Southside Behavioral Health complies with regulatory requirements. As DBHDS expectations and requirements burgeon across all of its departments, it is increasingly challenging to meet requirements with current staff. Southside Behavioral Health is requesting consideration of funding for additional administrative and/or quality assurance staff to meet expectations. Consideration is also requested for DBHDS to partner with providers in the drafting of future regulations and guidance documents prior to the public comment period to gather input on implementation impacts.

12VAC35-106-40 Applications

• Request timeframes for a response back from DBHDS

12VAC35-106-60 Inspection Requirements

• Two hours may not be enough time for rural CSBs or agencies with multiple locations.

12VAC35-106-80 Changes to Licenses and notifications to the department

• Previous versions of regulations give a timeframe of 45 days request to keep 45 calendar days instead of changing to 45 business days.
• In regards to modifications of service descriptions please provide more detail either within the regulations or in a guidance document. Is this meant to imply that all program revisions need to be submitted, along with the service modification form?

12VAC35-106-90 Variances

• Request timeframes for response back from DBHDS

12VAC35-106-110 Compliance

• In regards to section B, how will this be determined?
• (B)(5) uses the word defects is this perhaps a typo? Should it be deficiencies?

12VAC35-106-120 Corrective Action Plan

• Request timeframes for a response back from DBHDS.
• While addressing systemic deficiencies is important it is important to recognize that not all instances of non-compliance are systemic.

12VAC35-106-190 Organizational Structure

• (B) What adjustments will be made to this stipulation considering recent events and increasing telework? Directors often have out-of-town meetings and are only available by phone will they need to designate an acting director every time they are away from the premises?

12VAC35-106-200 Executive Director or Administrator

• (C)(1-2) Please change his to their as it is more gender-neutral.

12VAC35-106-240 Criminal Background and Registry Searches

• (2-3) Thank you for this addition
• (D) The addition of “annual” is confusing, please give additional information here. Do we need to ask all employees for an annual disclosure statement?

12VAC35-106-250 Personnel Records

• (8) Please rephrase so it is clear that any valid driver’s license is acceptable. We have many employees from North Carolina as we are on the VA/NC line.

12VAC35-106-290 Employee Training

• (1) Typo in the number of days for initial training 14 needs to be changed to 15.
• (2) Specify that medication administration training is only for staff whose positions involve medication administration.

12VAC35-106-300 Notification of Policy Changes

• (B) Request that DBHDS provides guidance with examples of “substantive changes”. Does this mean that DBHDS has to approve changes to a provider’s policies?

12VAC35-106-310 Tuberculosis Screening

• (B) what does self-presentation mean, please define.
• (B) Additional administrative burden with additional annual training.

12VAC35-106-480 Emergency Medical Information

• (A)(6) Including details of medical protocols on a face sheet can make this document cumbersome and more difficult for emergency medical personnel to use.  Recommend this be revised so that the face sheet lists the types of protocols a person may have, but that the details be maintained separately and be readily available for EMS personnel.
• (A)(9) Does this requirement apply to all services as it would seem to be needed more for residential programs?

12VAC35-106-500 Service Description Requirements

• Please consider revising so that service descriptions are to be readily available for people to review, without implying a need to post on the walls in residential settings such as ICF/IIDs and Group Homes, as this detracts from having the environment look and feel like a typical home in a community-based setting.

12VAC35-106-570 Reporting to the Department

• (C) Request to change to 30 business days.

12VAC35-106-589 Risk Management

• (C)(2) What is DBHDS looking for to test staff competence?

12VAC35-106-590 Monitoring and Evaluating Service Quality

• Having an Office of Human Rights process and an Office of Licensing process will be confusing to consumers.

12VAC35-106-720 Computers and Internet Access

• Recommend relocation to the residential services chapter, as this has limited applicability to other services.