A. A provider shall submit a written service modification application at least 45 30 days in advance of a proposed modification to its license. The modification may address the characteristics of individuals served (disability, age, or gender), the services offered, the locations where services are provided, existing stipulations, or the maximum number of individuals served under the provider license.

B. Upon receipt of the completed service modification application, the commissioner may revise the provider 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.

The commissioner may grant a variance to a specific regulation if he determines that such a variance will not jeopardize the health, safety, or welfare of individuals. A provider shall submit a request for such variance in writing to the commissioner. The request shall demonstrate that complying with the regulation would be a hardship unique to the provider and that the variance will not jeopardize the health, safety, or welfare of individuals. The department may limit the length of time a variance will be effective. The provider shall not implement a variance until it has been approved in writing by the commissioner.

A. If there is noncompliance with any applicable regulation during an initial or ongoing review, inspection, 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 a written corrective action plan for each violation cited.

C. The corrective action plan shall include a:

1. Detailed description of the corrective actions to be taken that will minimize the possibility that the violation will occur again and correct any systemic deficiencies;

2. Date of completion for each corrective action; and

3. Signature of the person responsible for oversight of the implementation of the pledged corrective action.

3. Responsible person designated to oversee implementation of the pledged corrective action.

D. The provider shall submit a corrective action plan to the department within 15 business days of the issuance of the licensing report. One extension 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. Upon receipt of the corrective action plan, the department shall review the plan and 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 department has not approved the revised plan. If the submitted revised corrective action plan is not approved, the provider shall follow the dispute resolution process identified in this section.

F. When the If a provider disagrees with a citation of a violation or the disapproval of a revised corrective action plan, 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 director is final.

G. The provider shall implement their an approved written corrective action plan for each violation cited by the date of completion identified in the plan.

H. The provider shall monitor implementation and effectiveness of approved corrective actions as part of its quality improvement program required by 12VAC35-105-620. If the provider determines that an approved corrective action was fully implemented, but did not prevent the recurrence of a regulatory violation or correct any systemic deficiencies, the provider shall:

1. Continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies; or

2. Submit a revised corrective action plan to the department for approval.

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 significant changes 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 at least 30 days prior to the cessation of services. The provider shall continue to provide all services that are identified in each individual's ISP after it has given official notice of its intent to cease operations and until each individual is appropriately discharged in accordance with 12VAC35-105-693. The provider shall further continue to maintain substantial compliance with all applicable regulations as it discontinues its services.

E. C. All individuals receiving services and their authorized representatives shall be notified of the provider's intent to cease services in writing at least 30 days prior to the cessation of services. This written notification shall be documented in each individual's ISP.

A. The provider shall provide the following evidence of its operating authority:

1. 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 proprietors trading under their own name shall provide a certificate from the State Corporation Commission pursuant to § 59.1-69 of the Code of Virginia .

B. The provider shall provide an organizational chart that clearly identifies its governing body and organizational structure.

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 its management or leadership structure.

A. The provider shall document financial 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. The department may require an audit of all financial records by an independent Certified Public Accountant (CPA) or as otherwise provided by law or regulation.

3. Providers operating as a part of a local government agency are not required to provide a balance sheet; however, they shall provide a financial statement.

C. B. The provider In addition to the indemnity coverage required pursuant to 12VAC35-105-220, the provider shall have written internal controls to minimize the risk of theft or embezzlement of provider funds.

D. C. The provider shall identify in writing the title and qualifications of the person who has with the authority and responsibility for the fiscal management of its services. At a minimum, the person who has the authority and responsibility for fiscal management shall be bonded or otherwise indemnified.

E. D. 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.

A. The provider shall submit building plans and specifications for any planned construction at a new location, changes in the use of existing locations, and any structural modifications or additions to existing locations where services are provided 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. The provider shall submit an interim a plan to the department addressing safety and continued service delivery if new for any planned construction involving (i) changes in the use of existing locations or (ii) structural modifications or additions to new or existing buildings is planned. This section does not apply to correctional facilities, jails, or home and noncenter-based services.

A. The physical environment, design, structure, furnishings, and lighting shall be appropriate to and safe for the individuals served and the services provided.

B. The physical environment shall be accessible to individuals with physical and sensory disabilities, if applicable.

C. The physical environment and furnishings shall be clean, dry, free of foul odors, safe, and well-maintained.

D. Floor surfaces and floor 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° to 110°F 100° to 120°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. H. If smoking is permitted, the provider shall make provisions for alternate smoking areas that are separate from the service environment. This subsection does not apply to home-based services.

J. I. For all program areas added after September 19, 2002, minimum room height shall be 7-1/2 feet.

K. J. This section does not apply to home-based and noncenter-based or crisis services. Sponsored residential services shall certify compliance of sponsored residential homes with this section.

A. 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 in accordance with 12VAC5-421 .

B. Documentation of the most recent three inspections inspection and approval shall be kept on file. This section does not apply to sponsored residential services or to group homes or and community residential homes.

The provider shall document at the time of its original application and annually thereafter that buildings and equipment in residential service locations 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.

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 personnel records maintained in electronic databases.

C. Providers shall comply with requirements of the Americans with Disabilities Act and the Virginians with Disabilities Act regarding retention of employee health-related information in a file separate from personnel files.

A. Providers shall comply with the requirements for obtaining criminal history background checks as outlined in §§ 37.2-416, 37.2-506, 37.2-416.1, 37.2-506.1, and 37.2-607 of the Code of Virginia for individuals hired after July 1, 1999.

B. The provider shall develop a written policy for criminal history background checks and registry searches that addresses what actions the provider must take if an applicant has certain prior convictions or a founded case of child abuse or neglect . The policy shall require at a minimum a disclosure statement stating that the applicant disclose whether the person has (i) ever been convicted of or is the subject of pending charges for any an offense and shall address what actions the provider will take should it be discovered that a person has a founded case of abuse or neglect or both, or a conviction or pending criminal charge listed in §§ 37.2-416, 37.2-416.1, 37.2-506, and37.2-506.1, or 37.2-607 of the Code of Virginia or (ii) has had a founded case of child abuse or neglect . Any plea of nolo contendere shall be considered a conviction for purposes of this section.

C. The provider shall submit all personally descriptive applicant information required by the department necessary to complete the criminal history background checks and registry searches.

D. The provider shall maintain the following documentation:

1. The disclosure statement from the applicant stating whether he has ever been convicted of or is the subject of pending charges for any offense required pursuant to subsection B; and

2. Documentation Evidence that the provider submitted all information required by the department necessary to complete the : criminal history background checks and registry searches , ; report from the Central Criminal Records Exchange; or memoranda from the department transmitting the results to the provider, if as applicable , ; and the results from the Child Protective Registry search.

A. Each employee or contractor shall have a access to his current written job description that includes:

1. Job title;

2. Duties and responsibilities required of the position; and

3. Job title of the immediate supervisor; and

4. Minimum knowledge, skills, and abilities, ; education or training; or 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. The provider shall have written documentation of the mechanism used to advise employees or contractors of changes to their job responsibilities.

A. Any Each person who assumes the responsibilities of any a position as an employee or a contractor shall meet the minimum qualifications of that position as determined by in accordance with the current job descriptions description.

B. Employees and contractors shall comply, as required, with the regulations of the Department of Health Professions. The provider shall design, implement, and document the process used to verify professional credentials.

C. Supervisors shall have experience in working with individuals being served and in providing the services outlined in the service description.

D. Job descriptions shall include minimum knowledge, skills and abilities, professional qualifications and experience appropriate to the duties and responsibilities required of the position.

E. All staff Each employee or contractor shall demonstrate a working knowledge of the policies and procedures that are applicable to his specific job or position.

A. Employee or contractor personnel records, whether hard-copy or electronic, shall include:

1. Individual identifying information;

2. Education and training history;

3. Employment history; and

4. Results of 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 searches of the registry of founded complaints of child abuse and neglect;

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 or organizations, 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.

New employees, contractors, volunteers, and students shall be oriented commensurate with their function or job-specific responsibilities within 15 business days. The provider shall document that the orientation covers each of the following policies, 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. 2. Practices that assure an individual's rights including orientation to human rights regulations;

4. Applicable personnel policies;

5. 3. Emergency preparedness procedures;

6. 4. Person-centeredness;

7. 5. Infection control practices and measures;

8. 6. Other policies and procedures that apply to specific positions and specific duties and responsibilities; and

9. 7. Serious incident reporting, including when, how, and under what circumstances a serious incident report must be submitted and the consequences of failing to report a serious incident to the department in accordance with this chapter.

All The provider shall keep all employees or and contractors shall be kept informed of policy changes that affect their performance of duties. The provider shall have written documentation of the process used to advise employees or contractors of policy changes.

The provider shall implement a written grievance policy and shall inform employees of grievance procedures. The provider shall have documentation of the process used to advise employees of grievance procedures.

A. The provider shall 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 to supplant direct care positions. The provider staffing plan shall not include volunteers or students.

A. Each new employee, contractor, student, or volunteer who will have direct contact with individuals 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 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.

B. All employees, contractors, students, or volunteers in substance abuse co-occurring outpatient or residential treatment services shall be certified as receive tuberculosis education free on an annual basis by a qualified licensed practitioner. The education shall focus on self-presentation in the event of exposure to active tuberculosis or the development of symptoms of active tuberculosis.

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.

A. The scope of emergency preparedness in relation to this section applies to disasters and emergencies as defined by § 44-146.16 of the Code of Virginia. The provider shall develop a written emergency preparedness and response plan for all of 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 coordination with the local emergency authorities to determine local disaster risks and community-wide plans to address different disasters and emergency situations.

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. 3. 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.

5. 4. 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 Procedures for:

a. Warning and , notifying, and communicating with individuals receiving services; ,

b. 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. b. Providing emergency access to secure areas and opening locked doors;

e. Evacuation procedures, including for individuals who need evacuation assistance;

f. c. Conducting evacuations Evacuating to emergency shelters or other alternative sites , relocating individuals receiving residential or inpatient services to new service locations, and accounting for all individuals receiving services;

g. Relocating individuals receiving residential or inpatient services, if necessary;

h. d. Notifying family members or authorized representatives; and

i. Alerting emergency personnel and sounding alarms;

j Locating and shutting off utilities when necessary; and

k. e. Maintaining a 24 hour telephone answering 24-hour communications capability to respond to emergencies for individuals receiving services.

6. 5. Processes for managing the following under emergency conditions:

a. Activities related to the provision of care, treatment, and services including scheduling, modifying, or discontinuing services; controlling protecting confidential information about individuals receiving services; providing medication; and coordinating transportation services; and

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.

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.

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

B. The provider shall evaluate each individual receiving services and, based on that evaluation the individualized evaluations, shall provide appropriate environmental supports and adequate staff to safely evacuate all individuals during an emergency.

C. The provider shall implement annual emergency preparedness and response training for all employees, contractors, students, and volunteers. This training shall also be provided as part of orientation for new employees and cover that covers 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.

D. The provider shall review the emergency preparedness plan annually and make necessary revisions. Such revisions shall be communicated to employees, contractors, students, volunteers, and individuals receiving services and incorporated into orientation and training for employees, contractors, students, and volunteers and into the orientation of individuals to services materials.

E. In the event of a disaster, fire, emergency, or any other condition that may jeopardize the health, safety, or welfare of individuals, the provider shall take appropriate action to protect the health, safety, and welfare of individuals receiving services and take appropriate actions to remedy the conditions as soon as possible.

F. 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 regularly scheduled emergency preparedness training for all employees, contractors, students, and volunteers.

G. In the event of a disaster, fire, emergency, or any other condition that may jeopardize the health, safety, or welfare of individuals, the provider should first respond and stabilize the disaster or emergency. After the disaster or emergency is stabilized, the provider should report the disaster or emergency to the department, but no later than 24 hours after the incident occurs.

H. Providers of residential services shall have at all times a three-day supply of emergency food and water for all residents individuals 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.

I. F. All provider locations shall be equipped with at least one approved type ABC type-ABC portable fire extinguisher with a minimum rating of 2A10BC installed in each kitchen.

J. G. All provider locations shall have an appropriate number of properly installed smoke detectors based on the size of the location, which shall include at a minimum:

1. At least one smoke detector on each level of multi-level buildings, including the basement;

2. At least one smoke detector in each bedroom in locations with bedrooms;

3. At least one smoke detector in any area adjacent to any bedroom in locations with bedrooms; and

4. Any additional smoke detectors necessary to comply with all applicable federal and state laws and regulations and local ordinances.

K. H. Smoke detectors shall be tested monthly for proper operation.

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

1. Exits;

2. Primary and secondary evacuation routes;

3. Accessible egress routes;

4. Portable fire extinguishers; and

5. Flashlights.

M. J. This section does not apply to home and noncenter-based services.

Article 1
Service Description and Staffing

The provider shall develop a written mission statement that clearly identifies its philosophy, purpose, and goals.

A. The provider shall develop, and implement, review, and revise its descriptions of services offered according to the provider's mission and shall make service descriptions available for public review.

B. The provider shall outline how each service offers a structured program of 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 individualized services plan.

C. The provider shall prepare a written description of each service it offers. Elements of each service description required by subsection A shall include:

1. Service goals;

2. A description of care, treatment, skills acquisition, or other supports provided;

3. Characteristics and needs of individuals to receive services;

4. Contract services, if any;

5. Eligibility requirements and admission, continued stay, and exclusion criteria;

6. Service termination and discharge or transition criteria; and

7. Type and role of employees or contractors.

D. The provider shall revise the written service description whenever the operation of the service changes.

E. The provider shall not implement services that are inconsistent with its most current service description.

F. E. 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 receiving services.

G. F. 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 developmental day support services with adults.

H. G. The service description for substance abuse treatment services shall address the timely and appropriate treatment of 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 receive services safely within the service to the department for approval. If the plan is approved, the department shall add a stipulation to the license authorizing the provider to serve individuals who are under temporary detention orders.

A. The provider shall implement a written staffing plan that includes the types, roles, and numbers of employees and contractors that are required to provide the service. This staffing plan shall reflect the:

1. Needs of the individuals receiving services;

2. Types of services offered;

3. Service description;

4. Number of individuals to receive services at a given time; and

5. Adequate number of staff required to safely evacuate all individuals during an emergency.

B. The provider staffing plan shall not include volunteers or students and shall not rely on students or volunteers to supplant direct care positions.

B. C. The provider shall develop a written transition staffing plan for new services, added locations, and changes in capacity.

C. D. The provider shall meet the following staffing requirements related to supervision.

1. The provider shall describe how employees , volunteers, and contractors , and student interns will be supervised in the staffing plan and how that supervision will be documented.

2. Supervision of employees , volunteers, and contractors , and student interns shall be provided by persons who have experience in working with individuals receiving services and in providing the services outlined in the service description.

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 meets the qualification for supervision as defined in this section.

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 or mental health supports, shall be provided by a QMHP-A, 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. An individual who is a QMHP-T may not provide this type of supervision.

7. Supervision of developmental services shall be provided by a person with at least one year of documented experience working directly with individuals who have developmental disabilities and holds at least a bachelor's degree in a human services field such as sociology, social work, special education, rehabilitation counseling, nursing, or psychology. Experience may be substituted for the education requirement.

8. 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.

D. E. 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 receiving services in residential services with medical or nursing needs; speech, language, or hearing problems; or other needs where specialized training is necessary.

E. F. 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. G. Staff in direct care positions providing brain injury services shall 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.

A. The provider shall 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 each 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 Providers of crisis or case management services shall assist individuals who are not admitted to identify other appropriate services.

D. The For individuals who are not admitted, the provider shall retain documentation of the individual's initial contacts contacts and screening referenced in subsection B for for a period of six months. Documentation shall be included in the individual's record if the individual is admitted to the service.

A. The provider shall implement a written policy regarding the orientation of to services for individuals and their authorized representatives, if applicable to services.

B. As appropriate to the scope and level of services , the policy shall require the provision to individuals and authorized representatives , if applicable, the following information:

1. The mission of the provider or service;

2. Service confidentiality Confidentiality practices and protections for individuals receiving services;

3. 2. Human rights policies and protections and instructions on how to report violations;

4. 3. Opportunities for participation in services and discharge planning;

5. 4. Fire safety and emergency preparedness procedures, if applicable;

6. 5. The provider's grievance complaint procedure;

7. 6. Service guidelines including criteria for admission to and discharge or transfer from services;

8. 7. Hours and days of operation;

9. 8. Availability of after-hours service; and

10. 9. Any charges or fees due from the individual.

C. In addition, to the provisions of subsection B, orientation for individuals receiving treatment services in a correctional facility shall receive an orientation to cover the facility's security restrictions.

D. The provider shall document that the individual and authorized representative, if applicable, received an orientation to services.

A. The provider shall implement written procedures that define the process for transitioning an individual between or among services operated by the provider. At a minimum the policy shall address Except when transfer is ordered by a court of competent jurisdiction, the receiving service shall obtain at the time of transfer :

1. The process by which the provider will assure continuity of services during and following transition; Documentation by the sending service of:

A. The provider shall have written policies and procedures regarding the discharge or termination of individuals from the its service. These policies and procedures shall include medical and clinical criteria for discharge.

B. Discharge instructions shall be provided in writing to the individual, the individual's authorized representative, and the successor provider, as applicable. Discharge At a minimum, discharge instructions shall include , at a minimum, medications and dosages , if applicable ; names, telephone numbers, and addresses of any successor providers to whom the individual is referred; current medical issues or conditions; and the identity of the individual's treating health care providers practitioners .

C. The provider shall make appropriate arrangements or referrals to all service services or successor 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, the individual's authorized representative, and the individual's family members, as appropriate, have been involved in the discharge planning process.

F. E. A written discharge summary shall be completed The provider shall complete a written discharge summary within 30 days of discharge and shall include, that includes at a minimum, the following:

1. Reason for the individual's admission to and discharge from the service;

2. Description of participation by the individual's or the individual's 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 were made for future services;

6. Progress made by the individual in achieving goals and objectives identified in the ISP and a summary of critical events during service provision;

7. Discharge date Date of discharge and when the discharge summary was actually written or documented;

8. Discharge medications prescribed by the provider, if applicable;

9. Date the discharge summary was actually written or documented; and

10. 8. Signature of the person who prepared provider's employee or contractor responsible for preparing the discharge summary.

G. F. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.

A. The provider shall implement written policies and procedures for prompt intervention in the event of a crisis as defined in 12VAC35-105-20 or a behavioral, medical, or psychiatric emergency that may occur during screening and referral, at admission, or during the period of service provision.

B. The policies and procedures shall include:

1. A service-specific working definition of what constitutes a crisis or behavioral, medical, or psychiatric emergency;

2. Procedures for immediately accessing appropriate internal and external resources. 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 or mental health clinical services are not available at the time of the emergency;

3. Employee or contractor responsibilities; and

4. 3. Location of emergency medical information for 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.

A. The provider shall implement a policy, appropriate to the scope and level of service offered 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. The provider will manage medical care needs or respond to abnormal findings.

5. The provider will communicate medical assessments and diagnostic laboratory results to the individual and authorized representative, as appropriate.

6. The provider will keep accessible to staff and contractors on duty the names, addresses, and phone numbers of the individual's medical and dental providers.

7. The provider 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 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 provide or arrange for the provision of appropriate medical care. Providers of other services shall define instances when they shall provide or arrange for appropriate medical and dental care and instances when they shall refer the individual to appropriate medical care.

D. The provider shall implement written infection control measures including the use of universal precautions.

E. D. The provider shall report outbreaks of infectious diseases to the Department of Health pursuant to § 32.1-37 of the Code of Virginia.

A. Providers Within 30 days of an individual's admission, providers of residential or inpatient services shall either administer a physical examination or obtain results of physical exams an examination conducted within 30 days of an individual's admission the previous 12 months . 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; and

5. The the date of examination and signature of a qualified practitioner.

C. Locations designated for physical examinations shall ensure individual privacy.

D. The provider shall 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 record.

E. D. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.

A. The provider shall 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 outside the facility;

4. Employees Training requirements necessary for employees or contractors who are authorized to administer medication and training required for administration of medication; and

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 The Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia) .

C. Medications shall be administered as prescribed and 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.

A. 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;

3. The Virginia Board of Nursing regulations; and

4. Applicable federal laws and regulations relating to controlled substances.

B. A provider responsible for medication administration and storage or pharmacy operation shall provide in-service training to employees and consultation to individuals and authorized representatives on issues of basic pharmacology including medication side effects.

A. The provider shall implement written policies and procedures that describe conditions for the use of behavior interventions that comply with the requirements of 12VAC35-115, including 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 interventions;

3. List and define behavior 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 accordance with each individual's ISP;

4. 2. Protect the safety and well-being of the individual at all times, including during fire and or other emergencies; and

5. 3. Specify the mechanism for monitoring and documenting the use of behavior interventions; and

6. Specify the methods for documenting the use of behavior interventions.

B. Employees and contractors trained in behavior support interventions shall implement and monitor all behavior interventions.

C. Policies and procedures related to behavior 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 interventions on other individuals receiving services.

E. Injuries resulting from or occurring during the implementation of seclusion or restraint shall be reported to the department as provided in 12VAC35-115-230 C.

A. The provider shall develop and implement a written records management policy that describes confidentiality, accessibility, security, and retention of paper and electronic records pertaining to individuals, including:

1. Access and limitation of access, duplication, or dissemination, and acquisition of individual information only to persons who are legally 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 that to protect records from loss, unauthorized alteration, inadvertent or unauthorized access, disclosure of information, and transportation of records between service sites;

5. 4. 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; and

6. Designation of the person responsible for records management; and

7. 5. Disposition of records in the event that the service ceases operation. If the disposition of records 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 related to privacy of health records 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) and implementing regulations (45 CFR Parts 160, 162, and 164).

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 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 persons making the entries. For paper records, errors shall be corrected by striking through and initialing the incorrect information. If records are electronic, the provider shall implement a written policy to include the identification of errors and corrections to the record.

A. There shall be a separate primary record for each individual admitted for service. A separate record shall be maintained for each family member who is receiving individual treatment The provider shall maintain each individual's record in accordance with § 32.1-127.1:03 of the Code of Virginia .

B. All individuals admitted to the service shall have identifying information readily accessible in the individual's service record. Identifying information 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 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 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.

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 to protect electronic records.

The provider shall implement a review process to evaluate both current and closed records for completeness, accuracy, and timeliness of entries.

In the service description the provider shall describe the level of services and the medical management provided.

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.

A. The provider shall document staff training in the areas of:

1. Management of withdrawal; and

2. First responder training.

B. Untrained employees or contractors shall not be solely responsible for the care of individuals.

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).