential facility service for adults when he believes the
operation of the home or facility residential service should be
suspended during the pendency of such proceeding.
B. Prior to the issuance of an order of summary suspension, the department shall contact the Executive Secretary of the Supreme Court of Virginia to obtain the name of a hearing officer. The department shall schedule the time, date, and location of the administrative hearing with the hearing officer.
C. The order of summary suspension shall take effect upon its issuance. It shall be delivered by personal service and certified mail, return receipt requested, to the address of record of the licensee as soon as practicable. The order shall set forth:
1. The time, date, and location of the hearing;
2. The procedures for the hearing;
3. The hearing and appeal rights; and
4. Facts and evidence that formed the basis for the order of summary suspension.
D. The hearing shall take place within three business days of the issuance of the order of summary suspension.
E. The department shall have the burden of proving in any summary suspension hearing that it had reasonable grounds to require the licensee to cease operations during the pendency of the concurrent revocation, denial, or other proceeding.
F. The administrative hearing officer shall provide written
findings and conclusions together with a recommendation as to whether the
license should be summarily suspended [ , ] to the
commissioner within five business days of the hearing.
G. The commissioner shall issue a final order of summary suspension or make a determination that the summary suspension is not warranted based on the facts presented and the recommendation of the hearing officer within seven business days of receiving the recommendation of the hearing officer.
H. The commissioner shall issue and serve on the group home or residential facility for adults or its designee by personal service or by certified mail, return receipt requested either:
1. A final order of summary suspension including (i) the basis
for accepting or rejecting the hearing officer's recommendation, and (ii)
notice that the [ licensee of the ] group home or residential
[ facility service ] may appeal the commissioner's
decision to the appropriate circuit court no later than 10 days following
issuance of the order; or
2. Notification that the summary suspension is not warranted by the facts and circumstances presented and that the order of summary suspension is rescinded.
I. The licensee may appeal the commissioner's decision on the summary suspension to the appropriate circuit court no more than 10 days after issuance of the final order.
J. The outcome of concurrent revocation, denial, and other proceedings shall not be affected by the outcome of any hearing pertaining to the appropriateness of the order of summary suspension.
K. At the time of the issuance of the order of summary
suspension, the department shall contact the appropriate agencies to inform
them of the action and the need to develop relocation plans for [ residents
the individuals receiving residential or center-based services ],
and ensure that any other legal guardians or responsible family members are
informed of the pending action.
12VAC35-105-130. Confidentiality of records.
Records that are confidential under federal or state law shall be maintained as confidential by the department and shall not be further disclosed except as required or permitted by law.
Part III
Administrative Services
Article 1
Management and Administration
12VAC35-105-140. License availability.
The current license or a copy shall be prominently displayed for public inspection in all service locations.
12VAC35-105-150. Compliance with applicable laws, regulations and policies.
The provider including its employees, contractors, students, and volunteers shall comply with:
1. These regulations;
2. Terms The terms and stipulations of the
license;
3. All applicable federal, state [ , ]
or local laws [ , ] and regulations including [ but
not limited to ]:
a. Laws regarding employment practices including the Equal Employment Opportunity Act;
b. The Americans with Disabilities Act and the Virginians with Disabilities Act;
c. Occupational Safety and Health Administration regulations;
d. Virginia Department of Health regulations;
e. Laws or and regulations of the Department of
Health Professions;
[ f. Virginia Department of Medical Assistance Services regulations;
f. g. ] Uniform Statewide Building Code;
and
[ g. h. ] Uniform Statewide Fire
Prevention Code.
4. Section 37.1-84.1 37.2-400 of the Code of
Virginia on the human rights of individuals receiving services and
related human rights regulations adopted by the state board; and
5. Section 37.1-197.1 of the Code of Virginia regarding
prescreening and predischarge planning. Providers responsible for complying
with § 37.1-197.1 are required to develop and implement policies and procedures
that include:
a. Identification of employees or services responsible for
prescreening and predischarge planning services for all disability groups; and
b. Completion of predischarge plans prior to an
individual's discharge in consultation with the state facility which:
(1) Involve the individual or his legally authorized
representative and reflect the individual's preferences to the greatest extent
possible consistent with the individual's needs.
(2) Include the mental health, mental retardation,
substance abuse, social, educational, medical, employment, housing, legal,
advocacy, transportation, and other services that the individual will need upon
discharge into the community and identify the public or private agencies or
persons that have agreed to provide them.
6. 5.The provider's own policies. All required
policies shall be in writing.
12VAC35-105-155. Preadmission screening, [ predischarge
discharge ] planning, involuntary commitment, and mandatory
outpatient treatment orders.
A. Providers responsible for complying with § [ § 37.2-60
and ] 37.2-505 of the Code of Virginia regarding community service
board [ and behavioral health authority ] preadmission
screening and [ predischarge discharge ] planning
shall [ establish and ] implement policies and
procedures that include:
1. Identification, qualification, training, and
responsibilities of employees responsible for [ prescreening
preadmission screening ] and [ predischarge
discharge ] planning.
2. Completion of [ predischarge plans
a discharge plan ] prior to an individual's discharge in
consultation with the state facility that:
a. [ Involve Involves ]
the individual or his authorized representative and [ reflect
reflects ] the individual's preferences to the greatest extent
possible consistent with the individual's needs.
b. [ Include Involves ]
mental health, mental retardation (intellectual disability), substance
abuse, social, educational, medical, employment, housing, legal, advocacy,
transportation, and other services that the individual will need upon discharge
into the community and [ identify identifies ]
the public or private agencies or persons that have agreed to provide them.
B. Any provider who serves individuals through an emergency
custody order, temporary detention order, or mandatory outpatient treatment order
shall [ develop and ] implement policies
and procedures to comply with §§ 37.2-800 through 37.2-817 of the Code of
Virginia.
12VAC35-105-160. Reviews by the department; requests for information.
A. The provider shall permit representatives from the department to conduct reviews to:
1. Verify application information;
2. Assure compliance with this chapter; and
3. Investigate complaints.
B. The provider shall cooperate fully with inspections and provide all information requested to assist representatives from the department who conduct inspections.
C. The provider shall collect, maintain, and report or
make available [ to the department ] the following
information [ to the department ]:
1. Each allegation of abuse or neglect shall be reported
to the assigned human rights advocate and the individual's authorized
representative within 24 hours from the receipt of the initial allegation and
the investigating authority shall provide a written report of the results of
the investigation of abuse or neglect to the provider and the human rights
advocate within 10 working days, unless an exemption has been granted, from the
date the investigation began. The report shall include but not be limited to
the following: whether abuse, neglect or exploitation occurred; type of abuse;
and whether the act resulted in physical or psychological injury. Reported
information shall include the type of abuse, neglect, or exploitation that is
alleged and whether there is physical or psychological injury to the
individual.
2. Deaths and Each instance of death or serious injuries
injury shall be reported in writing to the [ department department's
assigned licensing specialist ] within 24 hours of discovery and by
phone to the legally individual's authorized representative
[ as applicable ] within 24 hours to. Reported
information shall include [ , but not be limited to, ]
the following: the date and place of the individual's death or serious
injury; the nature of the individual's injuries and the
treatment required received; and the circumstances of the
death or serious injury. Deaths that occur in a hospital as a result of
illness or injury occurring when the individual was in a licensed service shall
be reported.
3. Each instance of seclusion or restraint that does not comply
with the human rights regulations or approved variances [ , ]
or that results in injury to an individual [ , ] shall be
reported to the legally individual's authorized representative
and the assigned human rights advocate within 24 hours.
[ 4. Reports and other such information
required by the department to establish compliance with these regulations or
any other local, state, and federal statutues or regulations.
D. The provider shall submit, or make available, reports and information that the department requires to establish compliance with these regulations and applicable statutes.
E. D. ] Records that are confidential under
federal or state law shall be maintained as confidential by the department and
shall not be further disclosed except as [ required or
permitted ] by law; however, there shall be no right of access to
communications that are privileged pursuant to § 8.01-581.17 of the Code of
Virginia.
[ F. If E. ] Additional
information requested by the department if compliance with a regulation
cannot be determined, the department shall issue a licensing report
requesting additional information. Additional information must shall
be submitted within 10 business days of the issuance of the licensing report requesting
additional information. Extensions may be granted by the department when
requested prior to the due date, but extensions shall not exceed an additional
10 business days.
[ F. G. ] Applicants and
providers shall not submit [ substantively any ]
misleading or false information to the department.
12VAC35-105-170. Corrective action plan.
A. If there is noncompliance with any of these regulations
applicable regulation during an initial or ongoing review or
investigation, the department shall issue a licensing report describing the
noncompliance and requesting the provider to submit a corrective action plan for
each violation cited.
B. The provider shall submit to the department and implement a
written corrective action plan for each regulation with which it is
found to be in noncompliance with these regulations identified on violation
as identified in the licensing report.
C. The corrective action plan shall include a:
1. Description of the [ systemic ] corrective
actions to be taken that will minimize the possibility that the violation
will occur again;
2. Date of completion for each corrective action; and
3. Signature of the person responsible for the service.
D. The provider shall submit a corrective action plans
plan to the department within 15 business days of the issuance of the
licensing report. Extensions may be granted by the department when requested
prior to the due date, but extensions shall not exceed an additional 10
business days. An immediate corrective action plan shall be required if
the department determines that the violations pose a danger to individuals receiving
the service.
E. A corrective action plan shall be approved by the
department Upon receipt of the corrective action plan, the department shall
review the plan and [ shall ] determine
whether the plan is approved or not approved. The provider has an
additional 10 business days to submit a revised corrective action plan after
receiving a notice that the plan submitted has not been approved by the
department.
F. When the provider disagrees with a citation of a
violation, the provider shall discuss this disagreement with the licensing
specialist initially. If the disagreement is not resolved, the provider may ask
for a meeting with the licensing specialist's supervisor [ , in
consultation with the director of licensing, ] to challenge a
finding of noncompliance. The determination of the [ supervisor
director ] is final.
G. The provider shall monitor implementation of [ pledged
approved ] corrective action and include a plan for [ such ]
monitoring in its quality assurance activities specified in 12VAC30-105-620.
12VAC35-105-180. Notification of changes.
A. The provider shall notify the department in writing prior to implementing changes that affect:
1. Organizational or administrative structure, including the name of the provider;
2. Geographic location of the provider or its services;
3. Service description as defined in these regulations;
4. Significant changes in qualifications required for a position
or qualifications of an individual occupying a position to the staffing
plan, position descriptions, or employee or contractor qualifications; or
5. Bed capacity for services providing residential or inpatient services.
B. The provider shall not implement the specified changes without the prior approval of the department.
C. The provider shall provide any documentation necessary for the department to determine continued compliance with these regulations after any of these specified changes are implemented.
D. A provider shall notify the department in writing of its
intent to discontinue services 30 days prior to the cessation of services. The
provider will shall continue to provide all services that are
identified in every each individual's Individualized Services
Plan (ISP) ISP after it has given official notice of its intent to
cease operations and until each individual is appropriately discharged. The
provider will shall further continue to maintain substantial
compliance with all applicable regulations as it discontinues its services.
E. All individuals receiving services [ or
and ] their authorized representatives shall be notified of the
provider's intent to cease services in writing 30 days prior to the cessation
of services. This written notification will shall be documented
in each individual's ISP. Also, refer to [ as outlined in
Records Management, Part V (12VAC35-105-870 et seq.) of this chapter ].
12VAC35-105-190. Operating authority, governing body and organizational structure.
A. The provider shall provide the following evidence of
its operating authority.:
1. A public organization Public organizations
shall provide documents describing the administrative framework of the
governmental department of which it is a component or describing the legal
and administrative framework under which it was established and operates.
2. All private organizations except sole proprietorships shall
provide a certification certificate from the State Corporation
Commission.
B. The provider's provider shall provide an
organizational chart that clearly identifies its governing body and
organizational structure shall be clearly identified by providing an
organizational chart.
C. The provider shall document the role and actions of the
governing body, which shall be consistent with its operating authority. The
provider shall identify its operating elements and services, the internal
relationship among these elements and services, and the its
management or leadership structure.
12VAC35-105-210. Fiscal accountability.
A. The provider shall document financial resources to
operate its services or facilities or shall have a line of credit sufficient to
cover 90 days of operating expense, based on a working budget showing projected
revenue and expenses arrangements or a line of credit that are adequate
to ensure maintenance of ongoing operations for at least 90 days on an ongoing
basis. The amount needed shall be based on a working budget showing
projected revenue and expenses.
B. At the end of each fiscal year, the provider shall prepare, according to generally accepted accounting principles (GAAP) or those standards promulgated by the Governmental Accounting Standards Board (GASB) and the State Auditor of Public Accounts:
1. An operating statement showing revenue and expenses for the fiscal year just ended.
2. A balance sheet showing assets and liabilities for the
fiscal year just ended. At least once every three years, all financial
records shall be audited by The department may require an audit of all
financial records by an independent Certified Public Accountant (CPA) or audited
as otherwise provided by law or regulation.
3. Providers operating as a part of a local government
agency are excluded from providing not required to provide a
balance sheet; however, they shall provide a financial statement.
C. The provider shall have written internal controls to minimize the risk of theft or embezzlement of provider funds.
D. The provider shall identify in writing the title and
qualifications of the person who has the authority and responsibility for the
fiscal management of its services. At a minimum, the person who has the
authority and responsibility for the fiscal management of the
provider shall be bonded or otherwise indemnified.
[ E. The provider shall notify the department in writing when its line of credit or other financial arrangement has been cancelled or significantly reduced at any time during the licensing period. ]
12VAC35-105-220. Indemnity coverage.
To protect the interests of individuals, employees, and the provider from risks of liability, there shall be indemnity coverage to include:
1. General liability;
2. Professional liability;
3. Vehicular Commercial vehicular liability; and
4. Property damage.
12VAC35-105-230. Written fee schedule.
If the provider charges for services, the written schedule of rates and charges shall be available to the individual or authorized representative upon request.
12VAC35-105-240. Policy on funds of individuals receiving services.
A. The provider shall [ establish and ]
implement a written policy for handling funds of individuals receiving
services, including providing for separate accounting of individual funds.
B. The provider shall have documented financial controls to minimize the risk of theft or embezzlement of funds of individuals receiving services.
C. The provider shall purchase a surety bond or otherwise provide assurance for the security of all funds of individuals receiving services deposited with the provider.
Article 2
Physical Environment
12VAC35-105-260. Building inspection and classification.
All locations shall be inspected and approved as required by
the appropriate building regulatory entity. Approval Documentation of
approval shall be a Certificate of Use and Occupancy indicating the
building is classified for its proposed licensed purpose. The provider shall
submit a copy of the Certificate of Use and Occupancy to the department for new
locations. This section does not apply to correctional facilities or home
and noncenter-based services. Sponsored residential services service
providers shall certify compliance of that their sponsored
residential homes comply with this regulation.
12VAC35-105-265. Floor plans.
All services shall submit floor plans with room dimensions to the department for new locations. This does not apply to home or noncenter-based services.
12VAC35-105-270. Building modifications.
A. Building The provider shall submit building
plans and specifications for new any planned construction of
locations, change in at a new location, changes in the use of
existing locations, and any structural modifications or additions to existing
locations where services are provided shall be submitted for review by
the department to determine compliance with the licensing regulations. This
section does not apply to correctional facilities, jails, or home and
noncenter-based services.
B. An The provider shall submit an interim plan to
the department addressing safety and continued service delivery shall be
required for new if new construction or for conversion, involving
structural modifications or additions to existing buildings is planned.
12VAC35-105-280. Physical environment.
A. The physical environment, design, structure,
furnishings, and lighting shall be appropriate to the population individuals
served and the services provided and.
B. The physical environment shall be accessible to individuals with physical and sensory disabilities [ , if applicable ].
B. C. The physical environment and furnishings
shall be clean, dry, free of foul odors, safe, and well-maintained.
C. The physical environment, design, structure, furnishing,
and lighting shall be appropriate to the population served and the services
provided.
D. Floor surfaces and floor covering coverings
shall promote mobility in areas used by individuals and shall promote
maintenance of sanitary conditions.
E. The physical environment shall be well ventilated. Temperatures shall be maintained between 65°F and 80°F [ in all areas used by individuals ].
F. Adequate hot and cold running water of a safe and
appropriate temperature shall be available. Hot water accessible to individuals
being served shall be maintained within a range of [ 100-120°F 100-110°F ].
If temperatures cannot be maintained within the specified range, the provider
shall make provisions for protecting individuals from injury due to scalding.
G. Lighting shall be sufficient for the activities being performed and all areas within buildings and outside entrances and parking areas shall be lighted for safety.
H. Recycling, composting, and garbage disposal shall not create a nuisance, permit transmission of disease, or create a breeding place for insects or rodents.
I. If smoking is permitted, the provider shall make provisions
for alternate smoking areas that are separate from the service
environment. This [ regulation subsection ] does not
apply to home-based services.
J. For all program areas added after September 19, 2002, minimum room height shall be 7-1/2 feet.
K. This [ section regulation ] does
not apply to home and noncenter-based services. Sponsored residential services
shall certify compliance of sponsored residential homes with this [ regulation
section ].
12VAC35-105-290. Food service inspections.
Any location where the provider is responsible for preparing
or serving food shall request inspection and [ shall ] obtain
approval by state or local health authorities regarding food service and
general sanitation at the time of the original application and annually
thereafter. Documentation of the most recent three inspections and approval
shall be kept on file. This [ regulation section
] does not apply to sponsored residential services or to group homes or
community residential homes.
12VAC35-105-300. Sewer and water inspections.
A. A location Service locations shall either
be on a public water and sewage systems system or the
location's on a nonpublic water and sewage system shall be
inspected and approved by state or local health authorities at the time of its
original application and annually thereafter. Documentation of the three most
recent inspections and approval shall be kept on file. Sponsored Prior
to a location being licensed, the provider shall obtain the report from the
building inspector pertaining to the septic system and its capacity. Nonpublic
water and sewer systems shall be maintained in good working order and in
compliance with local and state laws. Providers of sponsored residential
home services shall certify compliance of that their sponsored
residential homes comply with this [ regulation section
].
B. A location that is Service locations that are
not on a public water system shall have a water sample tested prior to being
licensed and annually by an accredited, independent laboratory for the
absence of chloroform. The water sample shall also be tested for lead or
nitrates if recommended by the local health department. Documentation of the
three most recent inspections shall be kept on file.
12VAC35-105-310. Weapons.
The provider or facility shall have and implement a
written policy governing the use and possession of firearms, pellet guns, air
rifles [ , ] and other weapons on the facility's
premises [ , including parking areas, ] of the
provider's services. The policy shall provide that no firearms, pellet
guns, air rifles [ , ] and other weapons on the
facility's premises shall be permitted unless the weapons are:
1. In the possession of licensed security or sworn law-enforcement personnel;
2. Kept securely under lock and key; or
3. Used under the supervision of a responsible adult in
accordance with policies and procedures developed by the facility provider
for the weapons' lawful and safe use.
12VAC35-105-320. Fire inspections.
The provider shall document at the time of its original
application and annually thereafter that buildings and equipment in residential
service locations with more than eight beds serving more than
eight individuals are maintained in accordance with the Virginia Statewide
Fire Prevention Code (13VAC5-51). This section does not apply to correctional
facilities or home and noncenter-based or sponsored residential home services.
12VAC35-105-325. Community liaison.
Each residential service shall designate a staff person as a community liaison responsible for facilitating cooperative relationships with neighbors, local law-enforcement personnel, local government officials, and the community at large.
Article 3
Physical Environment of Residential/Inpatient Service Locations
12VAC35-105-330. Beds.
A. The provider shall not operate more beds than the number for which its service location or locations are licensed.
B. A community intermediate care facility for the mentally
retarded ICF/MR may not have more than 20 12 beds at
any one location. This applies to new applications for services after September
19, 2002 and not to existing services or locations licensed prior to
[ the effective date of these regulations December 7,
2011 ].
12VAC35-105-340. Bedrooms.
A. Size of bedrooms 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.
3. This subsection does not apply to community gero-psychiatric residential services.
B. No more than four individuals shall share a bedroom,
except in group homes where no more than two individuals shall share a room.
This does not apply to group home locations licensed prior to [ the
effective date of these regulations December 7, 2011 ].
C. Each individual shall be assigned have adequate
[ private ] storage space accessible to the bedroom for
clothing and personal belongings.
D. This section does not apply to correctional facilities and
jails. Sponsored Providers of sponsored residential home services
shall certify compliance of that their sponsored residential
homes comply with this [ regulation section ].
12VAC35-105-350. Condition of beds.
Beds shall be clean, comfortable, and equipped with a
mattress, pillow, blankets, and bed linens. When a bed is soiled, providers
shall assist individuals with bathing as needed, and provide clean clothing and
bed linen. Sponsored Providers of sponsored residential home
services shall certify compliance of that their sponsored
residential homes comply with this [ regulation section ].
12VAC35-105-360. Privacy.
A. Bedroom and bathroom windows and doors shall provide privacy.
B. Bathrooms [ not ] intended for [ individual ]
use [ by more than one individual at the same time ] shall
provide privacy for showers and toilets.
C. No required path of travel to the bathroom shall be through another bedroom.
D. This section does not apply to correctional facilities and
jails. Sponsored Providers of sponsored residential home services
shall certify compliance of that their sponsored residential
homes comply with this [ regulation section ].
12VAC35-105-370. Ratios of toilets, basins [ , ] and showers or baths.
For all residential and inpatient locations established,
constructed [ , ] or reconstructed after January 13,
1995, there shall be at least one toilet, one hand basin, and shower or bath
for every four individuals. Sponsored This section does not apply to
correctional facilities or jails. Providers of sponsored residential home services
shall certify compliance of that their sponsored residential
homes comply with this [ regulation section ].
This section does not apply to correctional facilities or jails.
12VAC35-105-380. Lighting.
Each service location shall have adequate lighting in
halls and bathrooms at night. Sponsored Providers of sponsored
residential home services shall certify compliance of that their
sponsored residential homes comply with this [ regulation section
].
Article 4
Human Resources
12VAC35-105-390. Confidentiality and security of personnel records.
A. The provider shall maintain an organized system to manage and protect the confidentiality of personnel files and records.
B. Physical and data security controls shall exist for electronic
records personnel records maintained in electronic databases.
C. Providers shall comply with requirements of the American
Americans with Disabilities Act and the Virginians with Disabilities Act
regarding retention of employee health-related information in a file separate
from personnel files.
12VAC35-105-400. Criminal registry checks.
A. The provider shall develop a policy for the criminal
history and registry checks for all employees, contractors, students and volunteers.
The policy shall contain, at a minimum, a disclosure statement concerning
whether the person has ever been convicted of or is the subject of pending
charges for any offense Providers shall comply with the background check
requirements for direct care positions outlined in [ §
§§ ] 37.2-416 [ , 37.2-506, and 37.2-607 ]
of the Code of Virginia for individuals hired after July 1, 1999.
B. After July 1, 1999, providers shall comply with the
background check requirements for direct care positions outlined in §
37.1-183.3 of the Code of Virginia Prior to a new employee beginning his
duties, the provider shall obtain the employee's written consent and personal
information necessary to obtain a search of the registry of founded complaints
of child abuse and neglect maintained by the Virginia Department of Social
Services [ . ]
C. The provider shall submit all information required by
the department to complete the background checks for all employees, and for
contractors, students and volunteers, if required by the provider's policy develop
a [ written ] policy for criminal history and
registry checks for all employees, contractors, students, and volunteers. The
policy shall require at a minimum a disclosure statement from the employee,
contractor, student, or volunteer stating whether the person has ever been
convicted of or is the subject of pending charges for any offense and shall
address what actions the provider will take should it be discovered that an
employee, student, contractor, or volunteer has a founded case of abuse or
neglect or both, or a conviction or pending criminal charge.
D. Prior to a new employee beginning his duties, the
provider shall obtain the employee's written consent and personal information
necessary to obtain a search of the registry of founded complaints of child
abuse and neglect maintained by the Department of Social Services. Results of
the search of the registry shall be maintained in the employee's personnel
record The provider shall submit all information required by the
department to complete the background and registry checks for all employees and
for contractors, students, and volunteers if required by the provider's policy.
E. The provider shall maintain the following documentation:
1. The disclosure statement; and
2. Documentation that the provider submitted all information
required by the department to complete the background and registry checks, and
memoranda from the department transmitting the results to the provider, and
the results from the Child Protective Registry check.
12VAC35-105-410. Job description.
A. Each employee or contractor shall have a written job description that includes:
1. Job title;
2. Duties and responsibilities required of the position;
3. Job title of the immediate supervisor; and
4. Minimum knowledge, skills, and abilities, experience or professional qualifications required for entry level as specified in 12VAC35-105-420.
B. Employees or contractors shall have access to their current
job description. There The provider shall be a have
written documentation of the mechanism for advising used to
advise employees or contractors of changes to their job responsibilities.
12VAC35-105-420. Qualifications of employees or contractors.
A. Any person who assumes the responsibilities of any employee
position as an employee or a contractor shall meet the minimum
qualifications of that position as determined by job descriptions.
B. Employees and contractors shall comply, as required, with
the regulations of the Department of Health Professions. The provider shall
design and, implement a mechanism, and document the
process used to verify professional credentials.
C. Service directors Supervisors shall have
experience in working with the population individuals being
served and in providing the services outlined in the service description.
D. Job descriptions shall include minimum knowledge, skills
and abilities, professional qualification qualifications and
experience appropriate to the duties and responsibilities required of the
position.
[ E. All staff shall demonstrate a working knowledge of the policies and procedures that are applicable to his specific job or position. ]
12VAC35-105-430. Employee or contractor personnel records.
A. Employee or contractor personnel record records,
whether hard-copy or electronic, shall include:
1. Identifying Individual identifying
information;
2. Education and training history;
3. Employment history;
4. Results of the any provider credentialing
process including methods of verification of applicable professional licenses
or certificates;
5. Results of reasonable efforts to secure job-related references and reasonable verification of employment history;
6. Results of the required criminal background checks
and a search searches of the registry of founded complaints of
child abuse and neglect, if any;
7. Results of performance evaluations;
8. A record of disciplinary action taken by the provider, if any;
9. A record of adverse action by any licensing and oversight
bodies and or organizations and state human rights regulations,
if any; and
10. A record of participation in employee development activities, including orientation.
B. Each employee or contractor personnel record shall be retained in its entirety for a minimum of three years after the employee's or contractor's termination of employment.
12VAC35-105-440. Orientation of new employees, contractors, volunteers, and students.
New employees, contractors, volunteers, and students shall be oriented
commensurate with their function or job-specific responsibilities within 15
business days. Orientation to The provider shall document that the
orientation covers each of the following policies shall be documented.
Orientation shall include, procedures, and practices:
1. Objectives and philosophy of the provider;
2. Practices of confidentiality including access, duplication, and dissemination of any portion of an individual's record;
3. Practices that assure an individual's rights including orientation to human rights regulations;
4. Applicable personnel policies;
5. Emergency preparedness procedures;
[ 6. Person-centeredness; ]
[ 6. 7. ] Infection control practices
and measures; and
[ 7. 8. ] Other policies and procedures
that apply to specific positions and specific duties and responsibilities.
12VAC35-105-450. Employee training and development.
The provider shall provide training and development
opportunities for employees to enable them to perform [ fully ]
support the individuals served and to carry out the responsibilities of
their job jobs. The provider shall develop a training
policy must address that addresses the frequency of retraining on
medication administration, behavior [ management intervention ],
[ and ] emergency preparedness [ , and infection
control, to include flu epidemics ]. Training Employee
participation in training and development opportunities shall be
documented in the employee personnel records and accessible to the
department.
12VAC35-105-460. Emergency medical or first aid training.
There shall be at least one employee or contractor on duty at
each location who holds a current certificate [ , (i) ]
issued by [ a recognized the American Red Cross, the American
Heart Association, or comparable ] authority [ , ] in
standard first aid and cardiopulmonary resuscitation [ , (CPR) ]
or [ with (ii) as an ] emergency medical [ training
technician ]. A [ nurse or physician licensed
medical professional ] who holds a current professional license shall
be deemed to hold a current certificate in first aid, but not in CPR.
12VAC35-105-470. Notification of policy changes.
All employees or contractors shall be kept informed of policy changes that affect performance of duties. The provider shall have written documentation of the process used to advise employees or contractors of policy changes.
12VAC35-105-480. Employee or contractor performance evaluation.
A. The provider shall [ develop and ]
implement a [ written ] policy for evaluating employee or
and contractor performance.
B. Employee development needs and plans shall be a part of the performance evaluation.
C. The provider shall evaluate employee or and
contractor performance at least annually.
12VAC35-105-490. Written grievance policy.
The provider shall [ have implement ]
a written grievance policy and a mechanism to shall inform
employees of grievance procedures. The provider shall have documentation of
the process used to advise employees of grievance procedures.
12VAC35-105-500. Students and volunteers.
A. The provider shall [ have and ] implement
a [ written ] policy that clearly defines and communicates the requirements
for the use and responsibilities of students and volunteers including selection
and supervision.
B. The provider shall not rely on students or volunteers for the provision of direct care services. The provider staffing plan shall not include volunteers or students.
12VAC35-105-510. Tuberculosis screening.
A. Each new employee, contractor, student [ , ]
or volunteer who will have direct contact with individuals being served receiving
services shall obtain a statement of certification by a qualified licensed
practitioner indicating the absence of tuberculosis in a communicable form
within 30 days of employment or initial contact with individuals receiving
services. The employee shall submit a copy of the original screening to
the provider. A statement of certification shall not be required for an
a new employee who has separated from service with another licensed
provider with a break in service of six months or less or who is
currently working for another licensed provider. The employee must submit a
copy of the original screening to the provider.
B. All employees, contractors, students [ , ]
or volunteers in substance abuse co-occurring outpatient or substance
abuse residential treatment services shall be certified as tuberculosis
free on an annual basis by a qualified licensed practitioner.
C. Any employee, contractor, student [ , ] or volunteer who comes in contact with a known case of active tuberculosis disease or who develops symptoms of active tuberculosis disease (including, but not limited to fever, chills, hemoptysis, cough, fatigue, night sweats, weight loss [ , ] or anorexia) of three weeks duration shall be screened as determined appropriate for continued contact with employees, contractors, students, volunteers, or individuals receiving services based on consultation with the local health department.
D. An employee, contractor, student [ , ] or volunteer suspected of having active tuberculosis shall not be permitted to return to work or have contact with employees, contractors, students, volunteers [ , ] or individuals receiving services until a physician has determined that the person is free of active tuberculosis.
Article 5
Health and Safety Management
12VAC35-105-520. Risk management.
A. The provider shall designate a person responsible for risk management.
B. The provider shall [ document and ]
implement a [ written ] plan to identify, monitor, reduce
[ , ] and minimize risks associated with personal injury, infectious
disease, property damage or loss, and other sources of potential
liability.
C. As part of the plan, the The provider shall
conduct and document that a safety inspection has been performed at
least annually its own safety inspections of all each
service locations location owned, rented, or leased by
the provider. Recommendations for safety improvement shall be documented
and implemented by the provider.
D. The provider shall document serious injuries to employees, contractors, students, volunteers [ , ] and visitors. Documentation shall be kept on file for three years. The provider shall evaluate injuries at least annually. Recommendations for improvement shall be documented and implemented by the provider.
E. The risk management plan shall establish and implement
policies to identify any populations at risk for falls and to develop a
prevention/management program.
F. The provider shall develop, document and implement
infection control measures, including the use of universal precautions.
12VAC35-105-530. Emergency preparedness and response plan.
A. The provider shall develop a written emergency preparedness
and response plan for all of [ a provider's its ]
services and locations that describes [ its ] approach
to emergencies throughout the organization or community. This plan shall
include an analysis of potential emergencies that could disrupt the normal
course of service delivery including emergencies that would require expanded or
extended care over a prolonged period of time. The plan shall address:
1. Specific procedures describing mitigation, preparedness, response [ , ] and recovery strategies, actions, and responsibilities for each emergency.
2. Documentation of contact [ involvement
coordination ] with the local emergency coordinator authorities
to determine local disaster risks and community-wide plans to address different
disasters and emergency situations.
2. Analysis of the provider's capabilities and potential
hazards, including natural disasters, severe weather, fire, flooding, work
place violence or terrorism, missing persons, severe injuries, or other
emergencies that would disrupt the normal course of service delivery.
3. The process for notifying local and state authorities of the emergency and a process for contacting staff when emergency response measures are initiated.
4. Written emergency management policies outlining specific responsibilities for provision of administrative direction and management of response activities, coordination of logistics during the emergency, communications, life safety of employees, contractors, students, volunteers, visitors [ , ] and individuals receiving services, property protection, community outreach, and recovery and restoration.
4. 5. Written emergency response procedures for initiating
the response and recovery phase of the plan including a description of how,
when, and by whom the phases will be activated. This includes assessing the
situation; protecting individuals receiving services, employees, contractors,
students, volunteers, visitors, equipment [ , ] and vital
records; and restoring services. Emergency procedures shall address:
a. Communicating with employees, contractors and community
responders Warning and [ notification of
notifying ] individuals receiving services;
b. Warning and notification of individuals receiving
services Communicating with employees, contractors, and community
responders;
c. Designating alternative roles and responsibilities of staff during emergencies including to whom they will report in the provider's organization command structure and when activated in the community's command structure;
d. Providing emergency access to secure areas and opening locked doors;
d. e. Conducting evacuations to emergency
shelters or alternative sites and accounting for all individuals receiving
services;
e. f. Relocating individuals receiving
residential or inpatient services, if necessary;
f. g. Notifying family members and legal
guardians or authorized representatives;
g. h. Alerting emergency personnel and sounding
alarms;
h. i. Locating and shutting off utilities when
necessary; and
j. Maintaining a 24 hour telephone answering capability to respond to emergencies for individuals receiving services.
6. Processes for managing the following under emergency conditions:
a. Activities related to the provision of care, treatment,
and services including [ but not limited to ] scheduling,
modifying, or discontinuing services; controlling information about individuals
receiving services; providing medication; and transportation services;
b. Logistics related to critical supplies such as pharmaceuticals, food, linen, and water;
c. Security including access, crowd control, and traffic control; and
d. Back-up communication systems in the event of electronic or power failure.
7. Specific processes and protocols for evacuation of the provider's building or premises when the environment cannot support adequate care, treatment, and services.
5. 8. Supporting documents that would be needed
in an emergency, including emergency call lists, building and site maps
necessary to shut off utilities, designated escape routes, and list of major
resources such as local emergency shelters.
6. 9. Schedule for testing the implementation of
the plan and conducting emergency preparedness drills.
B. The provider shall [ develop and ]
implement periodic annual emergency preparedness and response
training for all employees, [ individuals receiving services, ]
contractors, students, and volunteers. Training This training
shall also be provided as part of orientation for new employees and
cover responsibilities for:
1. Alerting emergency personnel and sounding alarms;
2. Implementing evacuation procedures, including evacuation of individuals with special needs (i.e., deaf, blind, nonambulatory);
3. Using, maintaining, and operating emergency equipment;
4. Accessing emergency medical information for individuals receiving services; and
5. Utilizing community support services.
C. The provider shall review the emergency preparedness plan
annually and make necessary revisions. Such revisions shall be communicated to
employees, contractors, students and, volunteers, and
individuals receiving services and incorporated into training for
employees, contractors, students [ , ] and volunteers and
[ into the ] orientation of individuals to services.
D. In the event of a disaster, fire, emergency or any other
condition that may jeopardize the health, safety [ and, or ]
welfare of individuals, the provider shall take appropriate action to protect
the health, safety [ , ] and welfare of [ the ]
individuals receiving services and take appropriate actions to remedy the
conditions as soon as possible.
E. Employees, contractors, students [ , ]
and volunteers shall be knowledgeable in and prepared to implement the
emergency preparedness plan in the event of an emergency. The plan shall
include a policy regarding periodic regularly scheduled emergency
preparedness training for all employees, contractors, students [ , ] and
volunteers.
F. In the event of a disaster, fire, emergency, or any other
condition that may jeopardize the health, safety [ and, or ]
welfare of individuals, the provider should first respond and stabilize the
[ disaster/emergency disaster or emergency ]. After the
[ disaster/emergency disaster or emergency ] is
stabilized, the provider should report the [ disaster/emergency disaster
or emergency ] to the department, but no later than 72 24
hours after the incident occurs.
G. Providers of residential services shall have at all
times a three-day supply of emergency food and water for all residents and
staff. Emergency food supplies should include foods that do not require
cooking. Water supplies shall include one gallon of water [ , ]
per person [ , ] per day.
H. This [ section regulation ]
does not apply to home and noncenter-based services.
12VAC35-105-540. Access to telephone in emergencies; emergency telephone numbers.
A. Telephones shall be accessible for emergency purposes.
B. Current emergency telephone numbers and location of the
nearest hospital, ambulance service, rescue squad and other trained medical
personnel, poison control center, fire station and the police are prominently
posted near the telephones Instructions for contacting emergency
services and telephone numbers shall be prominently posted near the telephone
including [ directions to the nearest hospital and ]
how to contact provider medical personnel if appropriate.
C. This [ section regulation ] does
not apply to home and noncenter-based services and correctional facilities.
12VAC35-105-550. First aid kit accessible.
A. A well-stocked first aid kit shall be maintained and
readily accessible for minor injuries and medical emergencies at each service
location and to employees or contractors providing in-home services or
traveling with individuals. The minimum requirements of a well-stocked first
aid kit that shall be maintained include a thermometer, bandages, saline
solution, band-aids, sterile gauze, tweezers, instant ice-pack, adhesive tape,
first-aid cream, and antiseptic soap, an accessible, unexpired 30 cc
bottle of Syrup of Ipecac (for use at the direction of the Poison Control
Center or a physician), and activated charcoal (for use at the direction of the
Poison Control Center or a physician).
B. A cardiopulmonary resuscitation (CPR) face guard or mask shall be readily accessible.
12VAC35-105-560. Operable flashlights or battery lanterns.
Operable flashlights or battery lanterns shall be readily
accessible to employees and contractors in services that operate between dusk
and dawn to use in emergencies. This [ section regulation ]
does not apply to home and noncenter-based services.
12VAC35-105-580. Service description requirements.
A. The provider shall develop, implement, review [ , ]
and revise its descriptions of services offered according to the provider's
mission and shall have that information make service descriptions
available for public review.
B. The provider shall document that outline how
each service offers a structured program of care individualized
interventions and care designed to meet the individuals' physical and
emotional needs; provide protection, guidance and supervision; and meet the
objectives of any required [ service individualized services ]
plan.
C. The provider shall prepare a written description of each
service it offers. Service description elements Elements of each
service description shall include:
1. Goals Service goals;
2. Care A description of care, treatment,
training, habilitation, or other supports provided;
3. Characteristics and needs of the population individuals
to be served;
4. Contract services, if any;
5. Admission Eligibility requirements and admission,
continued stay, and exclusion criteria;
6. Termination of treatment Service termination
and discharge or transition criteria; and
7. Type and role of employees or contractors.
D. The provider shall revise a the written
service description whenever the [ operation of the ] service
[ description ] changes.
E. The provider shall not implement services that are inconsistent with its most current service description.
F. The provider shall admit only those individuals whose service needs are consistent with the service description, for whom services are available, and for which staffing levels and types meet the needs of the individuals served.
G. The provider shall provide for the physical separation of children and adults in residential and inpatient services and shall provide separate group programming for adults and children, except in the case of family services. The provider shall provide for the safety of children accompanying parents receiving services. Older adolescents transitioning from school to adult activities may participate in mental retardation (intellectual disability) day support services with adults.
G. If the provider offers substance abuse treatment
services, the H. The service description for substance abuse
treatment services shall address the timely and appropriate treatment of
[ substance abusing ] pregnant women [ with substance
abuse (substance use disorders) ].
I. If the provider plans to serve individuals as of a result of a temporary detention order to a service, prior to admitting those individuals to that service, the provider shall submit a written plan for adequate staffing and security measures to ensure the individual can be served safely within the service to the department for approval. If [ the plan is ] approved [ , ] the department will add a stipulation to the license authorizing the provider to serve individuals who are under temporary detention orders.
[ J. The provider shall have a written plan on
cultural and linguistic competency that assists the organization in delivering
culturally competent services and use the National Standards on Culturally and
Linguistically Appropriate Services (CLAS) as a primary guidance document. ]
12VAC35-105-590. Provider staffing plan.
A. The provider shall [ design and ]
implement a [ written ] staffing plan including that
includes the type types [ , and ] role
roles [ , ] and numbers of employees and
contractors [ that are ] reflects the required to
provide the service. This staffing plan shall reflect the:
1. Needs of the population individuals served;
2. Types of services offered;
3. The service description; and
4. The number Number of people to be
served at a given time.
B. The provider shall develop a written transition staffing plan for new services, added locations, and changes in capacity.
C. The provider shall meet the following staffing
requirements relate related to supervision.
1. The provider shall describe how employees, volunteers,
contractors [ , ] and student interns are to will
be supervised in the staffing plan and how that supervision will be
documented.
2. Supervision of employees, volunteers, contractors [ , ]
and student interns shall be provided by persons who have experience in working
with [ the population served individuals receiving services ]
and in providing the services outlined in the service description. In
addition, supervision of mental health services shall be performed by a QMHP
and supervision of mental retardation services shall be performed by a QMRP or
an employee or contractor with experience equivalent to the educational
requirement. Supervision of IFDDS Waiver services shall be performed by a QDDP
or an employee or contractor with equivalent experience. Supervision of Brain
Injury Waiver services or residential services shall be performed by a QBIP or
an employee or contractor with equivalent experience.
3. Supervision shall be appropriate to the services provided and the needs of the individual. Supervision shall be documented.
4. Supervision shall include responsibility for approving
assessments and individualized services plans [ , as appropriate ].
This responsibility may be delegated to an employee or contractor who is a
QMHP, QMRP, QDDP, or QBIP or who has equivalent experience meets the
qualification for supervision as defined in this [ regulation
section ].
[ 5. Supervision of mental health and substance
abuse services and co-occurring disorders shall be provided by a person who is
trained and experienced in providing psychiatric, mental health, or substance
abuse services to individuals who have a psychiatric or substance abuse
disorder diagnosis including (i) a doctor of medicine or osteopathy; (ii) a
psychiatrist who is a doctor of medicine or osteopathy specializing in
psychiatry and licensed in Virginia; (iii) a psychologist who has a master's
degree in psychology from a college or university with at least one year of
clinical experience; (iv) a social worker with at least a bachelor's degree in
human services or related field (social work, psychology, psychiatric
rehabilitation, sociology, counseling, vocational rehabilitation, human
services counseling, or other degree deemed equivalent to those described); (v)
a Registered Psychiatric Rehabilitation Provider (RPRP) registered with the
United States Psychiatric Rehabilitation Association (USPRA); (vi) a registered
nurse licensed in Virginia with at least one year of clinical experience; or
(vii) any other licensed mental health professional with at least one year of
clinical experience.
5. Supervision of mental health, substance abuse, or co-occurring services that are of an acute or clinical nature such as outpatient, inpatient, intensive in-home, or day treatment shall be provided by a licensed mental health professional or a mental health professional who is license-eligible and registered with a board of the Department of Health Professions.
6. Supervision of mental health, substance abuse, or co-occurring services that are of a supportive or maintenance nature, such as psychosocial rehabilitation, mental health supports shall be provided by a QMHP-A. An individual who is QMHP-E may not provide this type of supervision. ]
[ 6. 7. ] Supervision of
mental retardation (intellectual disability) services shall be provided by a
person with at least one year of documented experience working directly with
individuals who have mental retardation (intellectual disability) or other
developmental disabilities and holds at least a bachelor's degree in a human
services field [ including but not limited to
such as ] sociology, social work, special education, rehabilitation
counseling, nursing, or psychology. [ Experience may be substituted
for the education requirement. ]
[ 7. 8. ] Supervision of
individual and family developmental disabilities support (IFDDS) services shall
be provided by a person possessing at least one year of documented experience
working directly with individuals who have [ related
conditions developmental disabilities ] and is one of
the following: a doctor of medicine or osteopathy [ licensed in
Virginia ]; a registered nurse [ licensed in Virginia ];
or a person holding at least a bachelor's degree in a human [ service
services ] field [ including but not limited to
such as ] sociology, social work, special education, rehabilitation
counseling, or psychology. [ Experience may be substituted for
the education requirement. ]
[ 8. 9. ] Supervision of
brain injury services shall be provided at a minimum by a clinician in the
health professions [ field ] who is trained and
experienced in providing brain injury services to individuals who have a brain
injury diagnosis including: (i) a doctor of medicine or osteopathy [ licensed
in Virginia ]; (ii) a psychiatrist who is a doctor of medicine or
osteopathy specializing in psychiatry and licensed in Virginia; (iii) a
psychologist who has a master's degree in psychology from a college or
university with at least one year of clinical experience; (iv) a social worker
who has a bachelor's degree in human services or a related field (social work,
psychology, psychiatric evaluation, sociology, counseling, vocational rehabilitation,
human services counseling, or other degree deemed equivalent to those
described) from an accredited college or university with at least two years of
clinical experience providing direct services to individuals with a diagnosis
of brain injury; (v) a Certified Brain Injury Specialist; (vi) a registered
nurse licensed in Virginia with at least one year of clinical experience; or
(vii) any other licensed rehabilitation professional with one year of clinical
experience.
[ 9. Providers of intensive in-home services shall
define the nature and frequency of supervision by the LMHP provided to
employees working directly with individuals receiving services. The LMHP shall
provide direct supervision to these employees at least bi-weekly.
10. Individuals employed as supervisors prior to [the
effective date of these regulations] may supervise services based on their
experience.
11. Supervision shall include responsibility for
approving assessments and individualized services plans. This responsibility
may be delegated to an employee or contractor who meets the qualifications for
supervision as defined in these regulations. ]
D. The provider shall employ or contract with persons with
appropriate training, as necessary, to meet the specialized needs of and to ensure
the safety of individuals being served in residential services with medical or
nursing needs,; speech, language, or hearing problems;
or other needs where specialized training is necessary.
E. The provider Providers 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 services plans, crises,
staff training, and service design.
F. Direct care staff in who provide brain injury
services shall meet the qualifications of a QPPBI and successfully complete
an approved training curriculum on brain injuries within six months of
employment have at least a high school diploma and two years of experience
working with individuals with disabilities or shall have successfully completed
an approved training curriculum on brain injuries within six months of
employment.
12VAC35-105-600. Nutrition.
A. A provider preparing and serving food shall:
1. Have Implement a written plan for the
provision of food services, which ensures access to nourishing, well-balanced, [ healthful
varied, and healthy ] meals;
2. Make reasonable efforts to prepare meals that consider [ the ] cultural background, personal preferences, and food habits and that meet the dietary needs of the individuals served; and
3. Assist individuals who require assistance feeding themselves in a manner that effectively addresses any deficits.
B. Providers of residential and inpatient services shall [ develop
and ] implement a policy to monitor each individual's food consumption
[ and nutrition ] for:
1. Warning signs of changes in physical or mental status related to nutrition; and
2. Compliance with any needs determined by the individualized services plan or prescribed by a physician, nutritionist [ , ] or health care professional.
12VAC35-105-610. Community participation.
Opportunities shall be provided for individuals receiving
services Individuals receiving residential [ ,
and ] day support [ , and day treatment ]
services shall be afforded [ the opportunity
opportunities ] to participate in community activities [ that
are based on their personal interests or preferences ]. This
regulation applies to residential, day support and day treatment services. The
provider shall have written documentation that such opportunities were made
available to individuals served.
12VAC35-105-620. Monitoring and evaluating service quality.
The provider shall [ have implement ] a
mechanism written policies and procedures to monitor and evaluate service
quality and effectiveness on a systematic and ongoing basis. Input from
individuals receiving services and their authorized representatives, if
applicable, about services used and satisfaction level of participation in the
direction of service planning shall be part of the provider's quality assurance
system. The provider shall implement improvements, when indicated.
Article 2
Screening, Admission, Assessment, Service Planning [ , ]
and Orientation
12VAC35-105-630. Policies on screening, admission and
referrals. (Repealed.)
A. The provider shall establish written criteria for
admission that include:
1. A description of the population to be served;
2. A description of the types of services offered; and
3. Exclusion criteria.
B. The provider shall admit only those individuals whose
service needs are consistent with the service description, for whom services
are available, and for which staffing levels and types meet the needs of the
individuals served.
C. The provider shall complete a preliminary assessment
detailed enough to determine that the individual qualifies for admission and to
develop a preliminary individualized services plan for individuals admitted to
services. Employee or contractors responsible for screening, admitting and
referral shall have immediate access to written service descriptions and
admission criteria.
D. The provider shall assist individuals who are not
admitted to identify other appropriate services.
E. The provider shall develop and implement procedures for
screening, admitting, and referring individuals to services, to include staff
who are designated to perform these activities.
12VAC35-105-640. Screening and referral services
documentation and retention. (Repealed.)
A. The provider shall maintain written documentation of each
screening performed, including:
1. Date of initial contact;
2. Name, age, and gender of the individual;
3. Address and phone number, if applicable;
4. Presenting needs or situation to include
psychiatric/medical problems, current medications and history of medical care;
5. Name of screening employee or contractor;
6. Method of screening;
7. Screening recommendation; and
8. Disposition of individual.
B. The provider shall retain documentation for each
screening. For individuals not admitted, documentation shall be retained for
six months. Documentation shall be included in the individual's record if the
individual is admitted.
12VAC35-105-645. Initial contacts, screening, admission, assessment, service planning, orientation, and discharge.
A. The provider shall [ develop and ]
implement policies and procedures for initial contacts and screening,
admissions, and referral of individuals to other services and designate staff
to perform these activities.
B. The provider shall maintain written documentation of an individual's initial contact and screening prior to his admission including the:
1. Date of contact;
2. Name, age, and gender of the individual;
3. Address and telephone number of the individual, if applicable;
4. Reason why the individual is requesting services; and
5. Disposition of the individual including his referral to other services for further assessment, placement on a waiting list for service, or admission to the service.
C. The provider shall assist individuals who are not admitted to identify other appropriate services.
D. The provider shall retain documentation of the individual's initial contacts and screening for six months. Documentation shall be included in the individual's record if the individual is admitted to the service.
12VAC35-105-650. Assessment policy.
A. The provider shall document [ develop
and ] implement an a written assessment policy. The
policy shall define how assessments will be [ conducted and ]
documented.
B. The provider shall conduct an assessment to identify an
individual's physical, medical, behavioral, functional, and social strengths,
preferences and needs, as applicable. The assessment shall address:
1. Onset/duration of problems;
2. Social/behavioral/developmental/family history;
3. Employment/vocation/educational background;
4. Previous interventions/outcomes;
5. Financial resources and benefits;
6. Health history and current medical care needs;
7. Legal status, including guardianship, commitment and
representative payee status, and relevant criminal charges or convictions,
probation or parole status;
8. Daily living skills;
9. Social/family supports;
10. Housing arrangements; and
11. Ability to access services.
B. The provider shall [ solicit the
individual's own assessment and shall ] actively involve the
individual and authorized representative, if applicable, in the preparation of
initial and comprehensive assessments and in subsequent reassessments. In these
assessments and reassessments [ , ] the provider shall
consider the individual's needs, strengths, goals, preferences, and abilities
within the individual's cultural context.
C. The assessment policy shall designate employees or
contractors who are responsible for conducting assessments. Employees
or contractors responsible for assessments These employees or
contractors shall have experience in working with the population needs
of individuals who are being assessed and with, the
assessment tool or tools being utilized, and the provision of
services that the individuals may require.
D. Frequency of assessments.
1. A preliminary assessment shall be done prior to
admission;
2. The preliminary assessment shall be updated and finalized
during the first 30 days of service prior to completing the individualized
services plan. Longer term assessments may be included as part of the
individualized services plan. The provider shall document the reason for
assessments requiring more than 30 days.
3. Reassessments shall be completed when there is a need
based on the medical, psychiatric or behavioral status of the individual and at
least annually.
E. D. Assessment is an ongoing activity. The
provider shall make reasonable attempts to obtain previous assessments [ or
relevant history ].
E. An [ initial ] assessment
shall be [ completed 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 an initial assessment detailed enough to determine whether the
individual qualifies for admission and to [ develop
initiate ] an [ initial ] ISP for
those individuals who are admitted to the service. This [ initial ]
assessment shall assess immediate service, health [ , ]
and safety needs, and at a minimum [ address
include ] the individual's:
1. Diagnosis;
2. Presenting needs including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of problems;
3. Current medical problems;
4. Current medications;
5. Current and past substance use or abuse, including co-occurring mental health and substance abuse disorders; and
6. At-risk behavior to self and others.
F. A comprehensive assessment shall update and finalize the initial assessment. The timing for completion of the comprehensive assessment shall be based upon the nature and scope of the service but shall occur no later than [ 30 days, after admission for providers of mental health and substance abuse services and ] 60 days after admission [ for providers of mental retardation (intellectual disability) and developmental disabilities services ]. It shall address:
1. Onset and duration of problems;
2. Social, behavioral, developmental [ , ] and family history and supports;
3. Cognitive functioning including strengths and weaknesses;
4. Employment, [ vocation
vocational, ] and educational background;
5. Previous interventions and outcomes;
6. Financial resources and benefits;
7. Health history and current medical care needs, to include:
a. Allergies;
b. Recent physical complaints and medical conditions;
c. Nutritional needs;
d. Chronic conditions;
e. Communicable diseases;
f. Restrictions on physical activities if any;
g. Past serious illnesses, serious injuries, and hospitalizations;
h. Serious illnesses and chronic conditions of the individual's parents, siblings, and significant others in the same household; [ and ]
i. Current and past substance [ usage
use ] including alcohol, prescription and nonprescription
medications, and illicit drugs [ ; and. ]
[ j. Reproductive history including pregnancy
status. ]
8. Psychiatric and substance use issues including current mental health or substance use needs, presence of co-occurring disorders, history of substance use or abuse, and circumstances that increase the individual's risk for mental health or substance use issues;
9. History of abuse, neglect, sexual [ and,
or ] domestic violence, or trauma including psychological trauma;
10. Legal status including [ guardianship
authorized representative ], commitment, and representative payee
status;
11. Relevant criminal charges or convictions and probation or parole status;
12. Daily living skills;
13. Housing arrangements;
14. Ability to access services including transportation needs; and
15. As applicable, and in all residential services, fall risk, communication methods or needs, and mobility and adaptive equipment needs.
G. Providers of short-term intensive services including inpatient and crisis stabilization services shall develop policies for completing comprehensive assessments within the time frames appropriate for those services.
H. Providers of non-intensive or short-term services shall meet the requirements for the initial assessment at a minimum. Non-intensive services are services provided in jails, nursing homes, or other locations when access to records and information is limited by the location and nature of the services. Short-term services typically are provided for less than 60 days.
I. Providers may utilize standardized state or federally
sanctioned assessment tools that do not meet all the criteria of
12VAC35-105-650 as the initial or comprehensive assessment tools as long as the
tools assess the individual's health and safety issues and substantially meet
the requirements of this [ regulation section
].
J. Individuals who receive medication-only services shall be reassessed at least annually to determine whether there is a change in the need for additional services and the effectiveness of the medication.
[ K. The provider shall retain documentation for
each assessment for a period of six months. Documentation shall be included in
the individual's record if the individual is admitted.
L. The provider shall assist individuals who are not
scheduled for further assessment or who are not admitted to identify other
appropriate services. ]
12VAC35-105-660. Individualized services plan (ISP).
A. The provider shall develop a preliminary individualized
services plan for the first 30 days. The preliminary individualized services plan
shall be developed and implemented within 24 hours of admission and shall
continue in effect until the individualized services plan is developed or the
individual is discharged, whichever comes first actively involve the
individual and authorized representative, as appropriate, in the development,
review, and revision of a person-centered ISP. The individualized services
planning process shall be consistent with laws protecting confidentiality,
privacy, human rights of individuals receiving services, and rights of minors.
B. The provider shall develop an individualized services
plan for each individual as soon as possible after admission but no later than
30 days after admission. Providers of short-term services must develop and
implement a policy to develop individualized services plans within a time frame
consistent with the expected length of stay of individuals. Services requiring
longer term assessments may include the completion of those as part of the
individualized services plan as long as all appropriate services are
incorporated into the individualized services plan based on the assessment
completed within 30 days of admission and the individualized services plan is
updated upon the completion of assessment initial person-centered ISP
for the first 60 days [ for mental retardation (intellectual
disability) and developmental disabilities services or for the first 30 days
for mental health and substance abuse services ]. This ISP shall be
developed and implemented within 24 hours of admission to address immediate
service, health, and safety needs and shall continue in effect until the ISP is
developed or the individual is discharged, whichever comes first.
C. The individualized services plan shall address:
1. The individual's needs and preferences.
2. Relevant psychological, behavioral, medical,
rehabilitation and nursing needs as indicated by the assessment;
3. Individualized strategies, including the intensity of
services needed;
4. A communication plan for individuals with communication
barriers, including language barriers; and
5. The behavior treatment plan, if applicable.
D. The provider shall comply with the human rights
regulations in regard to participation in decision-making by the individual or
legally authorized representative in developing or revising the individualized
services plan.
E. The provider shall involve family members, guardian, or
others, if appropriate, in developing, reviewing, or revising, at least
annually, the individualized service plans consistent with laws protecting
confidentiality, privacy, the human rights of individuals receiving services
(see 12VAC35-115-60) and the rights of minors.
F. Employees or contractors responsible for implementation
of an individualized services plan shall demonstrate a working knowledge of the
plan's goals, objectives and strategies.
G. The provider shall designate a person who will develop
and implement individualized service plans.
H. The provider shall implement the individualized services
plan and review it at least every three months or whenever there is a revised
assessment. These reviews shall evaluate the individual's progress toward
meeting the plan's objectives. The goals, objectives and strategies of the
individualized services plan shall be updated, if indicated.
I. The individualized service plan shall be consistent with
the CSP for individuals served by the IFDDS Waiver.
J. In brain injury services, the individualized services
plan shall be reassessed and revised more frequently than annually, consistent
with the individual's course of recovery.
C. The provider shall [ develop and ]
implement a person-centered comprehensive ISP as soon as possible after
admission based upon the nature and scope of services but no later than [ 30
days after admission for providers of mental health and substance abuse
services and ] 60 days after admission [ for providers
of mental retardation (intellectual disability) and developmental disabilities
services ].
12VAC35-105-665. ISP requirements
A. The comprehensive ISP shall [ address
or include: 1. The be based on the ] individual's needs,
strengths, abilities, personal preferences, goals, and natural supports [ ;
identified in the assessment. The ISP shall include: ]
[ 2. A summary of or reference to the assessment;
3. 1. ] Relevant and attainable
goals, measurable objectives, and specific strategies for addressing each [ identifiable ]
need;
[ 4. 2. ] Services and
supports and frequency of services required to accomplish the goals including
relevant psychological, mental health, substance abuse, behavioral, medical,
rehabilitation, training, and nursing needs and supports [ as
indicated by the assessment ];
[ 5. 3. ] The role of the
individual and others in implementing the service plan;
[ 6. 4. ] A communication plan for
individuals with communication barriers, including language barriers;
[ 7. 5. ] A [ behavior
behavioral ] support or treatment plan, if applicable;
[ 8. 6. ] A safety plan that
addresses identified risks to the individual or to others, including a fall
risk plan;
[ 9. 7. ] A crisis or relapse
plan, if applicable;
[ 10. 8. ] Target dates for
accomplishment of goals and objectives [ and estimated
duration of ISP ];
[ 11. Discharge goals, if applicable; ]
[ 12. 9. ] Identification of
employees or contractors responsible for coordination and integration of
services, including employees of other agencies; and
[ 13. 10. ] Recovery plans
[ , if applicable ].
B. The ISP shall be signed and dated at a minimum by the
person responsible for implementing the plan and the individual receiving
services or the authorized representative. If the signature of the individual
receiving services or the authorized representative cannot be obtained
[ , ] the provider shall document his attempt to [ attain
obtain ] the necessary signature and the reason why he was unable
to obtain it.
C. The provider shall designate a person who will be responsible for developing, implementing, reviewing, and revising each individual's ISP in collaboration with the individual or authorized representative, as appropriate.
D. Employees or contractors who are responsible for implementing the ISP shall demonstrate a working knowledge of the objectives and strategies contained in the individual's current ISP.
E. Providers of short-term intensive services such as
inpatient and crisis stabilization services that are typically provided for
less than 30 days shall [ develop and ] implement
a policy to develop an ISP within a timeframe consistent with the length of
stay of individuals.
F. The ISP shall be consistent with the plan of care for individuals served by the IFDDS Waiver.
G. When a provider provides more than one service to an individual the provider may maintain a single ISP document that contains individualized objectives and strategies for each service provided.
H. Whenever possible the identified goals in the ISP shall be written in the words of the individual receiving services.
12VAC35-105-670. Individualized services plan requirements.
(Repealed.)
A. The individualized services plan shall include, at a
minimum:
1. A summary or reference to the assessment;
2. Goals and measurable objectives for addressing each
identified need;
3. The services and supports and frequency of service to
accomplish the goals and objectives;
4. Target dates for accomplishment of goals and objectives;
5. Estimated duration of service plan;
6. Discharge plan, where applicable; and
7. The employees or contractors responsible for coordination
and integration of services, including employees of other agencies.
B. The individualized services plan shall be signed and
dated, at a minimum, by the person responsible for implementing the plan and
the individual receiving services or the legally authorized representative. If
unable to obtain the signature of the individual receiving services or the
legally authorized representative, the provider shall document the reason.
12VAC35-105-675. Reassessments and ISP reviews.
A. Reassessments shall be completed at least annually and when there is a need based on the medical, psychiatric, or behavioral status of the individual.
B. The provider shall update the ISP at least annually. The provider shall review the ISP at least every three months [ from the date of the implementation of the ISP ] or whenever there is a revised assessment based upon the individual's changing needs or goals. These reviews shall evaluate the individual's progress toward meeting the plan's goals and objectives and the continued relevance of the ISP's objectives and strategies. The provider shall update the goals, objectives, and strategies contained in the ISP, if indicated, and implement any updates made.
12VAC35-105-680. Progress notes or other documentation.
The provider shall use signed and dated progress notes or
other documentation to document the services provided [ , ]
and the implementation of [ and outcomes the goals
and objectives ] of individualized services plans contained
in the ISP.
12VAC35-105-690. Orientation.
A. The provider shall [ develop and ]
implement a written policy regarding the orientation of individuals and the
legally their authorized representative representatives,
if applicable to services.
B. At a minimum, As appropriate to the scope and
level of services the policy shall require the [ provision to
individuals and ] the legally [ authorized ] representative
of [ representatives the ] following information, as
appropriate to the scope and level of services:
1. The mission of the provider or service;
2. Confidentiality Service confidentiality
practices and protections for individuals receiving services;
3. Human rights policies and protections and instructions on how to report violations;
4. Participation Opportunities for participation
in treatment services and discharge planning;
5. Fire safety and emergency preparedness procedures [ , if applicable ];
6. The provider's grievance procedure;
7. Service guidelines including criteria for [ admission to and ] discharge or transfer from services;
[ 8. Physical plant or building lay-out;
9. 8. ] Hours and days of operation; and
[ 10. 9. ] Availability of after-hours
service; and
[ 11. 10. ] Any charges or
fees due from the individual.
C. In addition, individuals receiving treatment services in a
correctional facilities will facility shall receive an
orientation to the facility's security restrictions.
D. The provider shall document that orientation has been
provided to individuals and the legal guardian/authorized representative the
individual and authorized representative, if applicable, received an
orientation to services.
12VAC35-105-691. Transition of individuals among service [ locations ].
A. The provider shall [ have
implement ] written procedures that define the process for transitioning
an individual between or among services [ or locations ]
operated by the provider. At a minimum the policy shall address:
1. The process by which the provider will assure continuity
of services during and following transition [ .; ]
2. The participation of the individual [ and
his family ] or [ his ] authorized
representative, as applicable, in the decision to move and in the planning for
transfer;
3. The process and timeframe for transferring the [ access to ] individual's record and ISP to the destination location;
4. The process and timeframe for [ transmitting
completing ] the transfer summary [ to the
destination location service ]; and
5. The process and timeframe for transmitting [ or
accessing ], where applicable, discharge [ and
admission ] summaries to the destination [ location
service ].
B. The transfer summary shall include at a minimum the following:
[ 1. Description of each service provided at the initial
location;
2. Description of each service to be provided at the
destination location;
3. 1. ] Reason for the
individual's transfer;
[ 4. 2. ] Documentation of
involvement by the individual [ and his family ]
or [ his ] authorized representative, as
applicable, in the decision to and planning for the transfer;
[ 5. 3. ] Current psychiatric
and [ known ] medical conditions or issues of the
individual and the identity of the individual's health care providers;
[ 6. 4. ] Updated progress of
the individual in meeting goals and objectives in his ISP;
[ 7. 5. ] Emergency medical information;
[ 8. 6. ] Dosages of all
currently prescribed medications and over-the-counter medications used by the
individual [ when prescribed by the provider or known by the case
manager ];
[ 9. 7. ] Transfer date; and
[ 10. 8. ] Signature of
employee or contractor responsible for preparing the transfer summary.
C. The transfer summary may be documented in the individual's progress notes or in information easily accessible within an electronic [ health ] record.
12VAC35-105-693. Discharge.
A. The provider 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.
B. Discharge instructions shall be provided in writing to
the individual [ and, ] his
authorized representative, [ and the successor provider, ]
as applicable. Discharge instructions shall include at a minimum medications
and dosages; names, phone 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. [ This
applies to residential and inpatient services only. ]
C. The provider shall make appropriate arrangements or referrals to all service providers identified in the discharge plan prior to the individual's scheduled discharge date.
D. The content of the discharge plan and the determination to discharge the individual shall be consistent with the ISP and the criteria for discharge.
E. The provider shall document in the individual's service record that the individual, his authorized representative, and his family members, as appropriate, have been involved in the discharge planning process.
F. A written discharge summary shall be completed within 30 days of discharge and shall include at a minimum the following:
1. Reason for the individual's admission to and discharge from the service;
2. Description of the individual's or authorized representative's participation in discharge planning;
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 have been made for future services;
6. Progress made by the individual in achieving goals and objectives identified in the ISP and summary of critical events during service provision;
7. Discharge date;
8. Discharge medications [ prescribed by the provider ], if applicable;
9. Date the discharge summary was actually written or documented; and
10. Signature of the person who prepared the summary.
Article 3
Crisis Intervention and Clinical Emergencies
12VAC35-105-700. Written policies and procedures for a
crisis or clinical emergency interventions; required elements.
A. The provider shall [ develop and ] implement
written policies and procedures for prompt intervention in the event of a
crisis or clinical a behavioral, medical, or psychiatric
emergency that occurs may occur during screening and referral or
during, at admission and, or during the period of service
provision. A clinical emergency refers to either a medical or psychiatric
emergency.
B. The policies and procedures shall include:
1. A definition of what constitutes a crisis and
clinical or behavioral, medical, or psychiatric emergency;
2. Procedures for stabilization and immediate access to immediately
accessing appropriate internal and external resources including a
provision for. This shall include a provision for obtaining
physician and mental health clinical services if the provider's or service's
on-call or back-up physician back up or mental health clinical
services are not available at the time of the emergency;
3. Employee or contractor responsibilities; and
4. Location of emergency medical information for individuals
each individual receiving services, including any advance psychiatric
or medical directive or crisis response plan developed by the individual,
which shall be readily accessible to employees or contractors on duty in
an emergency or crisis.
12VAC35-105-710. Documenting crisis intervention and clinical
emergency services.
A. The provider shall develop a method for documenting the
provision of crisis intervention and clinical emergency services.
Documentation shall include the following:
1. Date and time;
2. Nature Description of the nature of or
circumstances surrounding the crisis or emergency;
3. Name of individual;
4. Precipitating Description of precipitating
factors;
5. Interventions/treatment Interventions or treatment
provided;
6. Employees Names of employees or contractors involved
responding to or consulted during the crisis or emergency; and
7. Outcome.
B. If a crisis or clinical emergency involves an
individual who is admitted into service, documentation of the crisis
intervention documentation or provision of emergency services
shall become part of his record.
Article 4
Medical Management
12VAC35-105-720. Health care policy.
A. The provider shall [ develop and ]
implement a written policy, appropriate to the scope and level of
service that addresses provision of adequate and appropriate medical
care. This policy shall describe how:
1. Medical care needs will be assessed including circumstances that will prompt the decision to obtain a medical assessment.
2. Individualized services plans will address any medical care needs appropriate to the scope and level of service.
3. Identified medical care needs will be addressed.
[ 4. Substance abuse will be assessed.
5. 4. ] The provider manages
will manage medical care needs or responds respond to
abnormal findings.
[ 5. 6. ] The provider communicates
will communicate medical assessments and diagnostic laboratory results
to individuals the individual and authorized representatives
representative, as appropriate.
[ 6. 7. ] The provider keeps will
keep accessible to staff and contractors on duty the names,
addresses, and phone numbers of the individual's medical and
dental providers.
[ 7. 8. ] The provider ensures will
ensure a means for facilitating and arranging, as appropriate,
transportation to medical and dental appointments and medical tests, when
services cannot be provided on site.
B. The provider shall [ establish and ]
implement [ written ] policies to identify any
individuals who are at risk for falls and develop and implement a fall
prevention and management plan and program for each at risk individual.
C. Providers of residential or inpatient services shall
[ either ] provide or arrange for the provision of appropriate
medical care. A provider Providers of other services shall define
instances when it they shall provide or arrange for appropriate
medical and dental care and instances when it they shall refer
the individual to appropriate medical care.
D. The provider shall [ develop, document,
and ] implement [ written ] infection
control measures including the use of universal precautions.
E. The provider shall report outbreaks of infectious diseases to the Department of Health pursuant to § 32.1-37 of the Code of Virginia.
12VAC35-105-730. Medical information. (Repealed.)
A. The provider shall develop and implement a medical
evaluation or document its ability to obtain a medical evaluation that consists
of, at a minimum, a health history and emergency medical information.
B. A health history shall include:
1. Allergies;
2. Recent physical complaints and medical conditions;
3. Chronic conditions;
4. Communicable diseases;
5. Handicaps or restriction on physical activities, if any;
6. Past serious illnesses, serious injuries and
hospitalizations;
7. Serious illnesses and chronic conditions of the
individual's parents, siblings and significant others in the same household;
8. Current and past drug usage including alcohol,
prescription and nonprescription medications, and illicit drugs; and
9. Sexual health and reproductive history.
12VAC35-105-740. Physical examination [ for residential and inpatient services ].
A. [ The provider shall develop in consultation
with a qualified practitioner and implement a policy on the provision of
physical examinations in consultation with a qualified practitioner. ]
Providers of residential [ or inpatient ] services shall
administer or obtain results of physical exams within 30 days of an
individual's admission. [ The examination must have been conducted
within one year of admission to the service. ] Providers of inpatient
services shall administer physical exams within 24 hours of an individual's
admission.
B. A physical examination shall include, at a minimum:
1. General physical condition (history and physical);
2. Evaluation for communicable diseases;
3. Recommendations for further diagnostic tests and treatment, if appropriate;
4. Other examinations that may be indicated, if
appropriate; and
5. The date of examination and signature of a qualified practitioner.
C. Locations designated for physical examinations shall ensure individual privacy.
[ D. The provider shall make arrangements for the
timely receipt of any further diagnostic tests, treatments, or examinations
that may be indicated by the physical examination.
E. D. ] The provider shall [ document
review and follow-up with the ] results of the physical examination
and of any follow-up diagnostic tests, treatments, or examinations in the
individual's [ records record ].
12VAC35-105-750. Emergency medical information.
A. The provider shall maintain the following emergency medical information for each individual:
1. If available, the name, address, and telephone number of:
a. The individual's physician; and
b. [ A relative, The ] legally
authorized representative [ , ] or other person to be
notified;
2. Medical insurance company name and policy or Medicaid,
Medicare [ , ] or CHAMPUS number, if any; and
3. Currently prescribed medications and over-the-counter medications used by the individual;
4. Medication and food allergies;
5. History of substance abuse;
6. Significant medical problems or conditions;
7. Significant ambulatory or sensory problems;
8. Significant communication problems; and
8. 9. Advance directive, if one exists.
B. Current emergency medical information shall be readily available to employees or contractors wherever program services are provided.
Article 5
Medication Management Services
12VAC35-105-770. Medication management.
A. The provider shall [ develop and ] implement
written policies addressing:
1. The safe administration, handling, storage, and disposal of medications;
2. The use of medication orders;
3. The handling of packaged medications brought by individuals from home or other residences;
4. Employees or contractors who are authorized to administer medication and training required for administration of medication;
5. The use of professional samples; and
6. The window within which medications can be given in relation to the ordered [ or established ] time of administration.
B. Medications shall be administered only by persons who are authorized [ to do so ] by state law.
C. Medications shall be administered only to the individuals for whom the medications are prescribed and shall be administered as prescribed.
D. The provider shall maintain a daily log of all medicines received and refused by each individual. This log shall identify the employee or contractor who administered the medication, the name of the medication and dosage administered or refused, and the time the medication was administered or refused.
E. If the provider administers medications or supervises self-administration of medication in a service, a current medication order for all medications the individual receives shall be maintained on site.
F. The provider shall promptly dispose of discontinued drugs, outdated drugs, and drug containers with worn, illegible, or missing labels according to the applicable regulations of the Virginia Board of Pharmacy.
12VAC35-105-790. Medication administration and storage or pharmacy operation.
A. The A provider responsible for medication
administration and medication storage or pharmacy operations shall comply with:
1. The Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia);
2. The Virginia Board of Pharmacy regulations [ (18VAC110-20) ];
3. The Virginia Board of Nursing regulations [ and Medication
Administration Curriculum (18VAC90-20-370 through 18VAC90-20-390) ];
and
4. Applicable federal laws and regulations relating to controlled substances.
B. The A provider responsible for medication
administration and storage or pharmacy operation shall provide in-service
training to employees and consultation to individuals or legally and
authorized representatives on issues of basic pharmacology including medication
side effects.
Article 6
Behavior Management Interventions
12VAC35-105-800. Policies and procedures on behavior management
techniques interventions and supports.
A. The provider shall [ develop and ] implement
[ written ] policies and procedures that describe the use of
behavior management techniques interventions, including [ ,
but not limited to, ] seclusion, restraint, and time out. The
policies and procedures shall:
1. Be consistent with applicable federal and state laws and regulations;
2. Emphasize positive approaches to behavior management interventions;
3. List and define behavior management techniques interventions
in the order of their relative degree of intrusiveness or restrictiveness and
the conditions under which they may be used in each service for each
individual;
4. Protect the safety and well-being of the individual at all times, including during fire and other emergencies;
5. Specify the mechanism for monitoring the use of behavior management
techniques interventions; and
6. Specify the methods for documenting the use of behavior management
techniques interventions.
B. The behavior management policies and procedures shall be
developed, implemented, and monitored by employees or contractors trained in
behavior management programming Employees and contractors trained in
behavior support interventions shall implement and monitor all behavior
interventions.
C. Policies and procedures related to behavior management
shall be available to individuals, their families, guardians and advocates
except that it does not apply to services provided in correctional facilities
interventions shall be available to individuals, their families, authorized
representatives, and advocates. Notification of policies does not need to occur
in correctional facilities.
D. Individuals receiving services shall not discipline,
restrain, seclude [ , ] or implement behavior management
techniques interventions on other individuals receiving services.
E. Injuries resulting from or occurring during the
implementation of behavior management techniques interventions
shall be recorded in the clinical individual's services record
and reported to [ the assigned human rights advocate and ] the
employee or contractor responsible for the overall coordination of services.
12VAC35-105-810. Behavioral treatment plan.
A [ written ] behavioral treatment plan
may be developed as part of the individualized services plan in response to behavioral
needs identified through the assessment process. A behavioral treatment plan
may include restrictions only if the plan has been developed according to
procedures outlined in the human rights regulations. Behavioral A
behavioral treatment plan shall be developed, implemented,
and monitored by employees or contractors trained in behavioral treatment.
12VAC35-105-820. Prohibited actions.
The following actions shall be prohibited:
1. Prohibition of contacts and visits with [ the individual's ] attorney, probation officer, placing agency representative, minister or chaplain;
2. Any action that is humiliating, degrading, or abusive;
[ 3. Corporal punishment; ]
[ 4. 3. ] Subjection to unsanitary
living conditions;
[ 5. 4. ] Deprivation of opportunities
for bathing or access to toilet facilities except as ordered by a licensed
physician for a legitimate medical purpose and documented in the individual's
record;
[ 6. 5. ] Deprivation of appropriate
services and treatment;
[ 7. 6. ] Deprivation of health care;
[ 8. 7. ] Administration of laxatives,
enemas, or emetics except as ordered by a physician or other professional
acting within the scope of his license for a legitimate medical purpose and
documented in the individual's record;
[ 9. 8. ] Applications of aversive
stimuli except as permitted pursuant to other applicable state regulations;
[ 10. 9. ] Limitation on contacts with
regulators, advocates or staff attorneys employed by the department or the Department
for the Rights of Virginians with Disabilities Virginia Office for
Protection and Advocacy.
[ 11. 10. ] Deprivation of drinking
water or food necessary to meet an individual's daily nutritional needs except
as ordered by a licensed physician for a legitimate medical purpose and documented
in the individual's record;
[ 12. 11. ] Prohibition on contacts and
or visits with family or legal guardian an authorized
representative except as permitted by other applicable state regulations or
by order of a court of competent jurisdiction;
[ 13. 12. ] Delay or withholding of
incoming or outgoing mail except as permitted by other applicable state and
federal regulations or by order of a court of competent jurisdiction; and
[ 14. 13. ] Deprivation of
opportunities for sleep or rest except as ordered by a licensed physician for a
legitimate medical purpose and documented in the individual's record.
12VAC35-105-830. Seclusion, restraint, and time out.
A. The use of seclusion, restraint, and time out shall comply with applicable federal and state laws and regulations and be consistent with the provider's policies and procedures.
B. Devices used for mechanical restraint shall be designed specifically for behavior management of human beings in clinical or therapeutic programs.
C. Application of time out, seclusion, [ and
or ] restraint shall be documented in the individual's record and
[ , at a minimum, ] include the following:
1. Physician's order [ for seclusion or mechanical restraint or chemical restraint ];
2. Date and time;
3. Employees or contractors involved;
4. Circumstances and reasons for use, including
[ but not limited to ] other behavior management
techniques attempted;
5. Duration;
6. Type of technique used; and
7. Outcomes, including documentation of debriefing of the individual and staff involved following the incident.
12VAC35-105-840. Requirements for seclusion room.
A. The room used for seclusion shall meet the design
requirements for buildings used for detention or seclusion of [ persons
individuals ].
B. The seclusion room shall be at least six feet wide and six feet long with a minimum ceiling height of eight feet.
C. The seclusion room shall be free of all protrusions, sharp
corners, hardware, fixtures or other devices which may cause injury to the occupant
individual.
D. Windows in the seclusion room shall be so constructed as to
minimize breakage and otherwise prevent the occupant individual
from harming himself.
E. Light fixtures and other electrical receptacles in the
seclusion room shall be recessed or so constructed as to prevent the occupant
individual from harming himself. Light controls shall be located outside
the seclusion room.
F. Doors to the seclusion room shall be at least 32 inches wide, shall 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.
G. The seclusion room shall contain only a mattress with a washable mattress covering designed to avoid damage by tearing.
H. The seclusion room shall maintain temperatures appropriate for the season.
I. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.
Article 7
Continuity of Service and Discharge
12VAC35-105-850. Transition of individuals among services.
(Repealed.)
A. The provider shall have written procedures to define the
process for the transition of an individual among services of the provider. At
a minimum, the policy will address:
1. Continuity of service;
2. Participation of the individual and his family;
3. Transfer of the individual's record;
4. Transfer summary; and
5. Where applicable, discharge and admission summaries.
B. The transfer summary will include at a minimum:
1. The originating service;
2. The destination service;
3. Reason for transfer;
4. Current psychiatric and medical condition of the
individual;
5. Updated progress on meeting the goals and objectives of
the ISP;
6. Medications and dosages in use;
7. Transfer date; and
8. Signature of employee or contractor responsible for
preparing the transfer summary.
12VAC35-105-860. Discharge. (Repealed.)
A. The provider shall have written policies and procedures regarding
the discharge of individuals from the service and termination of services.
These policies and procedures shall include medical or clinical criteria for
discharge.
B. Discharge instructions shall be provided, in writing, to
the individual or his legally authorized representative or both. Discharge
instructions shall include, at a minimum, medications and dosages, phone
numbers and addresses of any providers to whom the individual is referred,
current medical issues, conditions, and the identity of health care providers.
This regulation applies to residential and inpatient services.
C. The provider shall make appropriate arrangements or
referrals to all services identified by the discharge plan prior to the
individual's scheduled discharge date.
D. Discharge planning and discharge shall be consistent
with the individualized services plan and the criteria for discharge.
E. The individual's, the individual's legally authorized
representative and the individual's family's involvement in discharge planning
shall be documented in the individual's service record.
F. A written discharge summary shall be completed within 30
days of discharge and shall include, at a minimum, the:
1. Reason for admission and discharge;
2. Individual's participation in discharge planning;
3. Individual's level of functioning or functional
limitations, if applicable;
4. Recommendations on procedures, activities, or referrals
to assist the individual in maintaining or improving functioning and increased
independence and the status, location and arrangements for future services that
have been made;
5. Progress made achieving the goals and objectives
identified in the individualized services plan and summary of critical events
during service provision;
6. Discharge date;
7. Discharge medications, if applicable;
8. Date the discharge summary was actually
written/documented; and
9. Signature of person who prepared summary.
Part V
Records Management
12VAC35-105-870. [ Written Paper ] and
electronic records management policy.
A. The provider shall [ develop and ]
implement a written [ and electronic ] records
management policy that shall describe describes confidentiality,
accessibility, security, and retention of [ paper and electronic ]
records pertaining to individuals, including:
1. Access and limitation of access, duplication and,
or dissemination of individual information only to persons legally
who are authorized to access such information according to
federal and state laws;
2. Storage, processing [ , ] and handling of active and closed records;
3. Storage, processing [ , ] and handling of electronic records;
4. Security measures to that protect records from
loss, unauthorized alteration, inadvertent or unauthorized access, disclosure
of information, and transportation of records between service sites; physical
and data security controls shall exist for electronic records;
5. Strategies for service continuity and record recovery from interruptions that result from disasters or emergencies including contingency plans, electronic or manual back-up systems, and data retrieval systems;
6. Designation of the person responsible for records management; and
6. 7. Disposition of records in the event that
the service ceases operation. If the disposition of records would involve
involves a transfer to another provider, the provider shall have a
written agreement with that provider.
B. The records management policy shall be consistent with applicable state and federal laws and regulations including:
1. Section 32.1-127.1:03 of the Code of Virginia;
2. 42 USC § 290dd;
3. 42 CFR Part 2; and
4. The Health Insurance Portability and Accountability
Act (Public Law 104-191 , 42 [ 45 USC § 300gg et seq. ]
) and implementing regulations (42 CFR Part 146) (45 CFR Parts 160,
162, and 164).
12VAC35-105-880. Documentation policy.
A. The provider shall define, by policy, all records it maintains that address an individual's care and treatment and what each record contains.
B. The provider shall define, by policy, and implement
a system of documentation which that supports appropriate service
planning, coordination, and accountability. At a minimum this policy shall
outline:
1. The location of the individual's record;
2. Methods of access by employees or contractors to the individual's record; and
3. Methods of updating the individual's record by employees or contractors including the frequency and format of updates.
C. Entries in the individual's record shall be current, dated,
and authenticated by the person persons making the entry entries.
[ Errors For paper records, errors ] shall be corrected
by striking through [ and initialing ] the incorrect
information [ and initialing the correction ]. If
records are electronic, the provider shall [ develop and ] implement
a written policy to identify [ to include the
identification of errors and corrections on the identification of
corrections ] of to the record.
12VAC35-105-890. Individual's service record.
A. There shall be a [ single, ] separate
primary record for each individual [ or family ] admitted
for service. A separate record shall be maintained for each family member who
is receiving individual treatment.
B. All individuals admitted to the service shall have
identifying information on the face sheet readily accessible in
the individual's service record. Identifying information on a standardized
face sheet or sheets shall include the following:
1. Identification number unique for the individual;
2. Name of individual;
3. Current residence, if known;
4. Social security number;
5. Gender;
6. Marital status;
7. Date of birth;
8. Name of legal guardian or authorized representative,
if applicable;
9. Name, address, and telephone number for emergency contact;
10. Adjudicated legal incompetency or legal incapacity, if applicable; and
11. Date of admission to service.
C. In addition to the face sheet, an individual's
service record shall contain, at a minimum:
1. Screening documentation;
2. Assessments;
3. Medical evaluation, as applicable to the service;
4. Individualized services plans and reviews;
5. Progress notes; and
6. A discharge summary, if applicable.
12VAC35-105-900. Record storage and security.
A. When not in use, active and closed [ paper ] records shall be stored in a locked cabinet or room.
B. Physical and data security controls shall exist for to
protect electronic records.
12VAC35-105-910. Retention of individual's service records.
[ A. An Unless otherwise specified by state or
federal requirements, the The ] provider shall retain an
individual's service records shall be kept record for [ a
minimum of three years after his discharge date or date of last
contact unless otherwise specified by state or federal requirements the
time period specified by state or federal requirements ].
[ B. Permanent information kept on each individual shall
include The provider shall retain the following individual information
permanently:
1. Individual's name;
2. Social security number;
3. Date of individual's birth;
4. Dates of admission and discharge, and
5. Name and address of legal guardian authorized
representative, if any. ]
Part VI
Additional Requirements for Selected Services
Article 1
[ Medication Assisted Treatment ( ] Opioid Treatment Services
[ ) ]
12VAC35-105-925. Standards for the evaluation of [ the
need for ] new licenses for providers of services to [ persons
individuals ] with opioid addiction.
A. Applicants requesting an initial license to provide a new
service for the treatment of opioid addiction through the use of methadone or
any other opioid treatment medication or controlled substance shall
supply information to demonstrate the department that demonstrates
the [ need for, and ] appropriateness of [ , ] the
proposed service in accordance with this section.
[ B. Applicants shall demonstrate that the geographic
and demographic parameters of the service area are reasonable and the proposed
service is expected to serve a sufficient number of individuals to justify the
service as documented in subsection D of this section. For purposes of
demonstrating need, applicants shall define a service area that is located
entirely in Virginia and does not extend more than 100 miles from the proposed
location of the service. Applicants also shall identify the number of
individuals they seek to be licensed to serve.
C. Applicants shall submit admission policies that give
priority to individuals residing in the service area for admission and
placement on waiting lists.
D. Applicants shall demonstrate that there are persons
residing in their service areas who have an opioid addiction who would benefit
from the proposed service. The following information may be used by the
applicant to document that individuals in the service area are known or
reasonably expected to need the proposed service:
1. Numbers of persons on waiting lists for admission to any
existing opioid addiction or other public substance abuse treatment program in
the service area for the most recent available 12-month period;
2. Numbers of opioid use disorder cases (e.g., overdoses)
originating from the proposed service area that have been treated in hospital
emergency rooms for the most recent available 12-month period;
3. Projections of the number of persons in the service area
who are likely to obtain services for opioid addiction, based on drug-use
forecasting data;
4. Data reported on suicidal and accidental deaths related
to opioid use in the proposed service area for the most recent available
12-month period;
5. Data regarding arrests from local law-enforcement
officials in the proposed service area related to illicit opioid activities;
6. Data on communicable diseases for the proposed service
area related to injection drug abuse (e.g. HIV, AIDS, TB, and Hepatitis B and
C);
7. Data on the availability of any evidence-based
alternative service or services that have been proven effective in the
treatment of opioid addiction and that are accessible to persons within the
proposed service area, including services provided by physicians' offices; and
8. Letters of support from citizens, governmental officials,
or health care providers, that indicate that there are conditions or problems
associated with substance abuse in the community that demonstrate a need for
opioid treatment services in the service area.
E. The department shall determine whether a need exists for
the proposed service based on the documentation provided in accordance with
subsection D of this section and the consideration of the following standards:
1. Whether there are a sufficient number of persons in the
proposed service area who are likely to need the specific opioid treatment
service that the applicant intends to provide;
2. Whether the data indicate that evidence-based service
capacity in the service area is not responsive to or sufficient enough to meet
the needs of individuals with opioid addiction; and
3. Whether there is documentation of support to confirm the
need for the proposed service in the proposed service area.
F. B. ] The proposed site of the service
shall comply with § 37.2-406 of the Code of Virginia and, with the exception of
services that are proposed to be located in Planning District 8, shall not be
located within one-half mile of a public or private licensed day care center or
a public or private K-12 school.
[ G. C. ] In jurisdictions without
zoning ordinances, the department shall request that the local governing body
advise it as to whether the proposed site is suitable for and compatible with
use as an office and the delivery of health care services. The department shall
make this request when it notifies the local governing body of a pending
application.
[ H. D. ] Applicants shall demonstrate
that the building or space to be used to provide the proposed service is
suitable for the treatment of opioid addiction by submitting documentation of
the following:
1. The proposed site complies with the requirements of the local building regulatory entity;
2. The proposed site complies with local zoning laws or ordinances, including any required business licenses;
3. In the absence of local zoning ordinances, the proposed site is suitable for and compatible with use as offices and the delivery of health care services;
4. In jurisdictions where there are no parking ordinances, the proposed site has sufficient off-street parking to accommodate the needs of the individuals being served and prevent the disruption of traffic flow;
5. The proposed site can accommodate individuals during periods of inclement weather;
6. The proposed site complies with the Virginia Statewide Fire Prevention Code; and
7. The applicant has a written plan to ensure security for storage of methadone at the site, which complies with regulations of the Drug Enforcement Agency (DEA), and the Virginia Board of Pharmacy.
[ I. E. ] Applicants shall submit
information to demonstrate that there are sufficient personnel available to
meet the following staffing requirements and qualifications:
1. The program director shall be licensed or certified by the
applicable Virginia health regulatory board or by a nationally recognized
certification board [ , ] or eligible for this license or
certification with relevant training, experience, or both, in the treatment of
[ persons individuals ] with opioid addiction;
2. The medical director shall be a board-certified addictionologist
or have successfully completed or will complete within one year [ , ] a
course of study in opiate addiction that is approved by the department;
3. A minimum of one pharmacist;
4. Nurses;
5. Counselors shall be licensed or certified by the applicable
Virginia health regulatory board or by a nationally recognized certification
board [ , ] or eligible for this license or
certification; and
6. Personnel to provide support services.
[ J. F. ] Applicants shall submit a
description for the proposed service that includes:
1. Proposed mission, philosophy, and goals of the provider;
2. Care, treatment, and services to be provided, including a comprehensive discussion of levels of care provided and alternative treatment strategies offered;
3. Proposed hours and days of operation;
4. Plans for on-site security; and
5. A diversion control plan for dispensed medications, including policies for use of drug screens.
[ K. G. ] Applicants shall, in
addition to the requirements of 12VAC35-105-580 C 2, provide documentation of
their capability to provide the following services and support directly or by
arrangement with other specified providers when such services and supports are
(i) requested by an individual being served or (ii) identified as an individual
need, based on the assessment conducted in accordance with 12VAC35-105-60 B and
included in the individualized services plan:
1. Psychological services;
2. Social services;
3. Vocational services;
4. Educational services; and
5. Employment services.
[ L. H. ] Applicants shall submit
documentation of contact with community services boards or behavioral health
authorities in their service areas to discuss [ its their ]
plans for operating in the area and to develop joint agreements, as
appropriate.
[ M. I. ] Applicants shall
provide policies and procedures that [ require every six months ]
each individual served to be assessed [ every six months ] by
the treatment team to determine if that individual is appropriate for safe and
voluntary medically supervised withdrawal, alternative therapies including
other medication assisted treatments, or continued federally approved
pharmacotherapy treatment for opioid addiction.
[ N. J. ] Applicants shall submit
policies and procedures describing services they will provide to individuals
who wish to discontinue opioid treatment services.
[ O. K. ] Applicants shall provide
assurances that the service will have a community liaison responsible for
developing and maintaining cooperative relationships with community
organizations, other service providers, local law enforcement, local government
officials, and the community at large.
[ P. L. ] The department [ ,
including the Office of Licensing, Office of Human Rights, or Office of
Substance Abuse Services, ] shall conduct announced and unannounced
reviews and complaint investigations, in collaboration with the state
methadone authority, Virginia Board of Pharmacy, and DEA to
determine compliance with the regulations.
12VAC35-105-930. Registration, certification or accreditation.
A. The opioid treatment service shall maintain current registration or certification with:
1. The Federal federal Drug Enforcement
Administration;
2. The federal Department of Health and Human Services; and
3. The Virginia Board of Pharmacy.
B. If required by federal regulations, a A
provider of opioid treatment services shall [ be required to ] maintain
accreditation with an entity approved under federal regulations.
12VAC35-105-940. Criteria for involuntary termination from treatment.
A. The provider shall establish criteria for involuntary termination from treatment that describe the rights of the individual receiving services and the responsibilities and rights of the provider.
B. The provider shall establish a grievance procedure as part of the rights of the individual.
C. On admission, the individual shall be given a copy of the criteria and shall sign a statement acknowledging receipt of same. The signed acknowledgement shall be maintained in the individual's record.
D. Upon admission and annually all individuals shall sign an authorization for disclosure of information to allow programs access to the Virginia Prescription Monitoring System. Failure to comply shall be grounds for nonadmission to the program.
12VAC35-105-950. Service operation schedule.
A. The service's days of operation shall meet the needs of the
population individuals served. If the service dispenses or administers
a medication requiring daily dosing, the service shall operate seven days a
week, 12 months a year, except for official state holidays. Prior approval from
the state methadone authority shall be required for additional closed
days.
B. The service may close on Sundays if the following criteria are met:
1. The provider develops and implements policies and
procedures that address recently inducted individuals receiving services,
individuals not currently on a stable dose of medication, patients that present
noncompliance treatment behaviors, and individuals who previously picked up
[ take-homes take-home medications ] on
Sundays, security of take-home [ medication ] doses,
and health and safety of individuals receiving services.
2. The provider receives prior approval from the state methadone authority for Sunday closings.
3. Once approved, the provider shall notify individuals
receiving services in writing at least 30 days in advance of their intent to
close on Sundays. The notice shall address the risks to the individuals and the
security of take-home medications. All individuals shall receive an orientation
addressing take-home policies and procedures, and this orientation shall be
documented in the [ patient individual's ]
record prior to receiving take-home medications.
4. The provider shall establish procedures for emergency access to dosing information 24 hours a day, seven days a week. This information may be provided via an answering service, pager, or other electronic measures. Information needed includes the individual's last dosing time and date, and dose.
C. Medication dispensing hours shall include at least two hours each day of operation outside normal working hours, i.e., before 9 a.m. and after 5 p.m. The state methadone authority may approve an alternative schedule if that schedule meets the needs of the population served.
12VAC35-105-960. Physical examinations.
A. The individual shall have a complete physical [ evaluation
examination ] prior to admission to the service unless the individual
is transferring from another licensed opioid agonist service. [ A full
physical examination, including the The ] results of serology
and other tests [ , ] shall be [ completed available ]
within 14 days of admission.
B. Physical exams of each individual shall be completed annually or more frequently if there is a change in the individual's physical or mental condition.
C. The provider shall maintain the report of the individual's physical examination in the individual's service record.
D. On admission, all individuals shall be [ tested offered
testing ] for AIDS/HIV. The individual may sign a notice of refusal
without prejudice.
E. The provider shall coordinate treatment services for individuals who are prescribed benzodiapines and prescription narcotics with the treating physician. The coordination shall be the responsibility of the provider's physician and shall be documented.
12VAC35-105-970. Counseling sessions.
The provider shall conduct face-to-face counseling sessions
(either individual or group) at least every two weeks for the first year of an
individual's treatment and every month in the second year of the
individual's treatment. After two years, the number of face-to-face
counseling sessions that an individual receives shall be based on the
individual's progress in treatment. Absences The failure of an
individual to participate in counseling sessions shall be addressed as part
of the overall treatment process.
12VAC35-105-980. Drug screens.
A. The provider shall perform at least eight random drug screens during a 12-month period unless the conditions in subdivision B of this subsection apply;
B. Whenever an individual's drug screen indicates continued illicit drug use or when clinically and environmentally indicated, random drug screens shall be performed weekly.
C. Drug screens shall be analyzed for opiates, methadone (if ordered),
benzodiazepines [ , ] and cocaine. In addition, drug
screens for other drugs with that have the potential for
addiction shall be performed when clinically and environmentally indicated.
D. The provider shall [ develop and ] implement
a [ written ] policy on how the results of drug screens
shall be used to direct treatment.
12VAC35-105-990. Take-home medication.
A. Prior to dispensing regularly scheduled take-home medication, the provider shall ensure the individual demonstrates a level of current lifestyle stability as evidenced by the following:
1. Regular clinic attendance, including dosing and participation in counseling or group sessions;
2. Absence of recent alcohol abuse and [ other ] illicit
drug use;
3. Absence of significant behavior problems; and
4. Absence of recent criminal activities, charges [ , ] or convictions;
5. Stability of the individual's home environment and social relationships;
6. Length of time in treatment;
7. Ability to assure take-home medications are safely stored; and
8. Demonstrated rehabilitative benefits of take-home medications outweigh the risks of possible diversion.
B. The provider shall educate the individual on the safe transportation and storage of take-home medication.
12VAC35-105-1000. Preventing duplication of medication services.
To prevent duplication of opioid medication services to an
individual, the provider shall have [ develop and ]
implement a [ written ] policy and implement
procedures to contact for contacting every opioid treatment
service within a 50-mile radius before admitting an individual.
12VAC35-105-1010. Guests.
A. No medication shall be dispensed The provider
shall not dispense medication to any guest unless the guest has been receiving
such medication services from another provider and documentation from such
that provider has been received prior to dispensing medication.
B. Guests may receive medication for up to 28 days. To continue receiving medication after 28 days, the guest must be admitted to the service. Individuals receiving guest medications as part of a residential treatment service may exceed the 28-day maximum time limit.
12VAC35-105-1020. Detoxification prior to involuntary discharge.
Individuals The provider shall give an individual
who are is being involuntarily discharged shall be given an
opportunity to detoxify from opioid agonist medication not less than 10 days or
not more than 30 days prior to his discharge from the service, unless
the state methadone authority has granted an exception.
12VAC35-105-1040. Emergency preparedness plan.
The provider's emergency preparedness plan shall include provision for the continuation of opioid treatment in the event of an emergency or natural disaster.
12VAC35-105-1050. Security of opioid agonist medication supplies.
A. At a minimum, the provider shall secure opioid
agonist medication supplies shall be secured as follows: by
restricting access to medication areas to medical or pharmacy personnel.
1. Admittance to the medication area shall be restricted to
medical or pharmacy personnel;
2. B. Medication inventory shall be
reconciled The provider shall reconcile the medication inventory
monthly; and.
3. C. Inventory The provider shall
keep inventory records, including the monthly reconciliation, shall be
kept for three years.
B. D. The provider shall maintain a current plan
to control the diversion of medication to unprescribed or illegal uses.
Article 2
[ Medically ] Managed Withdrawal Services
12VAC35-105-1055. Description of level of care provided.
In the service description the provider shall describe the level of services and the medical management provided.
Article 2
Social Detoxification Services
12VAC35-105-1060. Cooperative agreements with community agencies.
The provider shall establish cooperative agreements with other community agencies to accept referrals for treatment, including provisions for physician coverage if not provided on-site, and emergency medical care. The agreements shall clearly outline the responsibility of each party.
12VAC35-105-1080. Direct-care training for providers of detoxification services.
A. The provider shall document staff training in the areas of:
1. Management of withdrawal; and
2. First responder training; or.
3. First aid and CPR training.
B. New employees or contractors shall be trained within 30
days of employment. Untrained employees or contractors shall not be solely responsible
for the care of individuals.
12VAC35-105-1090. Minimum number of employees or contractors on duty.
In detoxification service locations, at least two employees or contractors shall be on duty at all times. If the location is within or contiguous to another service location, at least one employee or contractor shall be on duty at the location with trained backup employees or contractors immediately available. In other managed withdrawal settings the number of staff on duty shall be appropriate for the services offered and individuals served.
12VAC35-105-1100. Documentation.
Employees or contractors on each shift shall document
services provided and significant events in the individual's record on each
shift.
12VAC35-105-1110. Admission assessments.
During the admission process, providers of detoxification
managed withdrawal services shall:
1. Identify individuals with a high-risk for medical complications or who may pose a danger to themselves or others;
2. Assess substances used and time of last use;
3. Determine time of last meal;
4. Administer a urine screen;
6. 5. Analyze blood alcohol content or administer
a breathalyzer; and
7. 6. Record vital signs.
Article 3
Services in Department of Corrections Correctional Facilities
12VAC35-105-1140. Clinical and security coordination.
A. The provider shall have formal and informal methods of resolving procedural and programmatic issues regarding individual care arising between the clinical and security employees or contractors.
B. The provider shall demonstrate ongoing communication between clinical and security employees to ensure individual care.
C. The provider shall provide cross-training for the clinical and security employees or contractors that includes:
1. Mental health, mental retardation (intellectual disability), and substance abuse education;
2. Use of clinical and security restraints; and
3. Channels of communication.
D. Employees or contractors shall receive periodic in-service training, and have knowledge of and be able to demonstrate the appropriate use of clinical and security restraint.
E. Security and behavioral assessments shall be completed at the time of admission to determine service eligibility and at least weekly for the safety of individuals, other persons, employees, and visitors.
F. Personal grooming and care services for individuals shall be a cooperative effort between the clinical and security employees or contractors.
G. Clinical needs and security level shall be considered when arrangements are made regarding privacy for individual contact with family and attorneys.
H. Living quarters shall be assigned on the basis of the individual's security level and clinical needs.
I. An assessment of the individual's clinical condition and needs shall be made when disciplinary action or restrictions are required for infractions of security measures.
J. Clinical services consistent with the individual's condition and plan of treatment shall be provided when security detention or isolation is imposed.
12VAC35-105-1150. Other requirements for correctional facilities.
A. Group bathroom facilities shall be partitioned between toilets and urinals to provide privacy.
B. If uniform clothing is required, the clothing shall be properly fitted, climatically suitable, durable, and presentable.
C. Financial compensation for work performed shall be determined by the Department of Corrections. Personal housecleaning tasks may be assigned without compensation to the individual.
D. The use of audio equipment, such as televisions, radios, and record players, shall not interfere with therapeutic activities.
E. Aftercare planning for individuals nearing the end of incarceration shall include a provision for continuing medication and follow-up services with area community services to facilitate successful reintegration into the community including specific appointment provided to the inmate no later than the day of release.
Article 4
Sponsored Residential Homes Services
12VAC35-105-1160. Sponsored residential home information.
Providers of sponsored residential home services shall maintain the following information:
1. Names and ages of residential sponsors;
2. Date of sponsored residential home agreement;
3. The maximum number of individuals that can be placed in the home at a given time;
4. Names and ages of all other individuals who are not
receiving services, but are residing in a sponsored residential
home;
5. Address and telephone number of the sponsored residential home; and
6. All Names of all staff employed in the home,
including on-call and substitute staff.
12VAC35-105-1170. Sponsored residential home agreements.
A. The provider shall [ develop and ] maintain
a written agreement with residential home sponsors. Sponsors are individuals
persons who provide the home where the service is located and are
directly responsible for the provision of services. The agreement shall include
the:
1. Be available for inspection by the licensing specialist;
and Provider's responsibilities;
2. Include a provision for granting the right of entry to
state licensing specialists or human rights advocates to investigate
complaints. Sponsor's responsibilities;
3. Scope of services;
4. Supervision;
5. Compensation;
6. Training; and
7. Reporting requirements and procedures.
B. The agreement shall be available for inspection by the licensing specialist and shall include a provision for granting the right of entry to state licensing specialists or human rights advocates to conduct inspections.
12VAC35-105-1180. Sponsor qualification and approval process.
A. The provider shall evaluate and certify each
sponsored residential homes home other than his own through face-to-face
interviews, home visits inspections, and other information documenting
compliance with this [ regulation section ].
The provider shall submit the certification form to the department before
individuals are placed in the home and ensure that the following
requirements are met annually.
B. The provider shall certify and document that all
each sponsored residential homes meet home meets the
criteria for physical environment and residential services [ designated ] in
these regulations.
C. The provider shall document the ability of the
sponsored staff's ability residential home staff to meet the
needs of the individuals placed in the home by assessing and documenting:
1. The sponsored staff's ability of the [ sponsor
or any ] staff to communicate and understand individuals
receiving services;
2. The sponsored staff's ability of the [ sponsor
or any ] staff to provide the care, treatment, training, or
habilitation for individual individuals receiving services in the
home;
3. The abilities of all members of the sponsored
household to accept individuals with disabilities and their disability-related
characteristics, especially the ability of children in the household to adjust
to nonfamily members living with them; and
4. The financial capacity of the sponsor to meet the sponsor's
own expenses for up to 90 days, independent of payments received for residents
living in the home.; and
5. The education, qualifications, and experience of the [ sponsor
or ] staff with the individuals served including Virginia
Department of Motor Vehicles driving record, tuberculosis screening, first-aid
and CPR certification, and completion of medication administration and behavior
[ management ] interventions training.
D. The provider shall obtain three job-related references,
past licensing history, criminal background checks, and a search
of the registry of founded complaints of child abuse and neglect maintained by
the Department of Social Services for the sponsor and all adults in
the home who are staff. The provider must develop policies for obtaining
references, background and registry checks for all adults in the home who are
not staff and not the individuals being served.
E. The provider shall [ develop and ]
implement written policies for obtaining references, criminal background
checks, and registry checks for all adults in the home who are neither staff
nor individuals being served. The policy shall indicate what action the
provider will take if the results indicate that a member of the sponsor family
has been convicted of a barrier crime or fails to meet the requirements of this
regulation should an ineligible result be received.
F. Sponsored The sponsored residential
home members shall submit to the provider the results of a physical and mental
health examination of family members when requested by the provider
based on indications of a physical or mental health problem issue.
F. G. Sponsored residential homes shall not also
operate as group homes or Department of Social Services approved homes
or foster homes.
H. The provider shall submit the name, address, and certification of the sponsored residential home to the department prior to adding the home. The provider shall submit the name and address of the sponsored residential home to the department prior to closing the home. The provider shall submit a service modification when approving homes more than 100 miles from the previously approved homes.
12VAC35-105-1190. Sponsored residential home service policies.
A. The provider shall [ develop and ] implement
[ written ] policies to provide orientation and supportive
services to sponsored the sponsored residential home staff
specific to individual the needs of the individuals receiving
services.
B. The provider shall [ develop and ] implement
a training plan for the sponsored sponsor staff consistent with resident
the needs of the individuals receiving services.
C. The provider shall specify staffing arrangements in all sponsored residential homes, including on-call and substitute care arrangements.
D. The provider shall [ develop and ] implement
a written policy on managing, monitoring, and supervising
sponsored residential homes. This policy shall address changes in
supervision arrangements as the number of homes increase.
E. The provider shall conduct at least semi-annual
unannounced visits to inspections of each sponsored residential homes
home other than his own. Inspections shall be performed at least on a
quarterly basis during the year with at least two being unannounced
inspections.
F. On an on-going basis and at least annually, the provider
shall review and document compliance of by each sponsored
residential homes home and sponsors sponsor with
regulations related to sponsored residential homes.
G. The provider shall develop written policies regarding
termination of for terminating a sponsored residential home.
H. The provider shall document that all residents or their
authorized representatives are provided the opportunity to choose a new
placement when the current placement ends. Prior to moving an individual to
another placement the provider shall conduct and document a meeting to include
the individual and [ their his ] authorized
representative, if applicable, case manager, the current sponsor, and a
receiving placement staff, if possible.
12VAC35-105-1200. Supervision.
A. The provider shall have a supervisor for every [ 20
15 ] sponsored residential homes where individuals are residing.
B. A responsible adult shall be available to provide supervision to the individual as specified in the individualized service plan.
B. C. Any member of the sponsor family who
transports individuals receiving services must have a valid driver's license
and automobile liability insurance. The vehicle used to transport individuals
receiving services shall have a valid registration and inspection sticker.
C. D. The sponsor shall inform the provider in
advance of any anticipated additions or changes in the sponsored residential
home or as soon as possible after an unexpected change occurs.
E. In addition to the current reporting requirements the
sponsor shall report all hospitalizations of [ the ]
individuals being served to the provider and the individual's case manager
within 24 hours.
12VAC35-105-1210. Sponsored residential home service records.
Providers of sponsored residential home services shall
maintain [ the following ] records on each sponsored
residential home [ , which shall include ]:
1. Documentation of three references for the owner of the sponsor home;
2. Criminal background checks and results of the search of the
registry of founded complaints of child abuse and neglect on for
all adults who are staff adult employees in the home;
3. Orientation and training provided by the provider to the sponsor and employees;
4. A The log of provider visits to each inspections
of the sponsored residential home including the date, the staff person
visiting employee conducting the inspection, the purpose of the visit
inspection, and a description of any significant events [ or
findings ]; and
5. The sponsor will maintain a daily log maintained
by the sponsor of significant events related to individuals receiving
services.
12VAC35-105-1220. Regulations pertaining to employees staff.
Providers will shall certify and document
compliance of sponsors with regulations pertaining to employees staff.
12VAC35-105-1230. Maximum number of beds or occupants in sponsored residential home.
The maximum number of individuals served in a sponsored
residential home beds is two. The maximum number of occupants in a
sponsored residential home is seven.
12VAC35-105-1235. Sponsored residential home services for children.
In addition, the following requirements shall be met for homes serving children:
1. The provider shall develop a service description based
upon evidence-based practices or an accepted therapeutic model of mental
health, [ mental retardation (intellectual disability),
developmental or ] substance abuse [ services ],
or brain injury care for children.
2. The provider shall use a treatment team model consisting of staff who provide intensive support and consultation to the sponsor parents.
3. Weekly team meetings and supervision shall be held with the sponsor parent or parents to review progress on each case, review the daily behavioral information collected, and adjust the child's individualized services plan.
4. The sponsor parent or parents shall keep a daily log of behavioral and other child specific information and be available for daily Monday through Friday contact from the provider.
5. The sponsor parent or parents shall receive 25 hours per year of in-service training pertaining to providing services for the child they serve in addition to the training otherwise required in these regulations. The sponsor parent or parents shall also participate in ongoing training at least once a quarter.
6. The provider is not considered a child placing agency. Children are placed with the provider by licensed child placing agencies, local departments of social services, or parents.
7. The sponsor parent or parents shall be at least 25 years old.
8. The sponsor parent or parents shall be able to provide care and supervision during nonschool hours.
9. The provider shall have access through directly providing
it or developing agreements for 24-hour emergency mental health care for
children [ served ] with serious emotional
disturbances [ served ].
Article 5
Case Management Services
12VAC35-105-1240. Service requirements for providers of case management services.
A. As part of the intake assessment, the provider of case
management services shall identify individuals whose needs may be addressed
through case management services.
B. Providers of case management services shall document
that the services below are performed consistent with the individual's
assessment and individualized services plan ISP.
1. Enhancing community integration through increased opportunities for community access and involvement and creating opportunities to enhance community living skills to promote community adjustment including, to the maximum extent possible, the use of local community resources available to the general public;
2. Making collateral contacts with the individual's significant others with properly authorized releases to promote implementation of the individual's individualized services plan and his community adjustment;
3. Assessing needs and planning services to include developing a case management individualized services plan;
4. Linking the individual to those community supports that are most
likely to promote the personal [ habilitative/rehabilitative habilitative
or rehabilitative ] and life goals of the individual as developed in
the individualized service plan (ISP) ISP;
5. Assisting the individual directly to locate, develop, or obtain needed services, resources, and appropriate public benefits;
6. Assuring the coordination of services and service planning within a provider agency, with other providers [ , ] and with other human service agencies and systems, such as local health and social services departments;
7. Monitoring service delivery through contacts with
individuals receiving services [ , and ] service
providers and periodic site and home visits to assess the quality of care and
satisfaction of the individual;
8. Providing follow up instruction, education [ , ]
and counseling to guide the individual and develop a supportive relationship
that promotes the individualized services plan ISP;
9. Advocating for individuals in response to their changing needs, based on changes in the individualized services plan;
10. Developing a crisis plan for an individual that includes
the individual's references regarding treatment in an emergency situation;
11. 10. Planning for transitions in [ the ]
individual's [ lives life ] ; and
12. 11. Knowing and monitoring the individual's
health status, any medical conditions, and his medications and potential side
effects, and assisting the individual in accessing primary care and other
medical services, as needed.; and
12. Understanding the capabilities of services to meet the
individual's [ indentified identified ] needs
and preferences and to serve the individual without placing the individual,
other participants, or staff at risk of serious harm.
12VAC35-105-1250. Qualifications of case management employees or contractors.
A. Employees or contractors providing case management services shall have knowledge of:
1. Services and systems available in the community including primary health care, support services, eligibility criteria and intake processes and generic community resources;
2. The nature of serious mental illness, mental retardation and/or
(intellectual disability), substance abuse [ (substance use
disorders) ], or co-occurring disorders depending on the population
[ individual's individuals ] served, including
clinical and developmental issues;
3. Different types of assessments, including functional assessment, and their uses in service planning;
4. Treatment modalities and intervention techniques, such as behavior management, independent living skills training, supportive counseling, family education, crisis intervention, discharge planning [ , ] and service coordination;
5. Types of mental health, [ mental retardation (intellectual
disability) developmental, ] and substance abuse programs
available in the locality;
6. The service planning process and major components of a service plan;
7. The use of medications in the care or treatment of the population served; and
8. All applicable federal and state laws [ , state and ]
regulations and local ordinances.
B. Employees or contractors providing case management services shall have skills in:
1. Identifying and documenting an individual's need for resources, services, and other supports;
2. Using information from assessments, evaluations, observation, and interviews to develop service plans;
3. Identifying and documenting how resources, services [ , ] and
natural supports such as family can be utilized to promote achievement of an
individual's personal [ habilitative/rehabilitative habilitative
or rehabilitative ] and life goals; and
4. Coordinating the provision of services by diverse public and private providers.
C. Employees or contractors providing case management services shall have abilities to:
1. Work as team members, maintaining effective inter- and intra-agency working relationships;
2. Work independently performing position duties under general supervision; and
3. Engage [ in ] and sustain ongoing relationships with individuals receiving services.
12VAC35-105-1255. Case manager choice.
The provider shall [ develop and ]
implement a [ written ] policy [ as
to describing ] how individuals are assigned case
managers and how they can request a change of their assigned case manager.
12VAC35-105-1270. Physical environment requirements of community gero-psychiatric residential services.
A. Providers shall be responsible for ensuring safe mobility
and unimpeded access to programs or services by installing and maintaining
ramps, handrails, grab bars, elevators, protective surfaces [ , ] and
other assistive devices or accommodations as determined by periodic review of
the needs of the individuals being served. Entries, doors, halls [ , ] and
program areas, including bedrooms, must have adequate room to accommodate
[ wheel chairs wheelchairs ] and allow for proper
transfer of individuals. Single bedrooms shall have at least 100 square feet
and multi-bed rooms shall have [ at least ] 80 square feet per
individual.
B. Floors must have resilient, nonabrasive, and slip-resistant floor surfaces and floor coverings that promote mobility in areas used by individuals and promote maintenance of sanitary conditions.
C. Temperatures shall be maintained between 70°F and 80°F throughout resident areas.
D. Bathrooms, showers [ , ] and program areas must be accessible to individuals. There must be at least one bathing unit available by lift, door [ , ] or swivel-type tub.
E. Areas must be provided for quiet and for recreation.
F. Areas must be provided for charting, storing of administrative supplies, a utility room, employee hand washing, dirty linen, clean linen storage, clothes washing, and equipment storage.
12VAC35-105-1280. Monitoring.
Employees or contractors shall regularly monitor individuals in all areas of the residence to ensure safety.
12VAC35-105-1290. Service requirements for providers of gero-psychiatric residential services.
A. Providers shall provide mental health, nursing and
rehabilitative services; medical and psychiatric services; and pharmaceutical
services for each individual as specified in the individualized services
plan ISP.
B. Providers shall provide crisis stabilization services.
C. Providers shall [ develop and ] implement
written policies and procedures that support an active program of mental health
and behavioral management [ services ] directed toward
assisting each individual to achieve outcomes consistent with the highest level
of self-care, independence [ , ] and quality of life.
Programming may be on-site or at another location in the community.
D. Providers shall [ develop and ] implement
written policies and procedures that respond to the nursing needs of each
individual to achieve outcomes consistent with the highest level of self-care,
independence [ , ] and quality of life. Providers shall be
responsible for:
1. Providing each individual services to prevent clinically
avoidable complications, including [ but not limited to ]:
skin care, dexterity and mobility, continence, hydration [ , ]
and nutrition;
2. Giving each individual proper daily personal attention and care, including skin, nail, hair [ , ] and oral hygiene, in addition to any specific care ordered by the attending physician;
3. Dressing each individual in clean clothing and encouraging each individual to wear day clothing when out of bed;
4. Providing each individual tub or shower baths as often as
needed, but not less than twice weekly [ , ] or a sponge bath
daily if the medical condition prohibits tub or shower baths.;
5. Providing each individual appropriate pain management; and
6. Ensuring that each individual has his own personal utensils, grooming items, adaptive devices [ , ] and other personal belongings including those with sentimental value.
E. Providers shall integrate [ behavioral/mental
health behavioral and mental health ] care and [ medical/nursing
medical and nursing ] care in the [ individualized services
plan ISP ].
F. Providers shall have available nourishment between scheduled meals.
12VAC35-105-1300. Staffing requirements for community gero-psychiatric residential services.
A. Community gero-psychiatric residential services shall be under the direction of a:
1. Program director with experience in gero-psychiatric
services [ .; ]
2. Medical director [ .; and ]
3. Director of clinical services who is a registered nurse with experience in gero-psychiatric services.
B. Providers shall provide qualified nursing supervisors,
nurses, and certified nurse aides on all shifts, seven days per week, in
sufficient number to meet the assessed nursing care and behavioral management
needs determined by the individualized services plans ISPs.
C. Providers shall provide qualified staff for behavioral,
psychosocial rehabilitation, rehabilitative, mental health, or recreational
programming to meet the needs determined by the individualized services plan
ISP. These services shall be under the direction of a registered nurse,
licensed psychologist, licensed clinical social worker, or licensed therapist.
12VAC35-105-1310. Interdisciplinary services planning team.
A. At a minimum, a registered nurse, a licensed psychologist, a
licensed social worker, a therapist (recreational, occupational or physical
therapist), a pharmacist, and a psychiatrist shall participate in the
development and review of the individualized services plan ISP.
Other employees or contractors as appropriate shall be included.
B. The interdisciplinary services planning team shall meet to
develop the individualized services plans ISP and review it
quarterly. Members of the team shall be available for consultation on an as
needed basis.
C. The interdisciplinary services planning team shall review the medications prescribed at least quarterly and consult with the primary care physician as needed.
D. The interdisciplinary services planning team shall
integrate medical care plans prescribed by the primary care physician into the individualized
services plan ISP and consult with the primary care physician as
needed.
12VAC35-105-1330. Medical director.
Providers of community gero-psychiatric community residential
services shall employ or have a written agreement with one or more psychiatrists
with training and experience in gero-psychiatric services to serve as medical
director. The duties of the medical director shall include [ , but are
not limited to ]:
1. Responsibility for [ the ] overall medical
and psychiatric care;
2. Advising the program director and the director of clinical
services on [ medical/psychiatric medical and psychiatric ]
issues, including the criteria for residents to be admitted, transferred
[ , ] or discharged;
3. Advising on the development, execution [ , ]
and coordination of policies and procedures that have a direct effect upon the
quality of medical, nursing [ , ] and psychiatric care
delivered to [ residents individuals ]; and
4. Acting as liaison and consulting with the administrator and the primary care physician on matters regarding medical, nursing [ , ] and psychiatric care policies and procedures.
12VAC35-105-1340. Physician services and medical care.
A. Each individual in a community gero-psychiatric residential
service shall be under the care of a primary care physician. Nurse
practitioners and physician assistants licensed to practice in Virginia may
provide care in accordance with their practice agreements. Prior to, or at the
time of admission, each individual, his legally authorized
representative, or the entity responsible for his care shall designate a
primary care physician.
B. The primary care physician shall conduct a physical examination at the time of admission or within 72 hours of admission into a community gero-psychiatric residential service. The primary care physician shall develop, in coordination with the interdisciplinary services planning team, a medical care plan of treatment for an individual.
C. All physicians or other prescribers shall review all medication orders at least every 60 days or whenever there is a change in medication.
D. The provider shall have a signed agreement with a local general hospital describing back-up and emergency medical care plans.
Article 7
Intensive Community Treatment and Program of Assertive Community Treatment
Services
12VAC35-105-1360. Admission and discharge criteria.
A. Individuals must meet the following admission criteria:
1. Severe Diagnosis of a severe and persistent
mental illness, predominantly schizophrenia, other psychotic disorder, or
bipolar disorder [ , ] that seriously impairs functioning in
the community. Individuals with a sole diagnosis of substance addiction or
abuse or mental retardation (intellectual disability) are not eligible
for services.
2. Impairments on a continuing or intermittent basis without
intensive community support to include one or more of the following Significant
challenges to community integration without intensive community support
including persistent or recurrent difficulty with one or more of the following:
a. Inability to consistently perform Performing
practical daily living tasks required for basic adult functioning in the
community;
b. Persistent or recurrent failure to perform daily living
tasks except with significant support of assistance by family, friends or
relatives Maintaining employment at a self-sustaining level or
consistently carrying out homemaker roles; or
c. Inability to be consistently employed at a
self-sustaining level or inability to consistently carry out homemaker roles;
or
d. Inability to maintain c. Maintaining a safe
living situation.
3. High service needs indicated due to one or more of
the following problems:
a. Residence in a state [ mental health facility hospital ]
or other psychiatric hospital but clinically assessed to be able to live in a
more independent situation if intensive services were provided or anticipated
to require extended hospitalization, if more intensive services are not
available;
b. High user of state mental health facility or other acute
psychiatric hospital inpatient services within the past two years or a frequent
user of psychiatric emergency services (more than four times per year) Multiple
admissions to or at least one recent long-term stay (30 days or more) in a
state [ mental health facility hospital ]
or other acute psychiatric hospital inpatient setting within the past two
years; or a recent history of more than four interventions by psychiatric
emergency services per year;
c. Intractable (i.e., persistent or very recurrent) Persistent
or very recurrent severe major symptoms (e.g., affective, psychotic, suicidal);
d. Co-occurring substance addiction or abuse of significant duration (e.g., greater than six months);
e. High risk or a recent history (within the past six months)
of criminal justice involvement (e.g., arrest and or
incarceration);
f. Unable to meet Ongoing difficulty meeting
basic survival needs or residing in substandard housing, homeless, or at
imminent risk of becoming homeless; or
g. Unable Inability to consistently participate
in traditional office-based services.
B. Individuals receiving PACT individuals or
ICT services should not be discharged for failure to comply with treatment
plans or other expectations of the provider, except in certain circumstances as
outlined. Individuals must meet at least one of the following criteria to be
discharged:
1. Moving Change in the individual's residence to a
location out of the service area;
2. Death of the individual;
3. Incarceration of the individual for a period to
exceed a year or long term hospitalization for (more than
one year); however, the provider is expected to prioritize these individuals
for PACT or ICT services upon their anticipated return to the community if the
individual wishes to return to services and the service level is appropriate to
his needs;
4. Choice of the individual (the with the
provider is responsible for revising the individualized services plan
ISP to meet any concerns of the individual leading to the choice of discharge)
discharge; or
5. Demonstration by the individual of an ability to function
Significant sustained recovery by the individual in all major role areas
with minimal team contact and support for at least two years as determined by
both the individual and ICT or PACT team.
12VAC35-105-1370. Treatment team and staffing plan.
A. ICT and PACT Services are delivered by
interdisciplinary teams.
1. The PACT and ICT team teams
shall have employees or contractors, 80% of whom meet the qualifications of
QMHP, who are qualified to provide the services described in 12VAC35-105-1410,
including at least five full-time equivalent clinical employees or contractors
on an ICT team and at least 10 full-time equivalent clinical employees or
contractors on a PACT team, a program assistant, and a full- or part-time
psychiatrist. The team shall include the following positions:
a. Team Leader - one full time equivalent (FTE) [ QMHP
QMHP-Adult ] with at least three years experience in the
provision of mental health services to adults with serious mental illness. The
team leader shall oversee all aspects of team operations and shall routinely
provide direct services to individuals in the community.
b. Nurses - one or more FTE registered nurse with one year
of experience or licensed practical nurse with three years of experience in the
provision of mental health services to adults with serious mental illness PACT
and ICT nurses shall be full-time employees or contractors with the following
minimum qualifications: A registered nurse (RN) shall have one year of
experience in the provision of mental health services to adults with serious
mental illness. A licensed practical nurse (LPN) shall have three years of
experience in the provision of mental health services to adults with serious
mental illness. ICT teams shall have at least one qualified full-time nurse.
PACT teams shall have at least three qualified full-time nurses at least one of
whom shall be a qualified RN.
c. Mental health professionals two or more FTE QMHPs
(half of whom shall hold a master's degree), including a vocational specialist
and a substance abuse specialist One full-time vocational specialist and
one full-time substance abuse specialist. These staff members shall provide
direct services to [ consumers individuals ]
in their area of specialty and provide leadership to other team members to
also assist individuals with their self identified employment or substance
abuse recovery goals.
d. Peer specialists - one or more FTE full-time [ equivalent ]
QPPMH or [ QMHP QMHP-Adult ] who is or has been a
recipient of mental health services for severe and persistent mental illness. The
peer specialist shall be a fully integrated team member who provides peer
support directly to individuals and provides leadership to other team members
in understanding and supporting individuals' recovery goals.
e. Program assistant - one full-time person with skills
and abilities in medical records management, operating and coordinating shall
operate and coordinate the management information system, maintaining
maintain accounts and budget records for individual and program
expenditures, and providing provide receptionist activities.
f. Psychiatrist - one physician who is board certified in psychiatry or who is board eligible in psychiatry and is licensed to practice medicine [ in Virginia ]. An equivalent ratio to 20 minutes (.008 FTE) of psychiatric time for each individual served must be maintained. The psychiatrist shall be a fully integrated team member who attends team meetings and actively participates in developing and implementing each individual ISP.
2. In addition, a PACT team includes at least three FTE
nurses (at least one of whom is an RN and five or more mental health
professionals. [ QMHP QMHP-Adult ] and
mental health professional standards:
a. At least 80% of the clinical employees or contractors,
not including the program assistant or psychiatrist, shall meet [ QMHP
QMHP-Adult ] standards and shall be qualified to provide the
services described in 12VAC35-105-1410.
b. Mental health professionals At least half of the clinical employees or contractors, not including the team leader or nurses and including the peer specialist if that person holds such a degree, shall hold a master's degree in a human service field.
3. Staffing capacity:
a. An ICT team shall have at least five full-time equivalent clinical employees or contractors. A PACT team shall have at least 10 full-time equivalent clinical employees or contractors.
B. b. ICT and PACT teams must shall
include a minimum number of employees (counting contractors but not counting
the psychiatrist and program assistant) to maintain an employee to individual
ratio of at least 1:10.
c. ICT teams may serve no more than 80 individuals. PACT teams may serve no more than 120 individuals.
d. A transition plan will shall be
required of PACT teams that will allow for "start-up" when newly
forming teams are not in full compliance with the PACT model relative to
staffing patterns and client [ consumer
individuals receiving services ] capacity.
C. B. ICT and PACT teams shall meet daily Monday
through Friday or at least four days per week to review and plan routine
services and to plan for address or prevent emergency and crisis
situations.
D. C. ICT teams shall operate a minimum of 8
hours per day, 5 days per week and shall provide services on a case-by-case
basis in the evenings and on weekends. PACT teams shall be available to
individuals 24 hours per day and shall operate a minimum of 12 hours each
weekday and 8 hours each weekend day and each holiday.
E. D. The ICT [ and or ]
PACT team shall make crisis services directly available 24 hours a day but may
arrange coverage through another crisis services provider if the team
coordinates with the crisis services provider daily. The PACT team shall
operate an after-hours on-call system and be available to individuals by
telephone or in person.
12VAC35-105-1390. ICT and PACT service daily operation and progress notes.
A. ICT teams and PACT teams shall conduct daily organizational meetings Monday through Friday at a regularly scheduled time to review the status of all individuals and the outcome of the most recent employee or contractor contact, assign daily and weekly tasks to employees and contractors, revise treatment plans as needed, plan for emergency and crisis situations, and to add service contacts that are identified as needed.
B. A daily log that provides a roster of individuals served in
the ICT or PACT services program and documentation of services provided and
contacts made with them shall be maintained and utilized in the daily team
meeting. There shall also be at least a weekly individual progress
note documenting progress or lack of progress toward goals and objectives as
outlined in the Psychosocial Rehabilitation Services Plan services
provided in accordance with the ISP or attempts to engage the [ consumer
individual ] in services.
12VAC35-105-1400. ICT and PACT assessment.
The provider shall solicit the individual's own assessment of
his needs, strengths, goals, preferences [ , ] and abilities
to identify the need for recovery oriented treatment, rehabilitation [ , ]
and support services and the status of his environmental supports within the
individual's cultural context. The With the participation of the
individual, the provider [ will shall ] assess:
1. Psychiatric history, mental status and diagnosis, including the content of an advance directive;
2. Medical, dental [ , ] and other health needs;
3. Extent and effect of drug or alcohol use;
4. Education and employment [ , ] including
current daily [ structures structured ] use of
time, school or work status, interests and preferences [ , ] and
the effect of psychiatric symptomatology on and supports and barriers to
educational and employment performance;
5. Social development and functioning [ , ]
including childhood and family history, culture and religious beliefs,
leisure interests, and social skills;
6. Housing and daily living skills, including the support needed to obtain and maintain decent, affordable housing integrated into the broader community; the current ability to meet basic needs such as personal hygiene, food preparation, housekeeping, shopping, money management [ , ] and the use of public transportation and other community based resources;
7. Family and social network [ , ] including
the current scope and strength of [ a an ] individual's
network of family, peers, friends, and co-workers, and their
understanding and expectations of the team's services;
8. Finances and benefits [ , ] including the management of income, the need for and eligibility for benefits, and the limitations and restrictions of those benefits; and
9. Legal and criminal justice involvement [ , ]
including [ the ] guardianship, commitment,
representative payee status, and [ the ] experience as
either [ a ] victim or [ an ] accused person.
12VAC35-105-1410. Service requirements.
Providers shall document that the following services are
provided consistent with the individual's assessment and individualized services
plan ISP.
1. Ongoing assessment to ascertain the needs, strengths, and preferences of the individual;
2. Case management;
3. Nursing;
4. Symptom assessment and management Support for
wellness self-management, including the development and implementation of
individual recovery plans [ ;, ] symptom
assessment [ ;, ] and recovery education;
5. Psychopharmacological treatment, administration [ , ] and monitoring;
6. Substance abuse assessment and treatment for individuals
with a dual co-occurring diagnosis of mental illness and
substance abuse;
7. Individual supportive therapy;
8. Skills training in activities of daily living, social skills, interpersonal relationships, and leisure time;
9. Supportive in-home services;
10. Work-related services to help find and maintain employment;
11. Support for resuming education;
12. Support, education, consultation, and skill-teaching to family members and significant others;
13. Collaboration with families and assistance to individuals with children;
14. Direct support to help individuals secure and maintain decent, affordable housing that is integrated into the broader community and to obtain legal and advocacy services, financial support, money-management services, medical and dental services, transportation, and natural supports in the community; and
15. Mobile crisis assessment, intervention interventions
to prevent or resolve potential crises, and [ facilitation into and
out of admission to and discharge from ] psychiatric hospitals.
FORMS (12VAC35-105)
Initial Provider Application For Licensing (rev.1/10).
Renewal Provider Application For Licensing (rev. 2/09).
Service Modification - Provider Request, DMH 966E 1140 (rev. 1/09).
DOCUMENTS INCORPORATED BY REFERENCE (12VAC35-105)
Diagnostic Criteria from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, American Psychiatric Association,
Washington, D.C., 1994.