Chapter 105. Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services

Mobile MAT program locations are exempt from physical plant requirements located within 12VAC35-105-260 through 12VAC35-105-380.Statutory Authority§§ 37.2-302 and 37.2-400 of the Code of Virginia.

All crisis receiving centers, community-based crisis stabilization, crisis stabilization units, and REACH providers shall comply with the provisions of this part.Statutory Authority§§ 37.2-302 and 37.2-400 of the Code of Virginia.

A. Crisis receiving centers shall meet the following staffing requirements: 1. A licensed psychiatrist or nurse practitioner shall be available to the program, either in person or via telemedicine, 24 hours per day, seven days per week; 2. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shal…

A. The provider shall implement a written crisis assessment policy. The policy shall define how crisis assessments will be conducted and documented. B. The provider shall actively involve the individual and the individual's authorized representative, if applicable, in the prepara…

A. The provider shall actively involve the individual and the individual's authorized representative, as appropriate, in the development, review, and revision of a person-centered safety plan and, if appropriate, crisis individualized services plan (crisis ISP). The individualize…

A. All individuals receiving crisis services shall have a safety plan. 1. The safety plan shall be based on the individual's immediate service, health, and safety needs identified in the crisis assessment. The safety planning process shall be an ongoing activity. The safety plan …

A. Crisis providers are not subject to the provisions of 12VAC35-105-693. B. Community-based crisis stabilization providers of mobile crisis response and crisis receiving center providers shall make referrals to all follow-up service providers if determined appropriate and docume…

A. Crisis receiving centers, crisis stabilization units, and REACH CTH providers shall administer a nursing assessment within 24 hours of admission of an individual. B. Prior to admission, each individual shall have a screening for communicable diseases, including tuberculosis, a…

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 the organization is a component or describing the legal and administrat…

A. This section applies to all crisis receiving centers, crisis stabilization units, and REACH CTH providers. B. Unless the individual refuses, the provider shall take vital signs upon admission, during the provision of services as per the medical provider's orders, and at discha…

A. For the purpose of this section, "clean" means freshly laundered, sanitized, and not soiled or stained. B. Crisis receiving center providers shall arrange for each individual to have a recliner or bed. Crisis stabilization unit and REACH CTH providers shall arrange for each in…

A. This section only applies to crisis stabilization units and REACH CTH providers. B. 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 l…

A. The physical environment, design, structure, furnishings, and lighting shall be appropriate to the individuals receiving services and the services provided. B. The physical environment shall be accessible to individuals with physical and sensory disabilities. C. The physical e…

Seclusion is only allowed as permitted by 12VAC35-115 and other applicable state regulations.Statutory Authority§§ 37.2-302 and 37.2-400 of the Code of Virginia.

The room used for seclusion of persons shall meet the following design requirements: 1. The seclusion room shall be at least six feet wide and six feet long with a minimum ceiling height of eight feet. 2. The seclusion room shall be free of all protrusions, sharp corners, hardwar…

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise: "Abuse" means, as defined by § 37.2-100 of the Code of Virginia, any act or failure to act by an employee or other person responsible for the …

The provider shall appoint qualified persons to whom it delegates, in writing, the authority and responsibility for the administrative direction and day-to-day operation of the provider and its services. Statutory Authority§ 37.2-203 of the Code of Virginia.

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. In add…

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. Commercial vehicular liability; and 4. Property damage. Statutory Authority§ 37.2-203 of…

If the provider charges for services, the written schedule of rates and charges shall be available to the individual or authorized representative upon request. Statutory Authority§ 37.2-203 of the Code of Virginia.

A. The provider shall implement a 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 indiv…

A. The provider shall not use any advertising that contains false, misleading or deceptive statements or claims, or false or misleading disclosure of fees and payment for services. B. The provider's name and service names shall not imply the provider is offering services for whic…

All locations shall be inspected and approved as required by the appropriate building regulatory entity. 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…

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.Statutory Authority§ 37.2-203 of the Code of Virginia.

The provider shall submit a plan to the department addressing safety and continued service delivery for any planned construction involving (i) changes in the use of existing locations or (ii) structural modifications to new or existing buildings. This section does not apply to co…

A. The physical environment, design, structure, furnishings, and lighting shall be appropriate 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. T…

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…

A. Licenses are issued to providers who offer services to individuals who have mental illness, a developmental disability, or substance abuse (substance use disorders) or have brain injury and are receiving residential services. B. Providers shall be licensed to provide specific …

A. Service locations shall be on a public water and sewage system or on a nonpublic water and sewage system. 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 …

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 premises, including parking areas, of the provider's services. The policy shall provide that no firearms, pellet guns…

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 (13VAC5-52).…

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. Statutory Authority§ 37.2-203 of the Code…

A. The provider shall not operate more beds than the number for which its service location is licensed. B. An ICF/IID may not have more than 12 beds at any one location. This applies to new applications for services and not to existing services or locations licensed prior to Dece…

A. 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 a…

A. 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 linens. Providers of sponsored residential home services shall …

A. Bedroom and bathroom windows and doors shall provide privacy. B. Bathrooms intended for 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 secti…

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. This section does not apply to correctional facilities or jails or cri…

Each service location shall have adequate lighting in halls and bathrooms at night. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter. Providers of sponsored residential home services shall certify that their sponsored r…

A. The provider shall maintain an organized system to manage and protect the confidentiality of personnel files and records. B. Providers shall comply with requirements of the Americans with Disabilities Act (42 USC § 12101 et seq.) and the Virginians with Disabilities Act (§ 51.…

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 shall submit: 1. A working budget showing projected revenue and expenses for the first year of operatio…

A. Providers shall comply with the requirements for obtaining criminal history background checks as outlined in §§ 37.2-416, 37.2-416.1, 37.2-506, 37.2-506.1, and 37.2-607 of the Code of Virginia. B. The provider shall develop a written policy for criminal history background chec…

Each employee or contractor shall have access to the employee's or contractor's current written job description that includes: 1. Job title; 2. Duties and responsibilities; and 3. Minimum knowledge, skills, and abilities; education or training; or experience or professional quali…

A. Each person who assumes the responsibilities of a position as an employee or a contractor shall meet the minimum qualifications of that position in accordance with the current job description. B. Employees and contractors shall comply, as required, with the regulations of the …

A. Employee or contractor personnel records shall include: 1. Individual identifying information; 2. Education and training history; 3. Employment history; and 4. A record of disciplinary action taken by the provider, if any. B. Each employee or contractor personnel record shall …

Providers shall give a statement in writing regarding a current or past employee or other individual currently or previously associated with the provider in a capacity that requires a criminal history background check pursuant to § 37.2-416 or 37.2-506 of the Code of Virginia to …

New employees, contractors, volunteers, and students shall be oriented commensurate with the individual's function or job-specific responsibilities within 15 business days. The provider shall document that the orientation covers each of the following policies, procedures, and pra…

The provider shall provide training and development opportunities for employees to enable them to support the individuals receiving services and to carry out their job responsibilities. The provider shall develop a training policy that addresses the frequency of retraining on ser…