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

"Abuse"

"Admission"

"Assertive community treatment service" or "ACT"

"Authorized representative"

"Behavior intervention"

"Commissioner"

"Contractor"

"Community Psychiatric Support and Treatment" or "CPST"

"Crisis"

"Day support"

"Department"

"Developmental disability"

"Discharge"

"Discharge plan"

"Emergency services" or "crisis intervention"

"Individual" or "individual receiving services"

"Individualized services plan" or "ISP"

"Informed choice"

"Initial assessment"

"Location"

"Medication"

"Medication administration"

"Mental health skill building" or "MHSS"

"Mental illness"

"Neglect"

"Noncenter-based"

"Person-centered"

"Provider"

"Referral"

"Restraint"

"Restriction"

"Screening"

"Service"

"Supportive in-home"

"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:

"Activities of daily living" or "ADLs" means personal care activities and includes bathing, dressing, transferring, toileting, grooming, hygiene, feeding, and eating. An individual's degree of independence in performing these activities is part of determining the appropriate level of care and services.

"Behavioral Health Technician" or "BHT" means a person who has completed, at a minimum, an associate degree and registered with the Board of Counseling to practice in accordance with the provisions of § 54.1-3518 of the Code of Virginia and regulations of the Board of Counseling and provides collaborative behavioral health services.

"Care" or "treatment" means the individually planned therapeutic interventions that conform to current acceptable professional practice and that are intended to improve or maintain functioning of an individual receiving services delivered by a provider.

"Co-occurring disorders" means the presence of more than one and often several of the following disorders that are identified independently of one another and are not simply a cluster of symptoms resulting from a single disorder: mental illness, a developmental disability, substance abuse (substance use disorders), or brain injury.

"Comprehensive assessment" means a comprehensive and written assessment that updates and finalizes the initial assessment. The comprehensive assessment shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context and shall be completed in a time period appropriate to the nature and scope of the service provided. The comprehensive assessment includes all relevant social, psychological, medical, and level of care information as the basis for the development of the person-centered comprehensive ISP. The comprehensive assessment may be completed at the time of initial assessment if it includes all elements of the comprehensive assessment. In the event a comprehensive assessment is completed at the time of an initial assessment the provider is not required to update the assessment.

"Developmental services" means planned, individualized, and person-centered services and supports provided to individuals with developmental disabilities for the purpose of enabling these individuals to increase their self-determination and independence, obtain employment, participate fully in all aspects of community life, advocate for themselves, and achieve their fullest potential to the greatest extent possible.

"Early serious mental illness" means the initial onset of a diagnosable mental, behavioral, or emotional disorder that significantly impacts an individual’s functioning, potentially hindering their ability to achieve expected levels of interpersonal, academic or occupational success.

"Face-to-face" means encounters that occur in person unless explicitly indicated by a specific regulatory provision.

"Full-time employee" means, with respect to any month, an individual who is employed on average at least 30 hours of service per week.

"Individual support plan" means a comprehensive, person-centered plan for an individual receiving developmental disability services that sets out the supports and actions to be taken during the year by each provider, as detailed in each provider’s plan for supports to achieve the desired outcomes and goals. The individual support plan shall be developed collaboratively by the individual; the individual’s family or caregiver, as appropriate; providers; the support coordinator; and other interested parties.

"Initial ISP" means a written plan developed and implemented within one business day of admission to address immediate service, health, and safety needs as identified within the individual’s initial assessment.

"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.

"Medication error" means an error in administering a medication to an individual and includes when any of the following occur: (i) the wrong medication is given to an individual, (ii) the wrong individual is given the medication, (iii) the wrong dosage is given to an individual, (iv) medication is given to an individual at the wrong time or not at all, or (v) the wrong method is used to give the medication to the individual.

"Medication storage" means any area where medications are maintained by the provider, including a locked cabinet, locked room, or locked box.

"Noncenter-based day support" means structured programs that prepare adults with a developmental disability for typical activities of community life equal to those available to the general population, including opportunities for peer interaction and community integration. Noncenter-based day support services promote the individual’s inclusion and independent participation in his community and focus on enabling the individual to attain or maintain his highest potential level of functioning.

"Noncenter-based respite care" means providing temporary, short-term, time-limited substitute care on an episodic or routine basis of an individual for the purpose of providing relief to the individual's unpaid primary caregiver. Persons providing respite care are recruited, trained, and supervised by a licensed provider. Respite services are provided in the individual's home or place of residence, in the community.

"Plan for supports" means a provider’s plan for supporting the individual in achieving the individual’s desired outcomes and facilitating the individual’s health and safety. The provider’s plan for supports is one component of the individual support plan.

"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.

"Qualified paraprofessional in mental health" or "QPPMH" means a person who must meet at least one of the following criteria: (i) is registered with the United States Psychiatric Association (USPRA) as an Associate Psychiatric Rehabilitation Provider (APRP); (ii) has an associate degree in a related field (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and at least one year of experience providing direct services to individuals with a diagnosis of mental illness; (iii) is licensed as an occupational therapy assistant, and supervised by a licensed occupational therapist, with at least one year of experience providing direct services to individuals with a diagnosis of mental illness; or (iv) has a minimum of 90 hours classroom training and 12 weeks of experience under the direct personal supervision of a QMHP-A providing services to individuals with mental illness and at least one year of experience, including the 12 weeks of supervised experience.

"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 they know.

"Rehabilitation skills practice" means a subcomponent of restorative evidenced-based therapeutic interventions for individuals who need individualized, collaborative, hands-on training to build developmentally appropriate skills.

"Restorative evidence-based therapeutic interventions" means evidence-based practices designed to decrease symptoms of the individual's mental health diagnosis, restore functional skills of daily living, build natural supports, and achieve identified person-centered goals and objectives as set forth in the ISP. Restorative evidence-based therapeutic interventions is focused on the individual’s ability to succeed in the community and to show improvement in school, work, and home functioning.

"School-based therapeutic day treatment for children and adolescents" or "school-based TDT" means individualized and structured therapeutic interventions that serve (i) children and adolescents from birth through age 17, and under certain circumstances through age 21, with serious emotional disturbances, substance use, or co-occurring disorders; or (ii) children and adolescents from birth through age seven who are at risk of serious emotional disturbance, or substance use disorder, or co-occurring disorders. Therapeutic day treatment interventions are provided within a school setting and in coordination with school programming during the school day or to supplement the school day or year, such as after school hours or during summer school. School-based TDT combines psychotherapeutic interventions with education and mental health or substance abuse treatment to provide supports so at-risk children maintain placement within their school and home. This service shall include assessment; interventions to build daily living skills and to enhance social and interpersonal skills; care coordination; and individual, group, or family counseling.

"Serious emotional disturbance" or "SED" means an individual under the age of 18 having within the past year a diagnosable mental, behavioral, or emotional disorder resulting in functional impairment that substantially interferes with or limits the individual’s role or functioning in family, school, or community activities.

"Serious mental illness" or "SMI" means an individual over the age of 18 having within the past year a diagnosable mental, behavioral, or emotional disorder that substantially interferes with the individual’s life and ability to function.

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

"Skills training" means systematic skill building through curriculum-based psychoeducational and cognitive-behavioral interventions. These interventions break down complex objectives for role performance into simpler components, including basic cognitive skills such as attention, to facilitate learning and competency.

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 noncenter-based license:

1. Assertive community treatment;

2. Intensive in-home;

3. Mental health skill building;

4. Noncenter-based day support:

5. Noncenter-based respite care;

6. Supportive in-home; and

7. School-based therapeutic day treatment for children and adolescents.

A. Assertive community treatment (ACT) includes comprehensive, coordinated person-centered services delivered to individuals with severe and persistent mental illness that address the breadth of their needs and help achieve their personal goals. Services are provided collaboratively by a self-contained interdisciplinary community-based team of medical, behavioral health, and rehabilitation professionals. ACT services include ongoing assessment; medical, nursing, psychiatric, and psychosocial evaluation, care, and monitoring; skills restoration, crisis intervention, and case management; co-occurring substance use disorder services that are non-confrontational, trauma-informed, and person-centered that consider interactions of mental illness and substance use; skill-teaching to family members, significant others, and broader natural support systems that are directed exclusively to the well-being and benefit of the individual; direct support to help individuals obtain legal and advocacy services, and natural supports in the community; assistance in developing and maintaining natural supports and social relationships; and peer support services.

B. Noncenter-based day support includes routine assistance, skill-building, and safety supports in the acquisition, retention, or improvement of self-help, socialization, and adaptive skills for adults with a developmental disability. Services are provided to groups or individuals in non-center based or home-based settings and include community coaching and community engagement. Activities are conducted at naturally occurring times and in a variety of natural settings in which the individual may actively interact with persons without disabilities, other than those who are paid to support the individual. The activities shall enhance the individual's involvement with the community and facilitate the development of relationships and natural supports.

C. Intensive in-home includes family preservation interventions for children and adolescents who have or are at risk of serious emotional disturbance. This service is offered to increase functional and therapeutic interpersonal relations between family members and must include at least one parent, legal guardian, or responsible adult living in the home, with the goal of keeping the individual with the family. Services include modeling; 24-hour per day emergency response; crisis treatment; individual and family counseling; life, parenting, and communication skills; and case management and coordination.

D. Mental health skill building (MHSS) includes direct, face-to-face, goal-directed training for adults in the following areas: (i) functional skills and appropriate behavior related to the individual’s health and safety, instrumental activities of daily living, and use of community resources; (ii) assistance with medication management; and (iii) monitoring health, nutrition, and physical condition, with goals towards self-monitoring and self-regulation of all of these activities. Services offered include symptom management; assistance with adherence to psychiatric and physical health medication treatment plans; and skills training to promote the individual’s management of personal hygiene, food preparation, adequate nutrition, budgeting, and use of community resources. MHSS training usually takes place in a community setting.

E. Noncenter-based respite care includes trained, supervised supports delivered in an individual’s home or place of residence for the purpose of providing temporary, substitute care. Services offered include assistance with ADLs; monitoring of health status or physical condition; prescribed use of medication and other medical needs; meal preparation; housekeeping activities such as bed-making, cleaning, or the individual’s laundry; safety; participation in social, recreational, or community activities; and accompanying the individual to appointments or meetings.

F. Supportive in-home includes assistance, training, and community supports based on the needs of the individual that are necessary to attain and sustain independent community residential living. Services range from drop-in or friendly-visitor support and counseling to more intensive monitoring, training, respite care, and family services. These services normally do not involve overnight care by the provider; however, due to the flexible nature of these services, overnight care may be provided on an occasional basis.

G. School-based therapeutic day treatment for children and adolescents (school-based TDT) includes assessment; interventions to build daily living skills or enhance social skills; care coordination; and individual, group, or family counseling. School-based TDT includes services offered during standard instructional hours during the calendar school year in the school setting; services offered after instructional hours during the calendar school year as an after-school program; and services offered outside of the school year during summer school.

A. Providers shall implement screening policies and procedures that include:

1. Identification, qualification, training, and duties of employees responsible for screening;

2. The following minimum required elements of screening for a noncenter-based 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. Reasons why the individual is requesting services;

e. Current reported diagnoses and medical conditions;

f. Medical symptoms;

g. Psychoactive or other medications currently being used, including recent increases, decreases, discontinuation, misuse, or overdose of prescription medication;

h. Recent or current substance use or dependence including risk for intoxication or substance withdrawal; and

i. Status of the individual including his referral to other services for further assessment, placement on a waiting list for services, or admission to the service.

3. Methods to identify other appropriate services for referral to assist individuals who are not admitted to the service after screening.

B. The provider shall retain documentation of the individual’s screening for six months. For individuals who are admitted to the service, documentation shall be included in the individual’s record in accordance with 12VAC35-270-580.

C. The provider shall review all elements of the screening at the time of initial assessment and update as necessary.

A. The provider shall implement a written assessment policy. The policy shall define how assessments will be conducted and documented.

B. The provider shall actively involve the individual and the individual's authorized representative, if applicable, in the preparation of initial and comprehensive assessments. In these assessments, the provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.

C. The assessment policy shall designate appropriately qualified employees or contractors who are responsible for conducting, obtaining, or updating assessments and medical screenings. These employees or contractors shall have experience in working with the needs of individuals who are being assessed, the assessment tools being utilized, and the provision of services that the individuals may require.

D. Assessment is an ongoing activity. The provider shall make reasonable attempts to obtain previous assessments or relevant history. The provider shall use previous assessments or relevant history in order to complete an individual’s initial or comprehensive assessment. The provider shall use previous assessments or relevant history within the course of treatment, if applicable.

E. Providers shall utilize an assessment tool that meets the requirements in subsection F of this section for initial assessments, and subsection G of this section for comprehensive assessments. Providers may utilize a standardized state or federally sanctioned assessment tool that does not meet the criteria in these regulations if the tool is approved by the department prior to use.

F. Providers shall conduct an individual’s initial assessment prior to or at admission to the service. The provider shall complete, or obtain information from other qualified providers in order to complete, an initial assessment detailed enough to determine whether the individual qualifies for admission and to initiate an ISP for those individuals who are admitted to the service.

1. The initial assessment shall assess immediate service, health, and safety needs and shall be conducted using an assessment tool that evaluates at a minimum the following criteria concerning the individual:

a. Diagnosis;

b. Presenting needs including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of needs;

c. Current medical issues;

d. Current medications;

e. Current and past substance use or abuse, including co-occurring mental health and substance abuse disorders;

f. At-risk behavior to self and others; and

g. Risk factors that may impact the individual’s ability to seek treatment or continue to participate in services.

2. The comprehensive assessment may be completed at the time of initial assessment if it includes all elements noted within subsection G of this section. In the event a comprehensive assessment is completed at the time of an initial assessment, the provider is not required to update the assessment unless a reassessment is medically or clinically indicated.

G. Providers shall conduct a comprehensive assessment for each individual who is admitted to the service. A comprehensive assessment shall update and finalize the initial assessment, unless the comprehensive assessment is completed at the time of initial assessment as provided in subdivision F 2 of this section.

1. Completion of the comprehensive assessment shall be based upon the nature and scope of the service but shall occur no later than (i) 30 days after admission for providers of mental health and substance abuse services and (ii) 60 days after admission for providers of developmental services.

2. The comprehensive assessment may be completed at the time of initial assessment only if it includes all elements enumerated in subdivision 3 of this subsection. In the event a comprehensive assessment is completed at the time of an individual's initial assessment, the provider is not required to update the assessment unless a reassessment is medically or clinically indicated.

3. The comprehensive assessment shall be conducted using an assessment tool that evaluates, at a minimum, the following criteria:

a. Onset and duration of needs;

b. Social, behavioral, developmental, and family history and supports;

c. Cognitive functioning, including strengths and weaknesses;

d. Employment, vocational, and educational background;

e. Previous interventions and outcomes including interventions and outcomes that were unsuccessful, with the provider ensuring previous assessments are utilized to note prior interventions as required by subsection D of this section;

f. Overall financial situation, including resources, support and benefits, and whether the individual has the means to meet the individual's financial needs;

g. Health history and current medical care needs, to include:

(1) Allergies, including allergies to food and medications;

(2) Recent physical complaints and medical conditions;

(3) Nutritional needs;

(4) Chronic conditions;

(5) Communicable diseases;

(6) Restrictions on physical activities if any;

(7) Restrictive protocols or special supervision requirements;

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

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

(10) Current and past substance use, including alcohol, prescription and nonprescription medications, and illicit drugs.

h. Psychiatric and substance use issues including current mental health or substance use needs, presence of co-occurring disorders, history of substance use or dependence, and circumstances that increase the individual's risk for mental illness or substance use issues;

i. History of abuse, neglect, sexual or domestic violence, or other trauma, including psychological trauma;

j. Legal competency, including authorized representative, commitment, and representative payee status;

k. Relevant criminal charges or convictions and probation or parole status;

l. Daily living skills;

m. Housing arrangements;

n. Ability to access services, including transportation needs; and

o. As applicable, fall risk, communication needs, and mobility and adaptive equipment needs.

H. The provider shall retain documentation of the individual's assessments in the individual's record for a minimum of six years after the individual's discharge in accordance with § 54.1-2910.4 of the Code of Virginia and its written records management policy in accordance with 12VAC35-270-580.

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 ISP. The individualized services planning process shall be consistent with laws protecting confidentiality, privacy, human rights of individuals receiving services, and rights of minors.

1. Providers of developmental services shall collaborate with the individual's planning team to develop and implement the initial plan for supports, which is a component of the comprehensive ISP, no later than 24 hours after admission. The initial plan for supports shall address the individual's immediate health and safety needs for the first 60 days, may include assessment activities, and shall continue in effect until the ongoing comprehensive plan for supports is developed or the individual is discharged, whichever occurs first. An ongoing comprehensive plan for supports shall be completed within 60 days of admission.

2. Providers of mental health or substance abuse services shall develop and implement an initial person-centered ISP no later than 24 hours after admission. The initial ISP shall address the individual's immediate service, health, and safety needs for the first 30 days and shall continue in effect until the comprehensive ISP is developed or the individual is discharged, whichever occurs first. An ongoing comprehensive ISP based upon the nature and scope of services shall be completed as soon as possible, but no later than 30 days after admission.

B. If an individual has a case manager, informed choice shall be governed by the service-specific requirements governing case management providers (12VAC35-280). If the individual does not have a case manager, development of the initial ISP and the comprehensive ISP shall be based on the respective 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 his 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 clearly documented within the ISP or within documentation attached to the ISP, that alternative services were not available as well as the steps taken to identify alternative services.

3. Whenever there is a change to an individual's ISP it shall be clearly documented within the ISP or within documentation attached to the ISP that:

a. The individual participated in the development of or revision to the 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 ISP.

A. The initial ISP shall be based on the individual's immediate service, health, and safety needs identified in the initial assessment. The initial ISP shall include:

1. Relevant and attainable goals, measurable objectives, and specific strategies for addressing needs and preferences documented within the individual's initial assessment, including documentation that the individual's needs and preferences are consistent with a noncenter-based setting;

2. Services, supports, and frequency of services planned to accomplish the individual's goals, including relevant psychological, mental health, substance abuse, behavioral, developmental, medical, rehabilitation, training, and nursing needs and supports;

3. The role of the individual and others, including the individual's family, if appropriate, in implementing the initial ISP; and

4. Target dates for accomplishment of goals and objectives.

B. The comprehensive ISP shall be based on the individual's needs, strengths, abilities, personal preferences, goals, and natural supports identified in the comprehensive assessment. The comprehensive ISP shall include the following minimum provisions:

1. Relevant and attainable goals, measurable objectives, and specific strategies for addressing each need documented within the individual's comprehensive assessment, including documentation that the individual's needs require a noncenter-based setting;

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

3. The frequency at which services and supports must be provided to accomplish the individual's goals;

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

5. A communication plan for individuals with communication barriers, including language barriers;

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

7. A physical safety plan that addresses identified risks to the individual or to others, including a fall risk plan, if indicated by the individual's assessment;

8. A crisis or recovery plan, if applicable;

9. Target dates for accomplishment of goals and objectives;

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

11. A transportation plan, if applicable;

12. Services the individual elects to self-direct, if applicable; and

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

C. Both the initial ISP and the comprehensive ISP shall be signed and dated, at a minimum, by (i) the person responsible for implementing the plan and (ii) the individual receiving services or the individual's authorized representative, if applicable, in order to document agreement.

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, on a periodic basis, while each ISP is in effect. An attempt to obtain the necessary signature shall occur at a minimum each time the provider reviews the ISP as required by 12VAC35-274-80 E.

2. Each ISP shall be distributed to the individual and others authorized to receive it prior to implementation. The provider shall document dates of the distribution within the individual's record.

D. The provider shall designate an employee or contractor who shall be responsible for developing, implementing, reviewing, and revising each individual's comprehensive ISP in collaboration with the individual or the individual's authorized representative, as appropriate.

E. Employees or contractors who are responsible for implementing the ISP shall demonstrate a working knowledge of the objectives and strategies contained in the individual's current ISP, including an individual's detailed health and safety protocols.

1. Providers shall educate and train employees or contractors who are responsible for ISP implementation, based on the employee's or contractor's duties, on the objectives and strategies contained within the individual's current ISP.

2. When changes occur to an individual's ISP, the provider shall notify and train the appropriate employees or contractors who are responsible for ISP implementation, as applicable to their duties, for competency to implement the revised ISP.

3. After each training on the individual's current ISP, providers shall maintain documentation of the employee's or contractor's education, training, and competency as demonstrated through supervision.

F. When a provider provides more than one service to an individual, the provider may maintain a single ISP document that contains individualized objectives and strategies for each service provided.

G. Whenever possible the identified goals in the 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 implementation of the goals and objectives contained within the ISP.

I. A copy of the individual's most current ISP shall be readily accessible at all times, including by staff providing direct care services, while services are being provided.

A. Reassessments shall be completed at least annually and any time there is a need based on changes in the medical, psychiatric, behavioral, or other status of the individual. Reassessment shall include documentation justifying that the individual's needs continue to require a provider-operated noncenter-based setting.

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 revise the ISP, if the reassessment supports changes or if desired by the individual. If a reassessment does not support changes to the ISP, the provider shall document that no revisions are necessary and the reasoning.

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 protocols, if appropriate.

E. The provider shall complete quarterly reviews of the ISP in writing every three months from (i) the date of the implementation of the most recent comprehensive ISP or (ii) the most recent reassessment, whichever occurs later. Documentation of the quarterly ISP review shall be added to the individual's record no later than 15 calendar days from the date the review was due to be completed.

F. The quarterly ISP review shall be conducted in a person-centered manner, to determine if services are being delivered as described within the ISP. The individual receiving services and the individual's authorized representative, if applicable, shall be included in the ISP review, to determine if the individual's treatment needs and preferences are being met and the individual is satisfied with the services provided.

1. A quarterly review of the ISP shall evaluate the individual's progress toward meeting the ISP's goals and objectives and the continued relevance of the ISP's objectives and strategies. The provider shall update the goals, objectives, and strategies contained in the ISP, if indicated, and implement any updates made.

2. A quarterly review of the ISP shall document evidence of progress toward or achievement of a specific targeted outcome for each goal and objective.

3. For goals and objectives that were not accomplished by the identified target date, or for which the individual did not demonstrate sufficient progress, the provider shall meet and collaborate with other service providers and support team members to review the reasons for lack of progress and provide the individual an opportunity to make an informed choice of how to proceed. The provider shall retain documentation of this meeting and the individual's informed choice within the individual's record.

4. A quarterly review of the ISP shall note:

a. the individual's family involvement, if any, in the individual's treatment;

b. whether the individual no longer needs the intensity of care provided within a noncenter-based setting;

c. the individual's progress towards discharge; and

d. the status of the individual's discharge planning.

G. The provider shall ensure after each reassessment that the individual's most current ISP is easily accessible by the provider at all times, including by direct care staff while services are being provided to the individual.

A. The documentation system implemented by the provider pursuant to subdivision E of 12VAC35-270-580 shall ensure that progress notes are (i) maintained in a consistent format that satisfies the minimum provisions of subsection B of this section and (ii) entered into the individual's record in accordance with the provider's record management policy.

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

1. Be legible and readable;

2. Record the individual's interaction with the staff writing the progress note, including care provided and events relevant to diagnosis and treatment or care of the individual;

3. Provide a narrative or descriptive component;

4. Describe needed follow-up care or note which objective within the ISP will receive focus the next time the individual receives services; and

5. Be signed and dated by the staff member who rendered the service.

C. The provider shall document whether the individual no longer needs the intensity of care provided within a noncenter-based setting.

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

A. The provider 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 and the circumstances that will prompt the decision to obtain a medical assessment.

2. 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, or support the individual with, the provision of medical and dental care needs identified at admission.

4. The provider will provide, arrange, or support the individual with the provision of routine, ongoing, and follow-up medical and dental care services after admission.

5. The provider will communicate the results of physical examinations, medical assessments, diagnostic tests, treatments, or examinations conducted by the provider 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 telephone 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.

8. The provider will ensure the provision of emergency medical services for each individual.

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

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

In addition to the provisions of 12VAC35-270-300, providers of noncenter-based services shall incorporate the following service-specific supervision requirements into the provider staffing plan:

1. Supervision of mental health, substance abuse, or co-occurring services that are of an acute or clinical nature such as intensive in-home or school-based therapeutic 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.

2. Supervision of mental health, substance abuse, or co-occurring services that are of a supportive or maintenance nature, such as mental health supports, shall be provided by a QMHP, 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. A QMHP-T may not provide this type of supervision.

A. Assertive community treatment (ACT) services shall meet the following staffing requirements:

1. ACT services are delivered by interdisciplinary teams. Each ACT team shall have sufficient staffing composition to meet the varying needs of individuals receiving services as required by this subdivision.

a. Team leader. One team leader shall oversee all aspects of team operations and provide direct services to individuals in the community. The team leader shall be a full-time LMHP with three years of experience in the provision of mental health services to adults with serious mental illness; or a full-time registered QMHP with at least three years of experience in the provision of mental health services to adults with serious mental illness who was employed by a provider as a team leader prior to July 1, 2020.

b. Nurses. ACT nurses shall be full-time employees or contractors of the provider. ACT nurses shall have the following minimum qualifications: a registered nurse (RN) shall have at least one year of experience in the provision of mental health services to adults with serious mental illness. A licensed practical nurse (LPN) shall have at least three years of experience in the provision of mental health services to adults with serious mental illness.

(1) Small ACT teams shall have at least one full-time RN or LPN;

(2) Medium ACT teams shall have at least one full-time RN and at least one additional full-time LPN or RN; and

(3) Large ACT teams shall have at least one full-time RN and at least two additional full-time LPNs or RNs.

c. Vocational specialist. At least one full-time vocational specialist, who shall be a registered QMHP with demonstrated expertise in vocational services as demonstrated through experience or education.

d. Co-occurring disorder specialist. At least one full-time co-occurring disorder specialist, who shall be a LMHP; registered QMHP; or certified substance abuse specialist (CSAC) with training or experience working with adults with co-occurring serious mental illness and substance use disorder.

e. ACT peer specialists. At least one full-time equivalent peer recovery specialist who is or has been a recipient of mental health services for severe and persistent mental illness. The peer specialist shall be a certified peer recovery specialist (CPRS) or shall become certified in the first year of employment. The peer specialist shall be a fully integrated team member who provides (i) peer support directly to individuals receiving services and (ii) provides guidance to other team members in understanding and supporting individuals' recovery goals.

f. Program assistant. A full-time person with skills and abilities in medical records management who shall operate and coordinate information systems, maintain accounts and budget records for individual and program expenditures, and perform administrative support activities.

g. Psychiatric care provider. A physician who is board certified in psychiatry or who is board eligible in psychiatry and is licensed to practice medicine in Virginia or a psychiatric nurse practitioner practicing within the scope of practice as defined in 18VAC90-30-120. The psychiatric care provider shall maintain an equivalent ratio of 16 hours of psychiatric time per 50 individuals receiving services. The psychiatric care provider shall be a fully integrated team member who attends team meetings and actively participates in developing and implementing each individual's ISP.

h. Generalist clinical staff. ACT teams shall have additional clinical staff with the knowledge, skill, and ability required, based on the population and age of individuals receiving services, to carry out rehabilitation and support functions. At least 50 percent of the total number of generalist clinical staff shall be LMHPs, QMHPs, QMHP-Ts, or QPPMHs.

(1) Small ACT teams shall have at least one generalist clinical staff member;

(2) Medium ACT teams shall have at least two generalist clinical staff members; and

(3) Large ACT teams shall have at least three generalist clinical staff members.

2. Staff-to-individual ratios for ACT Teams:

a. Small ACT teams shall maintain an overall caseload of no more than 50 individuals with at least one staff member per eight individuals. The psychiatric care provider and a program assistant shall not count toward the staffing ratio.

b. Medium ACT teams shall maintain an overall caseload of no more than 74 individuals with at least one staff member per nine individuals. The psychiatric care provider and a program assistant shall not count toward the staffing ratio.

c. Large ACT teams shall maintain an overall caseload of no more than 120 individuals with at least one staff member per nine individuals. The psychiatric care provider and a program assistant shall not count toward the staffing ratio.

3. ACT teams shall be available to individuals 24 hours per day and shall operate a minimum of 12 hours each weekday, eight hours each weekend day, and eight hours each holiday.

4. The ACT team shall make crisis services directly available 24 hours a day but may arrange coverage through another crisis services provider if the team coordinates with the crisis services provider daily.

5. The ACT team shall operate an after-hours on-call system and be available to individuals by telephone or in person.

6. The ACT team shall have 24-hour responsibility for responding directly to psychiatric crises, including meeting the following criteria:

a. The team shall be available to individuals in crisis 24 hours per day, seven days per week, including in person when needed as determined by the team.

b. The team shall be the first-line crisis evaluator and responder for individuals receiving services from the team.

c. The team shall have access to the practical, individualized crisis plans developed to help them address crises for each individual receiving services.

B. Noncenter-based day support providers shall have sufficient staffing to meet the requirements of the ISPs of the individuals served.

C. Intensive in-home providers shall meet the following staffing requirements:

1. Have an LMHP who is responsible for clinical oversight of the program.

2. Provide individual and family counseling by a LMHP, LMHP-S, LMHP-R, or LMHP-RP.

3. Make emergency assistance available 24 hours a day, seven days a week.

D. Mental health skill building providers shall only render services by (i) a LMHP, LMHP-S, LMHP-R, or LMHP-RP or (ii) a QMHP, QMHP-T, or QPPMH under the supervision of a QMHP, QMHP-T, LMHP, LMHP-S, LMHP-R, or LMHP-RP.

E. Noncenter-based respite care providers shall serve individuals at a one-to-one ratio.

F. Supportive in-home providers may render services individually or simultaneously to more than one individual living in the home, depending on the individual's needs.

G. School-based therapeutic day treatment providers shall meet the following staffing requirements:

1. Render services by (i) a LMHP, LMHP-S, LMHP-R, or LMHP-RP or (ii) a QMHP or QMHP-T under the supervision of a LMHP, LMHP-R, LMHP-RP, or LMHP-S.

2. Provide individual, group, and family counseling by a LMHP, LMHP-S, LMHP-R, or LMHP-RP.

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

B. 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 crisis or emergency;

2. Employee or contractor responsibilities;

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

4. How and to what extent the provider will respond to any crisis that occurs after hours, based on the provider's licensed service type.

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 services and locations, which shall include specifics for preserving critical services at each location to allow for proper continuity of care. At a minimum, this plan shall address:

1. Policy and procedures for evacuating or relocating individuals receiving services, to include consideration of individuals with medical, functional, or accessibility needs.

2. Procedures for conducting fire, evacuation, and emergency medical drills on a regular basis.

3. The process for communicating during emergencies with individuals receiving services; their family members or authorized representatives; employees and contractors; local and state authorities, including the department; and community responders as appropriate.

A. Individuals must meet the following admission criteria:

1. Diagnosis of a severe and persistent mental illness, predominantly schizophrenia, other psychotic disorder, or bipolar disorder that seriously impairs functioning in the community. Individuals with a sole diagnosis of a substance use disorder, developmental disability, personality disorder, or brain injury are not eligible for services.

2. Significant challenges to community integration without intensive community support including persistent or recurrent difficulty with one or more of the following:

a. Performing practical daily living tasks;

b. Maintaining employment at a self-sustaining level or consistently carrying out homemaker roles; or

c. Maintaining a safe living situation.

3. High service needs indicated due to one or more of the following:

a. Residence in a state hospital or other psychiatric hospital but clinically assessed to be able to live in a more independent situation if intensive services were provided or anticipated to require extended hospitalization, if more intensive services are not available;

b. Multiple admissions to, or at least one recent long-term stay (30 days or more), in a state hospital or other acute psychiatric hospital inpatient setting within the past two years; or a recent history of more than four interventions by psychiatric emergency services per year;

c. Persistent or very recurrent severe major symptoms (e.g., affective, psychotic, suicidal);

d. Co-occurring substance addiction or abuse of significant duration (e.g., greater than six months);

e. High risk or a history (within the past six months) of criminal justice involvement (e.g., arrest or incarceration);

f. Ongoing difficulty meeting basic survival needs or residing in substandard housing, homeless, or at imminent risk of becoming homeless; or

g. Inability to participate consistently in traditional office-based services.

B. Individuals receiving ACT services may not be discharged for failure to comply with treatment plans or other expectations of the provider, except in certain circumstances as outlined. Individuals shall meet at least one of the following criteria to be discharged:

1. Change in the individual's residence to a location out of the service area;

2. Death of the individual;

3. Incarceration or long-term hospitalization of the individual for a period to exceed a year; however, the provider is expected to prioritize the individual for ACT services upon the individual's anticipated return to the community if the individual wishes to return to services and the service level is appropriate to his needs;

4. Choice of the individual to discharge, only after the provider responsible for revising the ISP documents all attempts to meet any concerns of the individual leading to the choice of discharge; or

5. Significant sustained recovery by the individual in all major role areas with minimal team contact and support for at least two years as determined by both the individual and ACT team.

A. The ACT team shall have sufficient capacity to provide multiple contacts per week to individuals experiencing severe symptoms or significant problems in daily living. The team shall provide an average of at least two contacts per individual per week. A minimum aggregate average of one hour per individual per week shall be face to face.

B. Each individual receiving ACT services shall be seen face to face by an employee or contractor as specified in the individual's ISP. Telemedicine may be appropriate to fulfill the face-to-face contact requirement if clinically indicated and if utilized for the convenience of the individual. Providers shall document all attempts to make contact, and if contact is not made, the reasons why contact was not made.

A. ACT teams shall conduct daily organizational meetings Monday through Friday, or at least four days a week, at a regularly scheduled time to review the status of all individuals and the outcome of the most recent employee or contractor contact, assign daily and weekly tasks to employees and contractors, revise treatment plans as needed, plan for emergency and crisis situations, and to add service contacts that are identified as needed.

B. A daily log that provides a roster of individuals in the ACT services program and documentation of services provided and contacts made with them shall be maintained and utilized in the daily organizational team meeting. For each individual served, there shall also be at least a weekly individual progress note documenting services provided in accordance with the individual's ISP or attempts to engage the individual in services.

The provider shall solicit the individual's own assessment of his needs, strengths, goals, preferences, and abilities to identify the need for recovery-oriented treatment, rehabilitation, and support services and the status of his environmental supports within the individual's cultural context. With the participation of the individual, the provider shall assess:

1. Psychiatric history, mental status and diagnosis, including the content of an advance directive;

2. Medical, dental, and other health needs;

3. Extent and effect of drug or alcohol use;

4. Education and employment, including current daily structured use of time, school or work status, interests and preferences, and supports and barriers to educational and employment performance;

5. Social development and functioning, including childhood and family history, religious beliefs, leisure interests, and social skills;

6. Housing and daily living skills, including the support needed to obtain and maintain decent, affordable housing integrated into the broader community; the current ability to meet basic needs such as personal hygiene, food preparation, housekeeping, shopping, money management, and the use of public transportation and other community-based resources;

7. Family and social network, including the current scope and strength of an individual's network of family, peers, friends, and co-workers, and their understanding and expectations of the team's services;

8. Finances and benefits, including the management of income, the need for and eligibility for benefits, and the limitations and restrictions of those benefits; and

9. Legal and criminal justice involvement, including guardianship, commitment, representative payee status, and experience as either a victim or an accused person.

ACT teams shall document that the following services are provided consistent with the individual's assessment and ISP:

1. Ongoing assessment to ascertain the needs, strengths, and preferences of the individual;

2. Case management;

3. Nursing;

4. Support for wellness self-management, including the development and implementation of individual recovery plans, symptom assessment, and recovery education;

5. Psychopharmacological treatment, administration, and monitoring;

6. Co-occurring diagnosis substance use disorder services that are non-confrontational, trauma-informed, person-centered, consider interactions of mental illness and substance use, and have goals determined by the individual;

7. Empirically supported interventions and psychotherapy;

8. Psychiatric rehabilitation, which may include skill-building, coaching, and facilitating access to necessary resources to help individuals with personal care, safety skills, money management, grocery shopping, cooking, food safety and storage, purchasing and caring for clothing, household maintenance and cleaning skills, social skills, and use of transportation and other community resources;

9. Work-related services that follow evidence-based supported employment principles, such as direct assistance with job development, locating preferred jobs, assisting the individual through the application process, and communicating with employers;

10. Support for resuming education;

11. Support, education, consultation, and skill-teaching to family members, significant others, and broader natural support systems, which shall be directed exclusively to the well-being and benefit of the individual;

12. Collaboration with families and assistance to individuals with children;

13. Assistance in obtaining and maintaining safe, decent, and affordable housing that follows the individual's preferences in level of independence and location, consistent with an evidence-based supportive housing model;

14. Direct support to help individuals obtain legal and advocacy services, financial support, money-management services, medical and dental services, transportation, and natural supports in the community;

15. Mobile crisis assessment, interventions to prevent or resolve potential crises, and admission to and discharge from psychiatric hospitals;

16. Assistance in developing and maintaining natural supports and social relationships;

17. Medication education, assistance, and support; and

18. Peer support services, such as coaching, mentoring, assistance with self-advocacy and self-direction, and modeling recovery practices.

A. Before a CPST provider may admit an individual to Tier 1 CPST, the individual shall meet the criteria for admission as defined by this chapter and the provider's policies. The provider's policy regarding admission to Tier 1 CPST shall, at a minimum, meet the requirements of 12VAC35-274-50 and the assessment required by that section shall document that the individual:

1. Has a primary ICD diagnosis or DSM diagnosis for mental illness; or

2. An unspecified or provisional diagnosis indicating behavioral health needs; and

3. For children and adolescents, an identified caregiver who lives in the same household shall be willing to participate in the service, as clinically appropriate.

B. Before a CPST provider may admit an individual to Tier 2 CPST, the individual shall meet the criteria for admission as defined by this chapter and the provider's policy. The provider's policy regarding admission to Tier 2 CPST shall, at a minimum, meet the requirements of 12VAC35-274-50 and the assessment required by that section shall document that the individual:

1. Has a primary ICD diagnosis or DSM diagnosis for mental illness;

2. Meets the criteria for early serious mental illness, serious mental illness, or serious emotional disturbance; and
3. For children and adolescents, an identified caregiver who lives in the same household shall be willing to participate in the service, as clinically appropriate.

Before a CPST provider may discharge an individual, the individual shall meet the criteria for discharge as defined by this chapter and the provider's policies, which shall meet all the requirements of 12VAC35-270-430. The provider's policy regarding discharge shall, at a minimum, also require the individual to:

1. No longer meet admission criteria; or

2. Successfully met the specific goals outlined in the treatment plan for discharge; or

3. Have not made progress on established service goals, nor is there expectation of any progress with continued service; or

4. No longer be engaged in the service, despite multiple attempts on the part of the provider to apply engagement strategies as defined within their policies; or

5. No longer need the service, as the individual is obtaining similar benefit through other services and resources.

A. CPST providers shall have sufficient staffing composition to meet the varied needs of individuals served by the provider as required by this section. Each CPST provider shall meet the following minimum position requirements:

1. A full-time clinical director who is a LMHP.

2. A LMHP with a minimum of two years experience working with individuals experiencing SMI or SED shall be available for consultation 24 hours a day, seven days a week.

B. Each CPST team shall meet the following minimum staffing requirements:

1. A LMHP who shall supervise the team, oversee the assessment and the ISP, and authorize the ISP. Assessments and ISPs may be completed by an LMHP, LMHP-R, LMHP-RP or LMHP-S; and

2. Every LMHP, LMHP-R, LMHP-RP, LMHP-S, and QMHP shall be trained in in evidence-based practices and decision models for assessment, treatment planning, and implementation of behavioral health interventions.

C. All CPST staff shall provide services under the direct supervision of an LMHP.

D. Applicants for an initial conditional CPST license may submit a transition plan to the department for approval that will allow for "start-up" when newly forming providers are not in full compliance with the CPST model relative to staffing patterns and individuals receiving services capacity. A transition plan must be approved prior to the issuance of the license. Approved transition plans shall be limited to a six-month period.

A. CPST Tier 1 and Tier 2 programs shall meet the following programmatic requirements. The program shall provide:

1. Crisis support 24 hours a day, seven days per week. Crisis support shall include the development and implementation of a crisis mitigation plan, any additional crisis planning necessary for the individual, crisis avoidance, and crisis intervention. The crisis mitigation plan shall not include referral to a crisis provider (CRC, CSU, or community-based crisis stabilization, including mobile crisis response) as a means of addressing the crisis. Crisis support shall be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, or QMHP.

a. Crisis support may occur via telephone or telemedicine. The individual's needs and preferences shall be the determining factor regarding whether crisis support is provided in person, via telemedicine, or via telephone.

b. If the individual's condition progresses and requires a higher level of care the individual shall be referred to the appropriate level of care.

2. Restorative evidence-based therapeutic interventions by a LMHP, LMHP-R, LMHP-RP, LMHP-S, or QMHP. If restorative evidence-based therapeutic Interventions is provided in a group with multiple individuals the ratio of team members to individuals served shall not exceed 1:6 for children and adolescents and 1:10 for adults.

3. Psychotherapy or counseling by a LMHP, LMHP-S, LMHP-R, or LMHP-RP acting within his scope of practice. If psychotherapy or counseling is provided in a group with multiple individuals the ratio of team members to individuals served shall not exceed 1:6 for children and adolescents and 1:10 for adults.

4. Care coordination on an individual basis by an LMHP, LMHP-R, LMHP-RP, LMHP-S, or QMHP.

B. CPST Tier 2 programs shall provide all the programmatic elements within A 1-4 and rehabilitation skills practice by a LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP, QMHP-T, or BHT. Rehabilitation skills practice shall be provided on an individual basis.

C. CPST programming shall take place in:

1. An individual's home;

2. An individual's community or natural settings; or

3. A provider's department-licensed office location. Services provided in the provider's department-licensed office location shall not exceed one hour a week per individual served and shall be for the benefit of the individual.

A. All CPST providers shall have an office location. The office location shall be within the Commonwealth of Virginia and have regular business hours. The office location shall be staffed during regular business hours.

B. The CPST office location shall be appropriate for storage of records and group programming. Records storage space shall meet the requirements of 12VAC35-270-580. Programming space shall ensure the privacy of individuals served.