Virginia Regulatory Town Hall
Department of Behavioral Health and Developmental Services
State Board of Behavioral Health and Developmental Services
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10/30/19  4:17 pm
Commenter: Carol Layer, Executive Director, Alexandria CSB

106-180. Governance through 106-190 Organizational Structure
  • 12VAC35-106-180. Governance.

A. The provider shall have a governing body that is accountable for and has authority over the policies and activities of the service and which includes persons with expertise in management, and finances, and individuals from or individuals related to the disability population served. A single individual on the governing body may serve multiple roles.

1. Records of the governing body shall specify the number of its members who are expert in each category listed above. Such records need not identify these members by name.

2. If the agency’s governing body is located outside of Virginia, the governing body shall establish an advisory board in Virginia comprised of Virginia residents from the disability population served or related to the disability population served.

B. The duties and responsibilities of the governing body shall include:

1. Appointment of a full-time executive director or administrator 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;

2. Establishment of an employment contract with a full time executive director or administrator;

3. Orientation for board members;

4. Annual conflict of interest disclosures by board members;

5. Oversight of programs, goals, budgets, operational reviews and licensure status;

6. Establishment of staggered term limits;

7. Definition of decision-making process;

8. Definition of scope of responsibilities for board and executive director or administrator;

9. Establishment of standing committees, at least one of which shall be on audit and finance;

10. Maintaining records documenting actions taken in accordance with 12VAC35-106-180(B)(1) through (9), and records of:

a. Minutes and records of meetings;

b. Reports to the governing body by the executive director or administrator;

c. Instructions and guidance provided to the executive director or administrator by the governing body;

d. Reviews by the governing body of the executive director’s or administrator’s performance, which shall be conducted at least annually; and

e. The governing body’s review and approval of the provider’s audit and annual operating budget.

C. The provider shall submit the following information to the department:

1. The names, addresses and phone numbers of all owners, officers, directors, and financial investors whether they are individuals, general and/or limited partnerships, corporate bodies, or subdivisions of other bodies, and anyone else that meets the definition of provider; the provider shall notify the department of any changes to this information at the same time the provider notifies the Virginia State Corporation Commission;

2. A certificate from the State Corporation Commission; and

3. Ownership or financial interest in the service, program or agency held by current employees, including the nature of such interest and the financial benefits received by the employee. The disclosure shall also state if no benefits are received.


Feedback:  Addition of governance section is regulatory overreach.  Virginia Code already specifies requirements for CSB governing body


  • 12VAC35-106-190. Organizational structure.

A. The provider shall maintain, and make available to any employee or client an organizational chart and written policy that describe the organizational structure including lines of authority, responsibility, communication, and staff assignment.

B. The provider’s full time executive director or administrator shall be on the premises during regular business hours. In his absence a professional staff person shall be designated to act in his place. The provider shall ensure the designee has the contact information for the administration in the event of an emergency.

C. Each provider shall establish a system of business management and staffing to ensure that the provider maintains complete and accurate audits, accounts, books, and records, including required financial, personnel, and client records.


Feedback: Overreach.  Section B is ambiguous in organizations that have multiple licenses in multiple locations.  Suggest that wording be amended to reflect that administrator or designee is available in case of emergency.  Also, typo- “administration” ought to read “administrator”



CommentID: 76776