A. The following words and terms when used in this chapter shall have the meanings ascribed in 12VAC35-270-20:

"Abuse"

"Admission"

"Authorized representative"

"Commissioner"

"Contractor"

"Crisis"

"Department"

"Developmental disability"

"Discharge"

"Discharge plan"

"Individual" or "individual receiving services"

"Medication"

"Medication administration"

"Person-centered"

"Provider"

"Referral"

"Residential" or "residential service"

"Restraint"

"Restriction"

"Screening"

"Service"

"Succession plan"

"Volunteer"

"Written," "writing," and "in writing"

B. The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

“Community-based crisis stabilization” means services that are short-term and designed to support an individual and the individual’s natural support system following contact with an initial crisis response service or as a diversion to a higher level of care. Providers deliver community-based crisis stabilization services in an individual’s natural environment and provide referrals and linkage to other community-based services at the appropriate level of care. Interventions may include mobile crisis response, brief therapeutic and skill-building interventions, integration of natural supports into the de-escalation and stabilization of the crisis, and coordination of follow-up services. Coordination of specialized services to address the needs of co-occurring developmental disabilities or substance use disorders are also available through this service. Services include advocacy and networking to provide linkages and referrals to appropriate community-based services and assist the individual and the individual’s family or caregiver in accessing other benefits or assistance programs for which the individual may be eligible. The goal of community-based crisis stabilization services is to stabilize the individual within the community and support the individual and, as appropriate, the individual’s support system (i) as a transitional step-down from a higher level of care if the next level of care service is identified but not immediately available for access; or (ii) as a diversion to a higher level of care.

“Crisis education and prevention plan” or “CEPP” means a standardized, department-approved, individualized, client-specific written document that provides a concise, clear, and realistic set of supportive interventions to prevent or de-escalate a crisis and assist an individual who may be experiencing a behavioral crisis. The goal of the CEPP is to identify problems that arose in the past or are emergent in order to (i) teach the individual skills to apply independently and (ii) plan strategies that offer the individual and the individual’s support system assistance in addressing and de-escalating problems in a healthy way.

“Crisis individualized services plan” or “crisis ISP” means a written plan that is developed by community-based crisis stabilization and crisis stabilization unit providers as soon as possible but no later than 48 hours after an individual’s admission to the service. A crisis ISP describes the individual's needs, attainable goals and measurable objectives to address those needs, and strategies to reach the individual's goals. A crisis ISP is person-centered, empowers the individual, and is designed to meet the needs and preferences of the individual. The crisis ISP is developed through a partnership between the individual and the provider. Due to the acute nature of crisis services, a crisis ISP will focus on shorter term needs, goals, and objectives that will help stabilize the individual so that the individual is able to move out of crisis services. Longer term needs, goals. and objectives may be noted and worked on in treatment, yet the goal is stabilization and movement out of crisis care to a more sustainable treatment plan.

"Crisis planning team" means the team that is consulted to plan the individual's safety plan or crisis ISP. The crisis planning team consists, at a minimum, of the individual receiving services, the individual's legal guardian or authorized representative, and a member of the provider's crisis staff. The crisis planning team may include the individual's support coordinator or case manager, family, or other identified persons as desired by the individual, such as the individual's family of choice.

“Crisis receiving center,” “CRC,” or “23-hour crisis stabilization” means a community-based, non-hospital, non-residential facility providing short-term assessment, observation, and crisis stabilization services to all referrals for up to 23 hours per day. This service is accessible 24 hours per day, seven days per week, 365 days per year, and is indicated when an individual requires a safe environment for initial assessment and intervention. This service includes a thorough assessment of an individual’s behavioral health crisis, psychosocial needs, and supports to determine the least restrictive environment most appropriate for stabilization. Key service functions include rapid assessment, crisis intervention, de-escalation, short-term stabilization, and appropriate referrals and linkages for ongoing care. A crisis stabilization unit may be co-located with a CRC.

"Crisis stabilization" means direct, intensive nonresidential or residential 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.

“Crisis stabilization unit” or “CSU” means a community-based, short-term 24-hour crisis service unit. CSUs serve as primary alternatives to inpatient hospitalization for individuals who are in need of a safe, secure environment for assessment and crisis treatment. CSUs also serve as a step-down option from psychiatric inpatient hospitalization and function to stabilize and reintegrate individuals who meet medical necessity criteria back into their communities. This service meets the requirements of a "residential crisis stabilization unit" of § 38.2-3412.1 of the Code of Virginia.

"Licensed mental health professional" or "LMHP" means a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, certified psychiatric clinical nurse specialist, licensed behavior analyst, or licensed psychiatric/mental health nurse practitioner.

"Licensed mental health professional-resident" or "LMHP-R" means the same as “resident” as defined in 18VAC115-20-10 for licensed professional counselors, 18VAC115-50-10 for licensed marriage and family therapists, or 18VAC115-60-10 for licensed substance abuse treatment practitioners. An LMHP-R shall be in continuous compliance with the regulatory requirements of the applicable counseling profession for supervised practice.

"LMHP-resident in psychology" or "LMHP-RP" means an individual in a residency, as that term is defined in 18VAC125-20-10, for clinical psychologists. An LMHP-RP shall be in continuous compliance with the regulatory requirements for supervised experience as found in 18VAC125-20-65.

"LMHP-supervisee in social work," "LMHP-supervisee," or "LMHP-S" means the same as "supervisee" as defined in 18VAC140-20-10 for licensed clinical social workers. An LMHP-S shall be in continuous compliance with the regulatory requirements for supervised practice as found in 18VAC140-20-50.

"Ligature risk" means any element of the environment that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.

"Mandatory outpatient treatment order" means an order issued by a court pursuant to § 37.2-817 of the Code of Virginia.

“Mobile crisis response” means an element of community-based crisis stabilization services that is available 24 hours per day, seven days per week, 365 days per year to provide rapid response, assessment, and early intervention to individuals experiencing a behavioral health crisis. Services are deployed in real time to the location of the individual experiencing a behavioral health crisis. The purpose of this service is (i) de-escalation of the behavioral health crisis to prevent harm to the individual or others; (ii) assisting in the prevention of an individual’s acute exacerbation of symptoms; (iii) development of an immediate plan to maintain safety; and (iv) coordination of care and linking to appropriate treatment services to meet the needs of the individual.

"Qualified mental health professional" or "QMHP" as defined by § 54.1-3500 of the Code of Virginia means a person who by education and experience is professionally qualified and registered by the Board of Counseling in accordance with 18VAC115-80 to provide collaborative mental health services for adults or children. A QMHP does not engage in independent or autonomous practice. A QMHP provides services as an employee or independent contractor of the department or a provider licensed by the department.

"Qualified mental health professional-trainee" or "QMHP-T" means a person receiving supervised training to qualify as a QMHP in accordance with 18VAC115-80 and who is registered with the Board of Counseling.

"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 a developmental disability, the concept of recovery does not apply in the sense that individuals with a developmental disability will need supports throughout their entire lives although these may change over time. With supports, individuals with a developmental disability are capable of living lives that are fulfilling and satisfying and that bring meaning to themselves and others whom they know.

“Renovation” means any replacement or upgrade of materials that will change the purpose or level of activities of a space.

"Signed" or "signature" means a handwritten signature, an electronic signature, or a digital signature, as long as the signer showed clear intent to sign.

Providers shall be licensed to provide specific services as defined in this chapter or as determined by the commissioner. The following services shall require a crisis license:

1. Community-based crisis stabilization;

2. Crisis receiving center; and

3. Crisis stabilization units.

A. Crisis providers shall not operate their services within a property zoned as a single-family residence. This provision does not apply to providers operating prior to September 19, 2002.

B. Every crisis facility shall be in a location suitable to meet the physical environment requirements of Part II of this chapter. Each facility shall allow for clear access by law enforcement, emergency services, and other appropriate crisis partners. This shall include appropriate parking and a dedicated drop off area at a door of the facility. Zoning placement within each community shall be a primary consideration and providers shall be required to submit a certificate of occupancy to document appropriate zoning to the Office of Licensing during the application process (12VAC35-270-40).

A. The crisis receiving center service includes ongoing assessment, crisis intervention, and clinical determination for the appropriate level of care to individuals experiencing a behavioral health crisis. Services are provided in a community-based, non-hospital setting for a period of up to 23 hours per day. This service shall be accessible 24 hours per day, seven days per week and is indicated when an individual is in an acute crisis and requires a safe environment for observation and assessment prior to determination of the next level of care. Services offered shall include assessment, psychiatric evaluation, a nursing assessment, and coordination of follow-up services. This service is required to meet physical environment requirements as listed within this chapter. Programs within this service for adults and children shall be separate and distinct. The provider shall provide for the physical separation of children and adults and shall maintain separate group programming for adults and children. Providers of both children's and adult services shall ensure that children receiving services and adults receiving services are not mixed in shared spaces. The provider shall provide for the safety of children accompanying parents receiving services. A crisis receiving center shall not be considered residential occupancy for the purposes of § 15.2-2291 of the Code of Virginia.

B. Community-based crisis stabilization includes short-term assessment, crisis intervention including mobile crisis response, and coordination of follow-up services to individuals experiencing a behavioral health crisis. Services shall be provided in the individual’s home, workplace, or other convenient and appropriate setting and shall be accessible 24 hours per day, seven days per week. Offering crisis stabilization in an office-based setting shall be based on the individual’s documented clinical needs, documented individual preference, or relation to the coordination of follow-up services. Services shall include assessment and screening, including explicit screening for suicidal or homicidal ideation; brief therapeutic and skill-building interventions; integration of natural supports into the de-escalation and stabilization of the crisis; crisis education; and coordination of follow-up services. The provider shall develop an immediate plan to maintain safety in order to prevent the need for a higher level of care. Coordination of follow-up services shall include advocacy on behalf of the individual, networking to provide linkages and referrals to appropriate community-based services or resources, and assisting the individual and the individual’s natural support system in accessing other benefits or assistance programs for which the individual may be eligible. When clinically necessary, crisis stabilization is also the mechanism by which pre-admission screenings for hospitalization may be performed by clinicians trained by the department in pre-admission screening.

C. The crisis stabilization unit service includes short-term psychiatric and substance-related assessment and brief intervention services to individuals experiencing abrupt and substantial changes in behavior noted by severe impairment or acute decompensation in functioning. Services are provided in a non-hospital, community-based unit. This service shall be accessible 24 hours per day, seven days per week, and is indicated when an individual requires a safe environment for assessment and stabilization. CSUs may also provide medically monitored residential services for the purpose of providing psychiatric stabilization and substance withdrawal management services on a short-term basis. Services offered shall include assessment; medical, nursing, psychiatric, and psychosocial evaluation; medical and nursing care; treatment planning; medication management; skills restoration; individual and group therapy; crisis intervention; and coordination of follow-up services. Programs within this service for adults and children shall be separate and distinct. The provider shall provide for the physical separation of children and adults and shall provide separate group programming for adults and children. Providers of both children's and adult services shall ensure that children receiving services and adults receiving services are not mixed in shared spaces. The provider shall provide for the safety of children accompanying parents receiving services.

A. In addition to the provisions of 12VAC35-270-300, providers of crisis services shall incorporate the following minimum provisions into the provider staffing plan.

B. Crisis receiving center providers shall meet the following staffing requirements:

1. A licensed psychiatrist or nurse practitioner shall be available to the program 24 hours per day, seven days per week, either in person or via telemedicine;

2. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall be available for conducting assessments;

3. Nursing services shall be provided by a registered nurse (RN) or a licensed practical nurse (LPN). Nursing staff shall be available 24 hours per day, in person. LPNs shall work directly under the supervision of a physician, nurse practitioner, or RN;

4.Medical, psychological, psychiatric, laboratory, and toxicology services shall be available by consult or referral; and

5. Adequate qualified direct care staff necessary to meet the needs of the individuals receiving services shall be on-site.

C. Community-based crisis stabilization providers shall meet the following staffing requirements:

1. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall conduct crisis assessments and, and for any CEPP not authored by an LMHP, review, and if the LMHP, LMHP-R, LMHP-RP, or LMHP-S agrees, sign the CEPP;

2. All staff are required to utilize a working global positioning system (GPS) enabled smart phone or GPS-enabled tablet;

3. Any time staff are dispatched for the provision of mobile crisis response, the provider shall dispatch a team that meets at least one of the following staffing composition requirements:

a. If a single person is dispatched for mobile crisis response:

(1) One licensed staff member; or

(2) One certified pre-screener.

b. If the provider dispatches a team for mobile crisis, the team shall include:

(1) One licensed staff member and one peer recovery specialist (PRS);

(2) One licensed staff member and one certified substance abuse counselor (CSAC), CSAC-supervisee, or certified substance abuse counselor assistant (CSAC-A);

(3) One licensed staff member and one QMHP or QMHP-T;

(4) One PRS and either one QMHP or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;

(5) One CSAC-A and either one QMHP or one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment;

(6) Two QMHPs or one QMHP and one QMHP-T. A licensed staff member shall be required to be available via telemedicine for the assessment;

(7) Two CSACs. A licensed staff member shall be required to be available via telemedicine for the assessment; or

(8) One QMHP and one CSAC or CSAC-supervisee. A licensed staff member shall be required to be available via telemedicine for the assessment.

D. Crisis stabilization unit providers shall meet the following staffing requirements:

1. A licensed psychiatrist or psychiatric nurse practitioner shall be available 24 per day, seven days per week either in-person or via telemedicine;

2. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall be available to conducting an assessment;

3. Nursing services shall be provided by either a RN or an LPN. Nursing staff shall be available in person 24 hours per day, seven days per week. LPNs shall work directly under the supervision of a physician, nurse practitioner, or RN. Nursing may be shared among co-located crisis programs;

4. Medical, psychological, psychiatric, laboratory, and toxicology services shall be available by consult or referral; and

5. Adequate qualified direct care staff necessary to meet the needs of the individuals receiving services shall be on-site.

A. Providers shall implement an initial contact policy that includes:

1. Identification, qualification, training and duties of employees responsible for initial contact with individuals.

2. To the best of the provider’s ability, the following minimum required elements of initial contact for a crisis setting:

a. Date of contact;

b. Legal name, preferred name, date of birth, sex, and gender of the individual;

c. Contact information, including address, telephone number, and email address of the individual, if applicable;

d. The individual’s local community services board and any other community services board providing services; and

e. Reason why the individual is requesting services.

3. Methods the provider will utilize to identify other appropriate services or resources to assist individuals who are not admitted to the provider’s service.

B. The provider shall retain documentation of the individual’s initial contacts for six months. For individuals admitted to the service, documentation shall be retained in accordance with the provider’s written records management policy pursuant to 12VAC35-270-580.

C. Providers may complete the individual’s initial contacts and crisis assessment at the same time, if appropriate.

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, and any family members or other identified persons as desired by the individual, in the preparation of crisis assessments. In these crisis assessments, the provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.

C. The crisis assessment policy shall designate appropriately qualified employees or contractors who are responsible for conducting, obtaining, or updating assessments including nursing assessments. These employees or contractors shall have experience in working with the needs of individuals who are being assessed, with the crisis assessment tools being utilized and the provision of services that the individuals may require. The crisis assessment policy shall include methods the provider will utilize to identify other appropriate services to assist individuals who are not admitted to the provider’s service.

D. Assessment is an ongoing activity. The provider shall make reasonable attempts to obtain previous assessments or history relevant to the crisis. The provider shall use the individual’s previous assessments or other relevant history within the course of treatment, if applicable, as noted within subsection F of this section.

E. Providers shall utilize standardized state-sanctioned or federally sanctioned crisis assessment tools as approved by the department or utilize their own crisis assessment tools that shall meet the requirements in subsection F of this section.

F. A crisis assessment shall be 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, or obtain information from other qualified providers in order to complete, a crisis assessment detailed enough to (i) determine whether the individual qualifies for admission and (ii) initiate a safety plan or crisis ISP as required by this chapter for those individuals who are admitted to the service.

1. The crisis assessment shall assess the individual’s service, health and safety needs and, at a minimum, include:

a. Diagnosis, including current and past substance use or dependence and risk for intoxication or substance withdrawal, and co-occurring mental illness or developmental disability;

b. Risk of harm, including elements that may make an individual a danger to self or others;

c. Cognitive functional status, including the individual’s ability to protect self from harm and provide for basic human needs;

d. Precipitating issues, including recent stressors or events;

e. Presenting needs, including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of needs. The assessor shall record:

(1) Any physical reaction to the presenting crisis, if these issues are mentioned by the individual or observed during the assessment. Examples include issues with sleep, appetite, or daily activities;

(2) The individual’s housing arrangements and living situation, if mentioned by the individual; and

(3) Any trauma, such as sexual abuse, physical abuse, or natural disaster, if appropriate, including whether a traumatic experience relates to the current crisis or is mentioned by the individual.

f. Additional current medical issues and symptoms, if applicable;

g. Current medications, including recent changes to medications. The assessor shall review current medications to the best of the individual’s ability;

h. Barriers or risk factors that will impact the individual’s ability to seek treatment or continue to participate in services, including the individual’s mood, ability, and willingness to engage in treatment, and access to transportation;

i. The individual’s recovery environment and circle of support; and

j. Communication modality and language preference.

2. For crisis stabilization units and community-based crisis stabilization providing services other than mobile crisis, the assessment shall also include:

a. Relevant treatment history and health history, to include as applicable:

(1) Past prescribed medications;

(2) Hospitalizations for challenging behaviors, mental illness, or substance use;

(3) Other treatments for challenging behaviors, mental illness, or substance use;

(4) Allergies, including allergies to food or medications;

(5) Recent physical complaints and medical conditions;

(6) Nutritional needs;

(7) Chronic conditions;

(8) Communicable diseases;

(9) Restrictions on physical activities if any;

(10) Restrictive protocols or special supervision requirements;

(11) Preferred interventions in the event behaviors or symptoms become a danger to self or others;

(12) All known contraindications to the use of seclusion, time out, or any form of physical or mechanical restraint, including medical contraindications and history of trauma;

(13) Past serious illnesses, serious injuries, and hospitalizations;

(14) Serious illnesses and chronic conditions of the individual's parents, siblings, and significant others in the same household; and

(15) Other interventions and outcomes, including interventions and outcomes that were unsuccessful, with the provider ensuring previous assessments are utilized to note these interventions.

b. The individual’s housing arrangements or living situation;

c. Trauma, such as sexual abuse, physical abuse, or natural disaster; and

d. Current or previous involvement in justice, welfare, or public benefit systems, such as legal proceedings, adult or child protective services, or social services departments.

3. If applicable to the individual’s crisis, the assessment shall also include:

a. The individual’s social, behavioral, developmental, and family history and supports;

b. Employment, vocational, and educational background;

c. Cultural and heritage considerations; and

d. Financial stressors.

G. Completion of the crisis assessment shall be as soon as possible after admission but no later than 24 hours after admission.

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, a crisis ISP. The individualized planning process shall be consistent with laws protecting confidentiality, privacy, human rights of individuals receiving services, and rights of minors. To the extent possible, the provider shall collaborate with the individual’s crisis planning team to develop, review and revise, and implement, as appropriate, the individual’s safety plan or crisis ISP.

B. Providers of developmental services shall collaborate with the individual’s support coordinator to develop, or review and revise, and implement, as appropriate, a provisional person-centered crisis education and prevention plan (CEPP) within 15 days of admission. An updated CEPP shall be completed within 45 days of admission. Developmental services providers may utilize a CEPP as an individual’s safety plan, if appropriate. If a CEPP is to be used as a safety plan, the provider shall meet the deadline listed in subsection C of this section.

C. Providers of mental health and substance abuse services shall develop, or review and revise, and implement, as appropriate, a person-centered safety plan immediately after admission that shall continue in effect until discharge from the provider’s crisis service.

D. Providers of crisis services shall develop and implement a crisis ISP, in addition to a safety plan, as soon as possible but no later than 48 hours after admission. This provision does not apply to mobile crisis response or crisis receiving centers.

E. Development of the safety plan and crisis ISP shall be based on the crisis assessment with the participation and informed choice of the individual receiving services.

1. To ensure the individual's participation and informed choice, the following shall be explained to the individual or the individual’s authorized representative, as applicable, in a reasonable and comprehensible manner:

a. The proposed services to be delivered;

b. Any alternative services that might be advantageous for the individual; and

c. Any accompanying risks or benefits of the proposed alternative services.

2. If no alternative services are available to the individual, it shall be documented within the individual’s service record that alternative services were not available as well as any steps taken to identify if alternative services were available.

3. Whenever there is a change to an individual’s safety plan or crisis ISP, the changes shall be documented within the safety plan or crisis ISP or within attached documentation that:

a. The individual participated in the development of or revision to the safety plan or crisis ISP;

b. The proposed and alternative services and their respective risks and benefits were explained to the individual or the individual’s authorized representative; and

c. The reasons the individual or the individual’s authorized representative chose the option included in the safety plan or crisis ISP.

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 plan shall include:

a. Warning signs that a crisis may be developing, such as thoughts, images, moods, situations, behavior or stressors that may trigger the individual;

b. Internal coping strategies or methods performed independently, such as relaxation techniques or physical activities;

c. People and social settings that the individual may turn to for distraction or support;

d. People the individual may ask for help;

e. Professionals or agencies the individual can contact during a crisis; and

f. Specific steps the individual can take to make the individual’s environment safe.

2. The safety plan may include:

a. A description of how to support the individual when pre-crisis behaviors are observed;

b. Specific instructions for the systems supporting the individual when pre-crisis behaviors are observed;

c. A description of how to support the individual when crisis behaviors are observed; and

d. Specific instructions for the systems supporting the individual during crisis.

B. Providers of community-based crisis stabilization and crisis stabilization unit shall also develop a crisis ISP for each individual. A crisis ISP shall be based on the individual’s immediate service, health, and safety needs identified in the crisis assessment. The crisis ISP shall include:

1. Relevant and attainable goals, measurable objectives to inform current and future treatment, and specific strategies for addressing each need documented within the individual’s crisis assessment;

2. Services, and supports, and frequency of services required to accomplish the goals, including relevant psychological, mental health, substance use, behavioral, medical, rehabilitation, training, and nursing needs and supports;

3. Any use of seclusion if allowed in the service per 12VAC35-115;

4. The role of the individual and others, including the individual’s family, if appropriate, in implementing the crisis ISP;

5. Identification of employees or contractors responsible for coordination and integration of services, including employees of other agencies;

6. A behavioral support or treatment plan, if applicable; and

7. Projected discharge plan and estimated length of stay within the service.

C. The crisis ISP shall be implemented as soon as possible after admission but no later than 48 hours after admission. The crisis ISP shall continue in effect until the individual is discharged from the provider’s crisis service.

D. In order to document agreement, both the safety plan and the crisis ISP shall be signed and dated, at a minimum, by (i) the person responsible for implementing the safety plan or crisis ISP and (ii) the individual receiving services or the individual’s authorized representative, if appropriate.

1. If the signature of the individual receiving services or the individual’s authorized representative cannot be obtained, the provider shall document attempts to obtain the necessary signature and the reason it was unobtainable. The provider shall attempt to obtain the necessary signature while the safety plan or crisis ISP is in effect, on a periodic basis and at a minimum each time the provider reviews the safety plan or crisis ISP as required by 12VAC35-278-100.

2. The provider shall document distribution of the safety plan and crisis ISP to the individual and others authorized to receive it within the individual's service record. If the safety plan or and crisis ISP cannot be distributed, the provider shall document the reason distribution attempts were unsuccessful. The provider shall attempt to distribute the safety plan and the crisis ISP for the length of time the safety plan or crisis ISP is in effect, on a periodic basis and at a minimum each time the provider reviews the safety plan or crisis ISP as required by 12VAC35-278-100.

E. The provider shall have a crisis ISP policy that designates an employee or contractor responsible for developing, implementing, reviewing, and revising each individual's safety plan and crisis ISP, in collaboration with the individual or the individual’s authorized representative, as appropriate.

F. The designated employees or contractors shall (i) have access to the individual's safety plan or crisis ISP, including detailed health and safety protocols, and (ii) be competent to implement the plans as written.

G. Whenever possible, the identified goals in the safety plan or crisis ISP shall be written in the words of the individual receiving services.

H. The provider shall use signed and dated progress notes to document the provider’s efforts towards the implementation of the goals and objectives contained within the safety plan or crisis ISP.

A. Reassessments shall be completed any time the individual is within the provider’s service and there is a need based on changes in the medical, psychiatric, behavioral, or other status of the individual.

B. The provider shall actively involve the individual and the individual’s authorized representative, if applicable, in reassessments. The provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.

C. Providers shall complete changes to the safety plan or crisis ISP, if necessary or if desired by the individual, as a result of the reassessment.

D. If necessary as a result of a reassessment, providers shall complete changes to medical protocols or collaborate with other providers to ensure changes are made to medical, medical equipment, behavioral, or other corresponding protocol.

E. After each reassessment the provider shall ensure that the individual’s most current crisis ISP is easily accessible to the employee or contractor responsible for implementing the safety plan or crisis ISP.

A. The records management policy required by 12VAC35-270-580 shall ensure that progress notes are maintained pursuant to this section.

B. The provider shall use signed and dated progress notes or other documentation to document the services provided. Progress notes shall at a minimum:

1. Be consistent across the provider’s service;

2. Be legible and readable;

3. Record the individual’s response to the intervention by staff who are responsible for implementing the treatment plan, including care provided and events relevant to diagnosis and treatment or care of the individual;

4. Have a narrative component, which notes relevant events that occurred during the provision of services;

5. Describe needed follow-up care; and

6. Be signed and dated by the staff who provided the service.

C. Progress notes shall be entered into the individual’s record each time the individual receives services.

D. Communication logs and supervision notes shall not be considered progress notes.

A. Community-based crisis stabilization providers of mobile crisis response and crisis receiving center providers shall make arrangements and referrals to all follow-up service providers. The provider shall document in the individual’s safety plan (i) the discharge arrangements or referrals or (ii) reasons why follow-up care was not indicated.

B. Community-based crisis stabilization providers, when providing mobile crisis response services, and crisis receiving center providers are not required to provide the discharge planning described within 12VAC35-278-130 to individuals receiving services.

A. Crisis providers are not subject to the provisions of 12VAC35-270-430.

B. Community-based crisis stabilization providers and crisis stabilization units 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.

C. Discharge instructions shall be provided in writing to the individual, the individual’s authorized representative, and any successor provider, as applicable. Discharge instructions shall include, at a minimum, medications and dosages; names, telephone 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. The provider shall make appropriate referrals to all service providers identified within the individual’s discharge instructions prior to the individual’s scheduled discharge date.

D. The provider shall document in the individual's service record whether the individual, the individual’s authorized representative, and the individual’s family members, as appropriate, were involved in the discharge planning process.

E. The content of the discharge plan and the determination to discharge the individual shall be consistent with the crisis ISP and the criteria for discharge.

A. For the purposes of this section, a crisis or a behavioral, medical, or psychiatric emergency is a situation that poses an imminent risk to the individual or others that cannot be addressed within the scope of the provider’s services. This does not include events that require the use of restrictive behavior intervention and supports as discussed within 12VAC35-270-500.

B. The provider shall implement written policies and procedures, as approved by the department, for prompt intervention in the event of a crisis or a behavioral, medical, or psychiatric emergency that may occur during screening and referral, at admission, or during the period of service provision.

C. The policies and procedures shall include:

1. 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;

2. Employee or contractor responsibilities; and

3. Location of the face sheets with emergency medical information as required by 12VAC35-270-460.

A. Crisis receiving centers and crisis stabilization units shall administer a nursing assessment within 24 hours of admission of an individual.

B. Prior to admission to crisis receiving centers or crisis stabilization units, each individual shall have a screening for communicable diseases, including tuberculosis, as evidenced by the completion of a screening form containing, at a minimum, the elements found on the Report of Tuberculosis Screening form published by the Virginia Department of Health. The screening may be no older than 30 days. No screening shall be required for an individual separated from a service with another licensed provider with a break in service of six months or less.

C. A staff member who is a medical professional shall conduct a nursing assessment. The nursing assessment shall collect information about the individual’s nonpsychiatric medical or surgical condition to determine whether a more thorough medical assessment is needed before a decision is made regarding continuation of treatment within the provider’s service or transfer to a more intensive level of care. The nursing assessment shall evaluate if there is a current medical crisis or underlying medical condition for the individual’s psychological crisis, such as any medical condition that affects the individual’s psychological state, presenting behavior, or ability to receive the provider’s service. The nursing assessment shall note the date of examination and include the signature of a qualified practitioner.

D. Locations designated for nursing assessments shall ensure individual privacy.

E. The provider shall (i) review the results of the nursing assessment, including any follow-up diagnostic tests, treatments, or examinations, and (ii) document the arrangements for follow-up care in the individual's record.

F. Each individual's health record shall include notations of any health or dental complaints mentioned by the individual or any injuries and shall summarize symptoms and treatment given.

G. Each individual’s health record shall include or document the facility's efforts to obtain treatment summaries of ongoing psychiatric or other mental health treatment and reports.

H. The provider shall develop and implement written policies and procedures that include use of standard health precautions and address communicable and contagious medical conditions.

I. Community-based crisis stabilization providers are not required to administer nursing assessments. The provider may administer a nursing assessment if the provider has the resources to do so or may obtain a medical history or relevant information that would be a part of a medical history if the individual receiving services provides it.

A. Providers shall ensure the provision of emergency medical services for each individual.

B. Crisis stabilization units shall implement a policy that addresses provision of adequate and appropriate medical and dental care. This policy shall describe to what extent and how:

1. Medical and dental care needs will be assessed including and the circumstances that will prompt the decision to obtain a medical assessment.

2. Crisis ISPs will address any medical and dental care needs appropriate to the scope and level of service.

3. The provider will provide or arrange for the provision of medical and dental care needs identified at admission.

4. During the provision of the provider’s services, the provider will provide or arrange for the provision of routine ongoing and follow-up medical and dental care services.

5. The provider will communicate the results of physical examinations, medical assessments, diagnostic laboratory results, treatments, or examinations to the individual and the individual's 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.

C. Providers shall provide or arrange for the provision of appropriate medical care.

D. The provider shall 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.

F. Employees, contractors, students, or volunteers of CSUs shall complete tuberculosis education as part of initial orientation and thereafter on an annual basis. The education shall focus on self-presentation in the event of exposure to active tuberculosis or the development of symptoms of active tuberculosis disease.

In the event of a medication error or adverse drug reaction:

1. First aid shall be administered if indicated.

2. Employees or contractors shall promptly contact a poison control center, pharmacist, nurse, or physician and shall take actions as directed.

3. The individual's physician shall be notified as soon as possible unless the situation is addressed in standing orders.

4. All actions taken by employees or contractors shall be documented, such as in incident reports or progress notes.

5. The provider shall review medication errors at least quarterly as part of the quality assurance in 12VAC35-270-570.

6. Medication errors and adverse drug reactions shall be recorded in the individual's medication log.

A. This section applies to all crisis receiving centers and crisis stabilization units.

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 discharge.

C. The provider shall implement written procedures regarding the collection of vital signs, including documentation of vital signs, all refusals, and follow-up actions taken.

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.

B. The provider shall develop a written emergency preparedness and response plan for all of its services and locations. This plan shall include specifics for each location and shall include the following:

1. An analysis and prioritization of vulnerability of all services and locations to various hazards that may impact the provider. Vulnerability is a combination of the likelihood and severity of hazard occurrence.

2. A base-level response plan that is applicable to all hazards and includes:

a. Documentation of preparedness activities such as emergency planning team meetings, incident reviews, plan revisions, etc.

b. Maintenance of a 24-hour phone line which can be used for communication during emergencies.

c. Documented procedure for activation of the emergency plan including a description of various triggers for activation, who may activate, and overall situation assessment, response escalation, situation stabilization, and life and property preservation as first priority during any response.

d. Documented procedure to notify the department of activation of the emergency plan as soon as possible, but no later than 24 hours after incident occurrence.

e. Documented polices, outlining specific responsibilities for incident command and the necessary incident management team including operations, logistics, planning and finance.

f. Documented policies and procedures to ensure, to the extent possible, the life safety of employees, contractors, volunteers, visitors, and individuals served.

g. Policy and procedures for building access and security to include both provision of a secure building under adverse circumstances and appropriate access to the building by emergency responders.

h. Documented policies and procedures for the resumption of normal activities following service disruption by and emergency including any necessary site inspections required before repatriation can take place.

i. Documented identification, consideration and mitigation activities related to high-priority vulnerabilities as identified by a vulnerability analysis.

3. An evacuation plan that includes:

a. Documented, current consideration of local or regional sites that could function as evacuation locations or stop-over points, including documentation of any arrangements the provider has made with such local or regional sites.

b. Policy and procedures for executing an evacuation or relocation of individuals receiving services to include individual and staff location tracking and preservation of all critical services (pharmacy, feeding, etc.).

c. Policy and procedures for handling PHI during an evacuation or relocation to ensure the PHI is both properly secured and accessible at the new location or by new service providers to allow for proper continuity of care.

C. The provider shall develop a written communication plan detailing:

1. The process for notifying local and state authorities of an emergency, including the department.

2. The process for notifying and communicating with staff, employees, contractors, volunteers, and community responders during emergencies.

3. The process for warning, notifying, and communicating with individuals receiving services.

4. The process for notifying and communicating with family members or authorized representatives during emergencies.

D. The provider shall develop a written Continuity of Operations Plan detailing:

1. Delegation of authority under emergency conditions.

2. Succession planning for emergency conditions, including in the event of the license holder’s death or incapacitation as required by subsection B 1 of 12VAC35-270-40. Community service boards are not required to have a succession plan.

3. Indication of which services are critical to the health and well-being of the individuals being served and therefore must be continued; services less critical that may be delayed; ancillary services that may be discontinued during emergency circumstances; and triggers with regard to the continuity of these services.

4. Documented plans for continuity of activities related to the provision of care, treatment, and services, including scheduling, modifying, or discontinuing services; PII and PHI access and security; providing medication; and transportation services.

5. Contingency planning for supply chain disruptions of critical supplies such as pharmaceuticals, food, water, toiletries, linens, and any other supplies required for subsistence.

E. The provider shall maintain documentation of outreach to local emergency officials to include local emergency managers at least annually.

F. The provider shall implement annual emergency preparedness and response training for all employees, contractors, students, and volunteers pursuant to 12VAC35-270-290. This training shall also be provided during the onboarding of new employees. This training shall include:

1. Activation and notification for the emergency plan.

2. Evacuation procedures that include consideration of individuals with medical, functional, and access needs.

3. Use, maintenance, and operations of any emergency equipment.

4. Medical record stewardship during emergencies.

5. Utilization of community support services in emergencies.

G. The provider shall document review of the emergency preparedness plan and continuity of operations annually and make necessary revisions. Such revisions shall be (i) communicated to employees, contractors, students, volunteers, and individuals receiving services and (ii) incorporated into training for employees, contractors, students, and volunteers and into the orientation of individuals to services.

H. Crisis stabilization units shall ensure a three-day supply of emergency food and water for all individuals and staff. Emergency food caches should include food that is easily prepared and does not need to be cooked. One gallon of potable water per person, per day is required.

1. The emergency food cache shall not include expired food.

2. The emergency food cache shall be appropriate for meeting the dietary needs of the population served.

3. The provider shall ensure any tools needed to prepare the emergency food supply (such as can openers or portable blenders) are stored with the emergency food cache.

4. The emergency food cache shall be separate from the provider’s day-to-day food supply.

5. The emergency food cache shall be packed and ready for transport in case of emergency.

A. In the event the provider employs or contracts with security employees this section shall apply.

B. The provider shall develop and implement written methods of resolving procedural and programmatic issues regarding individual care arising between the clinical and security employees or contractors.

C. The provider shall engage in and document ongoing communication between clinical and security employees to ensure care of individuals receiving services.

D. The provider shall provide cross-training for the clinical and security employees or contractors that includes:

1. Mental health, developmental disability, and substance abuse education;

2. Use of restraints; and

3. Channels of communication.

E. Employees or contractors shall receive periodic in-service training, and have knowledge of and be able to demonstrate the appropriate use of restraints.

F. Security and behavioral assessments shall be completed, as applicable, at the time of admission to determine service eligibility and at least weekly for the safety of individuals, other persons, employees, and visitors.

G. Personal grooming and care services for individuals shall be a cooperative effort between the clinical and security employees or contractors, as required by individual need if the individual has been deemed a safety risk.

H. Clinical needs and safety risk shall be considered when arrangements are made regarding privacy for individual contact with family and visitors.

I. Living quarters shall be assigned on the basis of the individual's safety risk and clinical needs.

J. A documented review of the individual's clinical condition and needs shall be made when restrictions or actions are required for safety measures.

K. Clinical services consistent with the individual's condition and plan of treatment shall be provided when safety measures or seclusion are utilized.

Seclusion is only allowed as permitted by 12VAC35-115 and other applicable state regulations.

A. For the purposes of this section, "clean" means freshly laundered, sanitized, and not soiled or stained.

B. Crisis receiving centers shall arrange for each individual to have a recliner. Crisis stabilization units shall arrange for each individual to have a bed.

C. Upon admission, the provider shall offer to launder the individual’s clothes.

D. The provider shall not operate more recliners or beds at each service location than the number for which its service location is licensed.

E. Providers shall ensure recliners are at a minimum three feet apart at the head, foot, and sides upright as well as in a reclined position. Providers shall ensure each recliner is positioned in such a way that the chair can recline.

F. Recliners, beds, and linens shall be clean, comfortable, and well-maintained.

G. Recliners shall be equipped with clean cushions and blankets. Beds shall be equipped with a clean mattress, a clean pillow, clean blankets, and clean bed linens. When a bed or recliner is soiled, providers shall assist individuals with bathing, as needed, and provide clean clothing and clean linens, including a clean waterproof mattress cover for a bed.

H. Providers shall change used linens at least every seven days and with each new admission.

I. Providers shall provide mattresses that are fire retardant as evidenced by documentation from the manufacturer, except in buildings equipped throughout with an automatic sprinkler system in accordance with the Virginia Statewide Building Code (13VAC5-63).

J. Providers shall inspect each individual’s recliner or bed upon discharge to (i) ensure the individual has all personal belongings and (ii) prepare the bed or recliner for cleaning.

A. This section applies to crisis receiving centers and crisis stabilization unit providers.

B. Providers shall have the ability to launder clothes and linens 24 hours a day.

C. A clean quantity of linens shall be available at all times to provide for proper care and comfort of individuals receiving services.

D. Linens and other laundry must be handled, stored, and processed to control the spread of infection.

E. Clean linens shall be stored in a clean and dry area, separate from soiled laundry, accessible to staff.

F. Soiled linens and laundry shall be stored in covered containers in separate, well-ventilated areas and shall not accumulate.

G. Soiled linens and laundry shall not be sorted, laundered, rinsed, or stored in bathrooms, bedrooms, kitchens, or food storage areas.

H. If the provider has multiple licensed services, the laundry facilities may be in a shared program area if access is restricted to staff only.

A. Bathrooms intended for use by more than one individual at the same time shall provide privacy for showers and toilets.

B. The right of privacy within bathrooms includes the right to be free of cameras or audio monitors within the bathroom or angled toward a bathroom.

C. Bathrooms shall be free of all protrusions, sharp corners, hardware, fixtures, ligature risks, or other devices that may cause injury to the individual. Windows in the bathrooms shall be constructed so as to minimize breakage and otherwise reduce the risk of the individual self-harming.

D. Bathroom equipment and fixtures shall be interior permanent structures plumbed according to state and local building regulations.

E. Crisis receiving center services shall make available on-site at least one shower for every sixteen individuals.

F. Crisis stabilization unit services shall make available on-site at least one shower or bath, one toilet, and one hand basin for every four individuals.

G. Providers of multiple licensed services shall provide separate bathrooms for each service. Bathrooms shall not be shared with unlicensed services.

A. This section only applies to crisis stabilization unit 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 less than 60 square feet of floor space per individual.

C. No more than four individuals shall share a bedroom.

D. Bedrooms shall be free of all protrusions, sharp corners, hardware, fixtures, ligature risks, or other devices that may cause injury to the individual.

E. Windows in the bedrooms shall be constructed so as to minimize breakage and otherwise reduce the risk of the individual self-harming.

F. No required path of travel to the bathroom shall be through another bedroom. Each individual's room shall have direct access to a corridor, living area, dining area, or other common area.

G. Each individual shall have adequate private storage space accessible to the bedroom for clothing and personal belongings.

H. Each sleeping area shall have a door that can be (i) closed for privacy or quiet and (ii) readily opened in case of fire or other emergency.

I. The environment of sleeping areas shall be conducive to sleep and rest.

J. Providers shall ensure beds are at least three feet apart at the head, foot, and sides.

K. Providers of crisis services to children shall provide separate sleeping areas for boys and girls four years of age or older.

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, hardware, fixtures, or other devices that may cause injury to the occupant.

3. Windows in the seclusion room shall be constructed to minimize breakage and otherwise prevent the occupant from self-harming.

4. Light fixtures and other electrical receptacles in the seclusion room shall be recessed or so constructed as to prevent the occupant from self-harming. Light controls shall be located outside the seclusion room.

5. Doors to the seclusion room shall be at least 32 inches wide, 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.

6. The seclusion room shall contain only a mattress with a washable mattress covering designed to avoid damage by tearing.

7. The seclusion room shall maintain temperatures appropriate for the season.

8. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.

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 or sensory disabilities.

C. The exterior and interior physical environment shall be kept clean and in good repair to (i) protect against dust, dirt, mold, or transmission of disease, and (ii) prevent the entrance or harboring of insects, rodents, vermin, and other pests. Exterior and interior furnishings shall be 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. There shall be clear pathways through the setting, free of tripping hazards, to ensure that all individuals can move about the setting safely. Any electrical cords, extension cords, or power strips utilized by the provider shall be properly secured and shall not be placed anywhere that the cord or strip can cause trips or falls.

E. Unless otherwise mandated by state or federal authorities, heat shall be evenly distributed in all rooms occupied by individuals such that a temperature no less than 68°F is maintained. Natural or mechanical ventilation to the outside shall be provided in all rooms used by individuals receiving services. Individual or mechanical ventilating systems shall be provided in all rooms occupied by individuals receiving services when the temperature in those rooms exceeds 80°F.

F. Plumbing shall be maintained in good operational condition. Adequate hot and cold running water of a safe and appropriate temperature shall be available. Hot water accessible to individuals receiving services shall be maintained within a range of 100° to 120°F. Precautions shall be taken to prevent scalding from running water.

G. Adequate provision shall be made for the collection and legal disposal of garbage and waste materials.

H. If smoking is permitted, the provider shall make provisions for alternate smoking areas that are separate from the service environment.

I. Bedroom, bathroom, and dressing area windows and doors shall provide privacy.

J. If a provider monitors or records individuals receiving services using audio-visual or other technology, the provider shall develop written policies and procedures for submission to the Office of Licensing and the Office of Human Rights for approval. The policies and procedures shall:

1. Describe how all staff, individuals, guardians, and authorized representatives, if applicable, will be notified of monitoring, including wearable and portable monitoring devices.

2. Outline the process for obtaining signed written acknowledgements from staff, individuals, guardians, and authorized representatives, if applicable, attesting to their understanding of the monitoring;

3. Require prominent postings informing individuals receiving services and others that recording or monitoring is taking place; and

4. Ensure all recordings are used in a manner that respects the dignity and confidentiality of individuals receiving services.

Q. Providers shall develop written policies and procedures approved by Office of Licensing governing searches. The policies and procedures shall:

1. Limit searches to instances where they are necessary to prohibit contraband;

2. Identify the specific personnel who are authorized to conduct contraband searches;

3.Ensure searches are conducted in such a way to protect the individual's dignity and in the presence of one or more witnesses; and

4. Document the actions to be taken by a provider if contraband is found by as a result of a search, including methods to manage or dispose of contraband.

R. Providers that serve temporary detention orders or emergency custody orders shall ensure the service is provided in a secure facility or a secure service space.

S. Providers shall ensure individuals' privacy from routine sight supervision by staff members while bathing, dressing, or conducting toileting activities. This subsection does not apply to medical personnel performing medical procedures or staff assisting individuals whose physical, mental, or safety needs dictate the need for assistance with these activities as justified in the individual's record.

T. Providers of both children's and adult services shall ensure that children receiving services and adults receiving services are not mixed in shared spaces.

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 of the Certificate of Use and Occupancy to the department for new locations.

The provider shall document at the time of its original application and annually thereafter that buildings and equipment are maintained in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-52).

A. The interior and exterior of all buildings shall be safe, properly maintained, clean, and in good working order. This includes, required locks, mechanical devices, indoor and outdoor equipment, recreational spaces, and furnishings.

B. The provider shall implement policies for infrastructure concerns including building and site maps to shut off utilities when necessary.

A. All services shall submit floor plans with room dimensions to the department for new locations. New locations require a modification application to be submitted to the department in accordance with 12VAC35-270-80 at least 30 days prior to opening the new location.

B. With the modification application submitted to the department pursuant to 12VAC35-270-80, the provider shall submit building plans and specifications for (i) any planned construction at a new location, (ii) changes in the use of existing locations, and (iii) any renovations, structural modifications, or additions to existing locations where services are provided.

C. The provider shall submit an interim plan to the department addressing the health and safety of individuals receiving services and continued service delivery if new construction or renovations to existing buildings is approved. The interim plan shall be submitted with the modification application required by 12VAC35-270-80.

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 sewage disposal system and its capacity. Nonpublic water and sewer systems shall be maintained in good working order and in compliance with local and state laws.

B. Service locations that are not on a public water system shall have a water sample tested by an accredited, independent laboratory for the absence of coliform (i) prior to being licensed and (ii) on an annual basis thereafter. The water sample shall also be tested for lead or nitrates if recommended by the local health department. Documentation of the three most recent test samples shall be kept on file.