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Electrical Work in Critical Data Centers (6235_VOSH INT 2017.pdf)
February 22, 2017
Letter to Mr. Anthony MartinezDear Mr. Martinez:
Thank you for your February 2, 2017, letter to the Virginia Department of Labor and Industry’s VOSH Program.
You were seeking interpretation of OSHA's Selection and use of work practices standard, 29 CFR 1910.333, as it relates to the infeasibility of de-energizing equipment under certain circumstances.
Your paraphrased scenario, question, and our response follow.
Scenario:
Your client provides data center services to customers who may provide 911 services, airline traffic control, and critical healthcare systems.
To perform electrical work on data center equipment in a de-energized state would cause a significant interruption to your client’s services to their customers.
Question:
Can our client provide a notice to their customers requiring them to identify themselves as having critical operations where de-energizing introduces additional or increased hazards, thus allowing your client to perform work while the equipment is energized.
Response:
The proposed notice to be sent to your client’s customers requires them to identify themselves as having critical operations such that de-energizing introduces additional or increased hazards.
Further, it requires these customers to complete and execute an “Energized Electrical Work Certification” which certifies that the customer has determined that they meet the requirements for an exemption for energized work.
This agreement maintains that the customer will indemnify and hold harmless your client against any damages or losses from your client performing energized work related to the customer’s services.
Contractual arrangements concerning limitations on liability between third parties are not subject to the Virginia occupational safety and health laws and regulations enforced by this Department, so we will not comment on that portion of your interpretation request.
Also, please note that such a "hold harmless" clause in no way exempts your client from VOSH regulatory requirements concerning work performed on energized equipment.
To qualify for the exception found in Note 1 of Main Street Centre 600 East Main Street, Suite 207 Richmond, Virginia 23219 PHONE (804) 371-2327 FAX (804) 371-6524 1910.333(a)(1), the employer must, on a case-by-case basis, determine if the orderly shutdown of the related equipment and processes would introduce additional or increased hazards.
If so, then the employer may perform the work using the electrical safe work practices found in 1910.331 - 1910.335, including, but not limited to, insulated tools, shields, barriers, and personal protective equipment.
If the orderly shutdown of the related equipment and processes would not introduce additional or increased hazards, but merely alter or interrupt production, then the de-energization of the equipment would be considered feasible, and the exception found in Note 1 of 1910.333(a)(1) would not apply.
These requirements apply to the employer whose employees perform the energized work.
Therefore, it would be your client’s responsibility to determine if de-energized work is infeasible.
If it has been determined that de-energizing a circuit is not feasible and the work must be done energized, the employer, your client, shall enforce the following practices as applicable, including but not limited to:
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Work to be performed by a qualified person
Use of an Energized Electrical Work Permit
Completion of an Arc Flash Hazard Analysis
Labeling of electrical equipment for arc flash hazards
Use of PPE per arc flash labeling/information
Training of all employees
Providing safe electrical work practices can be accomplished by following the 1910.331 - 1910.335 standards as well as NFPA 70E consensus standard.
Based on the limited information you provided regarding the electrical safe work practices used by your client, it cannot be determined whether or not your client’s energized work processes protect employees who may be exposed to electrical hazards, including, but not limited to, electric shock and arc flash.
Further, your request seeks an interpretation for “all data centers”, which you state are located throughout the United States.
This letter of interpretation only applies to work covered under the jurisdiction of the Virginia Department of Labor and Industry and may not apply in other states.
Thank you for your interest in occupational safety and health.
We hope you find this information helpful.
VOSH requirements are set by statute, standards, and regulations.
Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations.
This letter constitutes VOSH’s interpretation of the requirements discussed.
If you have any further questions, please feel free to contact me at 804-786-7776.
Sincerely,
Jennifer L. Rose, CSP
VOSH Safety Program Director
Guidance for Certified Recovery Residences in Virginia (6816_ORS 01.pdf)
DBHDS, ORS-01, March 2020
Page 1 of 2
DBHDS Office of Recovery Services (ORS) Certified Recovery Residences Guidance Document (ORS-01)
Per Code of Virginia § 37.2-431.1. Certified Recovery Residences and corresponding DBHDS regulation, Certified Recovery Residences
[12VAC35-260] BACKGROUNDIn a May 2017 brief, the National Council for Behavioral Health reported:
Recovery housing refers to safe, healthy, and substance-free living environments that support individuals in recovery from addiction. While recovery residences vary widely in structure, all are centered on peer support and a connection to services that promote long-term recovery.
Recovery housing benefits individuals in recovery by reinforcing a substance-free lifestyle and providing direct connections to other peers in recovery and recovery services and supports.
Many residents live in recovery housing during and/or after outpatient addiction treatment. Length of stay is self-determined and can last for several months to years.
Residents often share resources, give experiential advice about how to access health care and social services, find employment, budget and manage finances, handle legal problems, and build life skills.
Many recovery homes are organized under the leadership of house manager and require residents to participate in a recovery program, such as 12-step and other mutual aid groups.
While many recovery residences are well-run, a national effort has been growing to bring standards to how recovery residences are operated due to “unscrupulous actors running sober living homes who profit off the misery of their occupants.”
Broad community feedback called for greater oversight for recovery housing in Virginia to ensure the health, safety, and welfare of individuals staying in recovery residences.
Chapter 220 of the 2019 Acts of Assembly (HB2045) (http://lis.virginia.gov/cgi-bin/legp604.exe?191+ful+HB2045ER) added a new section numbered § 37.2-431.1 in the Code of Virginia creating an avenue for the certification of recovery residences in Virginia through regulations adopted by the State Board of Behavioral Health and Developmental Services.
This legislation was developed through a stakeholder-driven process. The State Board of Behavioral Health and Developmental Services adopted 12 VAC 35-260, Certified Recovery Residences, effective March 7, 2020, to implement this legislation.
The regulation creates a voluntary process for entities that meet the qualifications, policies, and practices established by credentialing entities to be certified by the Department of Behavioral Health and Developmental Services (DBHDS or Department) as certified recovery residences.
The two credentialing entities specified in the regulation are:
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Virginia Association of Recovery Residences
Oxford House
Oxford House are nationally-recognized organizations that follow best practice standards for recovery from substance use disorders.
The certification process will be administered by the DBHDS Office of Recovery Services (ORS).
Voluntary certification of recovery residences in accordance with 12 VAC 35-260 and including them on a certification list maintained by DBHDS is intended to be utilized by courts, community services boards, individuals, and families to make it easier to locate recovery housing for individuals needing such housing.
CERTIFICATION LIST MAINTAINED BY THE OFFICE OF RECOVERY SERVICESThe Certified Recovery Residences regulations, 12 VAC 35-260, become effective March 7, 2020.
At that time, entities may begin to submit applications to DBHDS for verification of compliance with the requirements of the regulation, including verification that the entity is certified or accredited by or holds a charter from a credentialing entity.
Should a recovery residence choose to be certified by the Department, it must provide evidence that it meets the qualifications, policies, and practices of, and is certified or accredited or holds a charter from, one of the following credentialing entities:
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Virginia Association of Recovery Residences (VARR). https://varronline.org/
Oxford House. https://www.vaoxfordhouse.org/
Once an application has been received, the DBHDS Office of Recovery Services (ORS) will, using regularly updated lists received from VARR or Oxford House, verify the applicant’s accreditation or certification by, charter from, or membership in a credentialing entity.
Applications that are approved for certification as a certified recovery residence will be placed on the certification list maintained by ORS: http://www.dbhds.virginia.gov/office-of-recovery-services
Pursuant to 12 VAC 35-260-40(B), any recovery residence that fails to maintain accreditation or certification by, a charter from, or membership in a credentialing entity shall be removed from the certification list.
DBHDS will monitor certified recovery residences’ continued compliance with the requirement to maintain their accreditation, certification, charter, or membership.
The two credentialing entities, VARR and Oxford House, will notify ORS within three (3) business days of the date an entity is no longer accredited or certified by, or no longer holds a charter or membership with, the credentialing entity for any reason.
This notification will be made by completing the Notification of Non-Compliance for a Certified Recovery Residence form and sending it via email to ORS.
ORS will update the certification list on a weekly basis.
Questions regarding recovery residences should be directed to: Alethea Lambert, DBHDS Office of Recovery Services Email: Alethea.lambert@dbhds.virginia.gov Phone: 804.371.0462
Use of Video and Audio Monitoring in Provider Settings (7760_OHR 02.pdf)
7760_OHR 02.pdf
DBHDS OHR 02, 2024. 09.16, Page 1 of 4
DBHDS Office of Human Rights (OHR) Uses of Video and Audio Monitoring in Provider Service Settings
Effective 09/16/2024
Individuals receiving services licensed, funded, or operated by the Department of Behavioral Health and Developmental Services (“department” or “DBHDS”) have the right to reasonable privacy [ 12VAC35- 115-50 C 3 a ] and confidentiality [ 12VAC35- 115- 80]. The information provided in this guidance is regarding the use of monitoring devices as necessary for safety and operational purposes in a provider service setting relative to provider policies and the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services (“Human Rights Regulations,” 12VAC35- 115).
Defined Terms (See 12VAC35- 115-30 .)
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“Individual” means a person who is receiving services. The term includes the terms “consumer,” “patient,” “resident,” “recipient,” and “client.”
“Local human rights committee” or “LHRC” means a group of at least five volunteers appointed by the State Human Rights Committee. (The LHRC shall review any restriction on the rights of any individual imposed pursuant to 12VAC35-115-50, 12VAC35-115-100, that lasts longer than seven days or is imposed three or more times in a 30-day period, and shall review behavioral treatment plans with restrictions, restraint, or timeout pursuant to 12VAC35-115-105.)
“Monitoring device” is not a defined term in the Human Rights Regulations; however, when used in this document, it refers to any equipment used by a provider to capture, record, or transmit an image or sound, including audio or video.
“Provider” means any person, entity, or organization offering services that is licensed, funded, or operated by the department.
“Restriction” means anything that limits or prevents an individual from freely exercising his rights.
“Services” means care, treatment, training, habilitation, interventions, or other supports, including medical care, delivered by a provider licensed, operated, or funded by the department.
Provider Policies
Any providers that determine the need to utilize monitoring devices in a service setting must have policies and procedures that make clear for individuals, families, and staff the purpose for the use of the monitoring and how the provider will ensure individuals’ confidentiality, safety, and privacy.
Providers must make certain that processes established for monitoring will not be used to diminish or substitute for staff responsibilities specific to supervision and support of individuals receiving services.
Provider policies and procedures must:
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Specify whether the monitoring device is equipped with the capacity for audio or video or both;
Identify the location of the monitoring device(s);
Specify who is responsible for and who will have access to the live video, audio, or recordings;
Explain the process used for review of audio or video and whether it will be reviewed in real-time or at established intervals;
Specify whether access and review of live video or audio or recordings is limited to on-site viewing or is available for access remotely (off-site). If remote access is provided, indicate from where an authorized user may obtain access (i.e., provider staff may view only onsite from an administrative office, or from the staff’s home office, from an agency-issued cell phone, etc.);
Detail quality controls in place to ensure against unauthorized viewing, sharing, or tampering with the monitoring device(s) or recordings. This should include a process to remove access to view live or recorded audio or video when a previously authorized person no longer requires access for their duties, or the previously authorized person is no longer associated with the provider;
Indicate how long video or audio recordings will be stored, where they will be stored, and when they will be erased;
Describe how all staff, individuals, parents, guardians, and authorized representatives, if applicable, will be notified of the monitoring policy and procedures (e.g., upon hire, prior to admission) and outline procedures for obtaining signed written acknowledgments attesting to their understanding of the policy and procedures;
Make clear that all required oversight and protection agencies will have access to all recordings upon request, including the DBHDS Offices of Human Rights and Licensing, DSS Adult and Child Protective Services (APS and CPS), and law enforcement;
Acknowledge that recordings that identify an individual or otherwise include protected health information (PHI) such as full-face photos, photos of unique identifying marks, or discussion of services are subject to HIPAA. If a recording identifies an individual or contains PHI, it must be stored, used, and disclosed only in accordance with state and federal law.
Any new policy or policy change that impacts the rights of individuals receiving services requires review by the Office of Human Rights (12VAC35-115-260 A 9) prior to implementation.
Local Human Rights Committee Review
When positioned in common areas and the protections referenced above have been addressed in a provider’s policy and procedures, the use of monitoring devices does not require review by a Local Human Rights Committee (LHRC).
When the use of a monitoring device is being considered for placement in a non-common area such as inside a bathroom or bedroom, or the monitoring device is being considered for use as an individualized support, the provider must submit all applicable proposed policies, procedures, or individualized services plans (ISPs) to the Human Rights advocate for review, prior to implementation (12VAC35-115-260).
At a minimum, the ISP shall include the type of monitoring (audio or video or both); the reason for the monitoring; the specific location of the monitoring device; and detailed procedures for the use of the device. For example, “staff will turn off the monitor when the individual is changing their clothes,” or “the monitor will only be used during sleeping hours.”
If after consultation with the advocate, the proposed use of the monitoring device is determined to be a restriction for the individual, the provider will follow the appropriate process outlined in 12VAC35-115-50, 12VAC35-115-100, or 12VAC35-115-105 in order to implement the restriction. This may include review by an LHRC.
All provider requests for review by an LHRC must be submitted using a standard form and process. A recorded overview of the LHRC review forms and process are available on the OHR webpage, under the “Resources for Providers” tab linked here.
The assigned advocate will review with the provider regulatory requirements associated with the type of review being requested and provide information about upcoming scheduled LHRC meetings. The LHRC Meeting Schedule and due dates for submitting agenda items are located on the OHR webpage, under the “LHRC and SHRC” tab linked here.
Assurance of Rights (See 12VAC35- 115-40.)
Residential and inpatient programs should have signage posted notifying anyone entering the location(s) that monitoring is occurring.
Providers are responsible for ensuring individuals are aware of their rights and the procedure for filing and resolving a complaint for violation of their rights.
Information provided to individuals must be in the manner, format, and language most frequently understood by each individual, and include at a minimum, the name and current contact information of each individual’s assigned regional advocate and a description of the human rights advocate's role.
Any individual or authorized representative, if applicable, who believes an individual’s rights were violated, can make a complaint directly with the provider or through the human rights advocate: Office of Human Rights Contact List.
Virginia Forensic Evaluation Guidelines for SB1507/HB1908 (7625_FOR 06.pdf)
COMMONWEALTH of VIRGINIA NELSON SMITH COMMISSIONER DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES
Post Office Box 1797 Richmond, Virginia 23218 -1797
Telephone (804) 786 -3921 Fax (804) 371-6638 www.dbhds.virginia.gov
TO: Forensic Evaluators Approved by DBHDS to Complete Adult Pretrial Evaluations
FROM: Elizabeth Hunt, Ph.D., ABPP
Forensic Evaluation Manager DBHDS
DATE: November 15, 2023
SUBJECT: Additional Information on SB1507/HB1908 (DBHDS Guidance Document FOR 06)
Introduction and Background
The 2023 Session of the Virginia General Assembly passed SB1507/HB1908, which modifies Code of Virginia §§ 19.2-169.1 and 19.2-169.2, specifically the portions of the bill that were established under SB198 (2022). As a reminder, the changes from SB198 allowed for, in certain misdemeanor cases when a defendant is found incompetent to stand trial, the court to dismiss the charge(s) and refer the individual for the community services board or behavioral health authority (CSB) for an evaluation to determine whether the defendant meets criteria for temporary detention.
Overview of Changes under SB1507/HB1908
In
§ 19.2-169.1 (D)
, the modifications from SB1507/HB1908 are in bold and the code now states that “Upon completion of the evaluation, the evaluators shall promptly submit a report in writing to the court and the attorneys of record concerning (i) the defendant's capacity to understand the proceedings against him; (ii) the defendant's ability to assist his attorney; (iii) the defendant's need for treatment in the event he is found incompetent but restorable, or incompetent for the foreseeable future; and (iv) if the defendant has been charged with a misdemeanor violation of Article 3 (§ 18.2-95 et seq.) of Chapter 5 of Title 18.2 or a misdemeanor violation of § 18.2-119, 18.2-137, 18.2-388, 18.2-415, or 19.2-128, whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention pursuant to § 37.2-809 in the event he is found incompetent but restorable or incompetent for the foreseeable future.”While code language for SB198 indicated that the report “may” recommend that the court direct the CSB to conduct an evaluation to determine whether the defendant meets criteria for temporary detention, SB1507/HB1908 code language now indicates that the report “shall” include whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention. Thus, evaluators are required to include this recommendation in their opinion for applicable cases.
In
§ 19.2-169.2
, the modifications from SB1507/HB1908 apply to sections C and D. Section CThe code now states, “Notwithstanding the provisions of subsection A, in cases in which (i) the defendant has been charged with a misdemeanor violation of Article 3 (§ 18.2-95 et seq.) of Chapter 5 of Title 18.2 or a misdemeanor violation of § 18.2-119, 18.2-137, 18.2-388, 18.2-415, or 19.2-128; (ii) the defendant has been found to be incompetent pursuant to subsection E or F of § 19.2-169.1; and (iii) the competency report described in subsection D of § 19.2-169.1 recommends that the defendant be evaluated to determine whether he meets the criteria for temporary detention pursuant to § 37.2-809, the court may order the community services board or behavioral health authority serving the jurisdiction in which the defendant is located to (a) conduct an evaluation of the defendant and (b) if the community services board or behavioral health authority determines that the defendant meets the criteria for temporary detention, file a petition for issuance of an order for temporary detention pursuant to § 37.2-809. The community services board or behavioral health authority shall notify the court, in writing, within 72 hours of the completion of the evaluation and, if appropriate, file a petition for issuance of an order for temporary detention. Upon receipt of such notice, the court may dismiss the charges without prejudice against the defendant. However, the court shall not enter an order or dismiss charges against a defendant pursuant to this subsection if the attorney for the Commonwealth is involved in the prosecution of the case and the attorney for the Commonwealth does not concur in the motion.” Section D
The code now states, “If a defendant for whom an evaluation has been ordered pursuant to subsection C fails or refuses to appear for the evaluation, the community services board or behavioral health authority shall notify the court and the court shall issue a mandatory examination order and capias directing the primary law-enforcement agency for the jurisdiction in which the defendant resides to transport the defendant to the location designated by the community services board or behavioral health authority for examination.”
The language in SB198 indicated that the court could dismiss the charge(s) against the defendant in lieu of ordering restoration and order the CSB to conduct an evaluation to determine whether the defendant meets criteria for temporary detention. Thus, the dismissal and order to the CSB were occurring at the same time.
SB1507/HB1908 provides clarification that these steps now occur in a sequential manner and the charge(s) are not dismissed until the CSB files notice to the court that a temporary detention petition is being filed.
The language in section D was completely changed to include the use of law enforcement in transporting individuals who refuse or do not show for the temporary detention evaluation.
Application to Evaluations
These modifications went into effect on July 1, 2023.
As a reminder, these modifications apply to misdemeanor charges of larceny, trespassing, property/monument damage, disorderly conduct, failure to appear, or drunk in public.
Evaluators are now required to include language in the competency report about whether or not the defendant should be evaluated to determine whether he meets the criteria for temporary detention whenever a defendant is opined incompetent but restorable for the above-mentioned misdemeanor charges.
The following steps may be considered when completing competence to stand trial evaluations, though evaluators should also carefully read the Code:
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Step 1: Formulate an opinion of the defendant’s competence to stand trial
Step 2: If the defendant is incompetent to stand trial, make a determination regarding restorability. Refer to § 19.2-169.1(D) regarding situations when an unrestorable opinion may be offered at the point of the initial competence to stand trial evaluation, such as when the competency is due to an irreversible medical condition or if the defendant has been found unrestorable within the last two years. If the opinion is that the defendant is incompetent and likely to remain incompetent for the foreseeable future (unrestorably incompetent to stand trial, URIST), then make recommendations pursuant to § 19.2-169.3 (A) and standard procedures apply.
Step 3: If the opinion is that the defendant is incompetent, but restorable, review the defendant’s charges. Unless the defendant’s charges are solely the misdemeanor charges listed in the Code change, make a recommendation regarding restoration, including whether restoration should occur on an outpatient or inpatient basis. Standard procedures apply.
Step 4: [SB1507/HB1908 Revision] If the charges are one or more of the misdemeanor charges listed in the Code change, then review the civil commitment code sections, as well as § 19.2-169.1 (D) and § 19.2-169.2 (C) and (D). Your report is now required to include language regarding whether the defendant should be evaluated to determine whether he meets the criteria for temporary detention. If your opinion is that the defendant should be evaluated to determine whether he meets criteria for temporary detention, then include a statement in the opinion section of your report that notifies the court that the defendant should be evaluated to determine whether he meets criteria for temporary detention (you may also consider citing § 19.2-169.1 (D) and § 19.2-169.2 (C) and (D)). You should still include recommendations regarding restoration (including whether restoration should occur on an outpatient or inpatient basis) in the event the court does not pursue this option. In cases in which the opinion is that the defendant should be evaluated to determine whether he meets criteria for temporary detention, evaluators are also reminded of their ethical obligation to ensure the individual is safe and should take any additional steps and/or notify the appropriate entities as soon as possible. If your opinion is that the defendant should not be evaluated to determine whether he meets criteria for temporary detention, then make a recommendation regarding restoration, including whether restoration should occur on an outpatient or inpatient basis. Standard procedures apply.
In summary, the opinion section of your report should include the following (per the referenced code sections):
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1. Opinion on whether the defendant is competent or incompetent.
2. Restoration recommendation (outpatient or inpatient).
3. Your recommendation regarding whether or not the defendant should be evaluated to determine whether he meets criteria for temporary detention.
cc: DBHDS Facility Directors and Forensic Coordinators
Community Services Boards Executive Directors and Forensic Coordinators
University of Virginia Institute of Law, Psychiatry, and Public Policy
Virginia Association of Community Services Boards
Supporting High-Risk Individuals with Developmental Disabilities (6837_LIC 18.pdf)
DBHDS Guidance LIC18 .High Risk.2020.0 5.28
[Page]1 of 4[/Page]COMMONWEALTH of VIRGINIA
MEMORANDUM
To: DBHDS Licensed Providers
From: Jae Benz, Director, Office of Licensing
Cc: Angelica Howard, Specialized Investigation Unit Manager
Date: March 31, 2020
FINAL May 28, 2020
RE: Individuals with Developmental Disabilities with High Risk Health Conditions
Purpose
The purpose of this memo is to inform providers licensed by the Department of Behavioral Health and Developmental Services (“DBHDS”) that provide services to individuals with developmental disabilities (“DD”) of the importance of adequately supporting individuals with high-risk health conditions.
High-risk health conditions include decubitus ulcers (“pressure injuries”), aspiration pneumonia, and falls that result in serious injury.
DBHDS is committed to continually improving the health and safety of individuals receiving behavioral health and developmental services from DBHDS licensed providers.
Rigorous inquiries into serious incident reports (“SIRs”) can identify opportunities for provider and system improvements that will reduce risks to individuals receiving licensed services.
This memo also reminds providers of the available resources offered by the DBHDS Office of Integrated Health (“OIH”).
Overview
Current SIR tracking implemented by the Office of Licensing (“OL”) Incident Management Unit (“IMU”) has revealed that there have been incidents regarding individuals with DD who have decubitus ulcers (“pressure injuries”), aspiration pneumonia, and falls that result in serious injuries.
This memo serves as a reminder of the importance for licensed providers to ensure that any individuals with DD, that have these identified health conditions, are appropriately supported based on their assessed needs.
Providers shall ensure that they only accept individuals into their services who they can support and who meet their service description (12VAC35-105-580).
In addition, providers must compile appropriate assessments (12VAC35-105-650); develop specific individual service plans (ISPs) and applicable protocols to address identified needs (12VAC35-105-660 and -665); and reassess individuals as new diagnoses occur or when Level II incidents occur (12VAC35-105-160 D 2 and -675 A).
Providers should look at incidents at both the individual level and from a risk management perspective for all individuals (12VAC35-105-520 A -E).
In addition, providers are reminded that when reporting SIRs into the DBHDS Computerized Human Rights Information System (“CHRIS”), they should ensure that the correct diagnosis is selected, versus “unknown,” when applicable.
Providers should make any updates in the SIR report as soon as possible and no later than 48 hours from the time of their original submission.
This will aid with appropriate data collection.
Potential Areas of Assessment
Below are a few examples of potential questions based on the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services (“Licensing Regulations”) [12 VAC35-105].
Providers should consider and assess these examples in an effort to prevent or address decubitus ulcers (“pressure injuries”), aspiration pneumonia, and falls resulting in serious injuries.
Please note the following is not a comprehensive list and does not serve as a substitute for obtaining a medical assessment from a licensed professional:
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12VAC35-105-450. Employee Training and Development:
1. Do you have evidence that staff were trained to support the individual with the identified medical diagnosis based on best practice evidence (e.g., skin integrity training, aspiration pneumonia prevention, fall prevention)?
2. Have you ensured that all staff are trained on the required direct support professional (DSP) orientation training and associated competency checklists completed?
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1. Do you have a risk management plan in place to help minimize the risk for the identified individual and for other individuals that is based on best practice evidence?
2. Do you complete safety and environmental check forms to ensure the environment is safe for the individual in an effort to minimize falls based on best practice evidence?
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1. Did you ensure that you only admitted individuals whose needs are consistent with your service description? What steps did you take to ensure that you only admitted individuals whose needs are consistent with your service description?
2. What procedures do you have in place for notifying the support coordinator and guardian that you can no longer provide services safely due to health changes?
3. Is there a procedure in place for emergency removal from the home?
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1. Do you have appropriate staffing levels for supervision of the individuals based on their identified needs and best practice evidence?
2. Do you have staff trained in medication administration available for all shifts?
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1. Did you ensure that the individual received the appropriate nutrition and food consistency needed based on current protocol or physician orders?
2. Was all assistive technology and adaptive food equipment used for eating and drinking: a) per physician orders; and b) per speech therapist/physical therapist/occupational therapist (“SPT/PT/OT”) evaluations; and c) consistently carried out across all settings and addressed within the individual’s ISP?
3. Is there adequate supervision or level of support provided to the individual while eating?
4. Is there evidence that all staff are trained in appropriate use of, and support of, assistive technology and adaptive equipment for the individual for eating and drinking: a) per physician orders; and b) per SPT/PT/OT’s evaluations; and c) consistently carried out across all settings and addressed within the individual’s ISP?
5. Is there evidence that all staff across all settings are able to describe symptoms of dysphagia (difficulty swallowing)?
6. Is there evidence that all staff across all settings can accurately identify when a consultation with a dietician or SPT is needed?
7. Is there evidence that all staff can accurately identify the functions and services a primary care physician (PCP)/SPT/PT/OT/nurse can provide to an individual?
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1. Do you have a quality improvement plan and processes to help identify where improvements in service delivery may be needed to minimize the risk for these types of injuries and to implement quality improvement initiatives?
2. Do you have a system in place to track repeat incidents, hospitalizations, injuries, illnesses, falls, etc., in order to analyze and recognize patterns or trends among the individuals, which can help identify system process issues, educational or training needs, and the need for a referral to PCP/SPT/PT/OT/nurse or other specialized medical assessments and treatments?
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1. Do you have adequate assessment procedures documented to include reassessments when the injury or event is discovered?
2. Do your assessments include assessing for falls, pressure injuries, aspiration risk, and other potential individual health and safety risks?
3. Did you seek outside assessments of individuals when needed (SPT/OT/PT/nurse, etc.) to include regular safety and maintenance checks of all durable medical equipment (DME) such as wheelchairs, shower chairs, toileting chairs, rollators, walkers, hospital beds, standers, gait trainers, etc.)?
4. Do you have protocols and procedures in place to ensure that individuals who use wheelchairs have an annual seating assessment (best practice) and as needed?
5. Have you requested onsite training (from the Office of Integrated Health) for mobile rehabilitation evaluation / durable medical equipment evaluation / assistive technology (“MRE/DME/AT”) to help you identify the need for a new DME assessment?
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1. Did the ISP have adequate health and safety goals, objectives, and interventions to address identified medical and clinical therapeutic needs as indicated via assessments?
2. Are the ISPs individualized such that staff clearly know how to support the individual with medical, positioning, health, and nutritional needs per best practice evidence?
3. Have you documented discussion of identified risks and potential mitigating strategies with the individual and guardian or authorized representative, as applicable, to ensure informed choice and decision making?
4. Can your staff demonstrate a working knowledge of the ISP supports?
5. Are there separate detailed protocols needed to supplement the ISP (i.e., repositioning protocol, nutritional management protocol, fall prevention protocols, and DME/AT/adaptive equipment protocols)?
6. Do you have evidence that staff were trained on the ISP and specific DME/AT/adaptive equipment protocols by specialists such as an SPT/OT/PT, etc.?
7. If you have a nurse on staff, is the nurse attending ISP meetings for those individuals who had a recent serious incident (aspiration, fall, and pressure injury)?
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1. Do progress notes support implementation of the ISP?
2. Are there any other needed medical tracking forms or documentation to support the ISP goals (repositioning forms for skin pressure prevention, nutritional monitoring forms to document appropriate nutrition and food consistencies for prevention of aspiration pneumonia, body check forms after falls to monitor for any bruising, etc.), based on best practice evidence?
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1. Does your health care policy meet regulation requirements and include how identified medical needs like decubitus ulcers (“pressure injuries”), aspiration pneumonia, and high fall risks will be addressed, especially if you currently support individuals with these identified needs, based on best practice evidence?
2. Do you have a policy to identify those individuals who have a fall risk and to develop and implement a fall prevention and management plan for each individual at risk, based on best practice evidence?
3. Does your policy address when staff immediately contact 911 in the event of an emergency and do you have evidence that all staff have been trained in your policy?
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1. Does your emergency medical information or form include identifying those individuals who are at high risk for decubitus ulcers (“pressure injuries”), aspiration pneumonia, or falls, based on best practice evidence?
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1. Did you ensure all prescribed medications were administered as prescribed (checking medication administration record sheets (“MARS”) and available medications)?
2. Did your staff ensure any medical orders for treatment were followed (repositioning orders, nutritional consistency orders, and ensuring assistive devices like walkers are available to use and in good working condition)?
3. Are all supplies (for prescribed treatments) available per physician’s (PCP or other physician) orders?
Available Resources
The DBHDS Office of Integrated Health’s (OIH) website has several safety alerts and newsletters regarding skin integrity, aspiration pneumonia, and fall prevention.
DBHDS GUIDANCE LIC18 .High Risk.2020.0 5.28
[Page 1 of 4]COMMONWEALTH of VIRGINIA
MEMORANDUM
along with other vital resources. OIH also has the Health Support Network, which currently offers the following programs: Mobile Rehab Engineering, Dental Services, and Community Nursing, which provide educational and technical assistance on health and safety related topics.
Providers are highly encouraged to utilize this resource to keep informed about important health alerts that may affect individuals with DD.
Purpose
[Insert Purpose content here.]
Overview
[Insert Overview content here.]
Key Requirements and Responsibilities
[Insert Key Requirements and Responsibilities content here.]
Reporting and Documentation
[Insert Reporting and Documentation content here.]
Signature
Sincerely,
Jae Benz
Jae Benz
Director, Office of Licensing
DBHDS
Quality Improvement Requirements for Behavioral Health Providers (6414_LIC 16.pdf)
Revised.DBHDS, LIC16, November 2020
Section 1: Purpose
This document contains guidance to providers regarding the requirements for quality improvement adopted to address compliance with the *US Department of Justice's Settlement Agreement with Virginia* within the *Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services* [12VAC35-105] (“Licensing Regulations”).
Section 2: Regulations addressed
Note all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.”
12VAC35-105-620. Monitoring and Evaluating Service Quality.
12VAC35-105-620. Monitoring and evaluating service quality
A. The provider shall develop and implement written policies and procedures for a quality improvement program sufficient to identify, monitor, and evaluate clinical and service quality and effectiveness on a systematic and ongoing basis.-
Guidance: A quality improvement (QI) program is the structure used to implement quality improvement efforts. The structure of the program shall be documented in the provider’s policies. [Note: If you are a provider of group home, sponsored residential, supervised living residential, or day support services offered in the Developmental Disability (DD) waivers, and your agency is currently engaged in efforts to come into compliance with the Home and Community Based Services (HCBS) settings requirements (42 CFR § 441.301), consider including those efforts into your QI program.]
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Guidance: 12VAC35-105-20 defines a quality improvement plan as “a detailed work plan developed by a provider that defines steps the provider will take to review the quality of services it provides and to manage initiatives to improve quality. A quality improvement plan consists of systematic and continuous actions that lead to measurable improvement in the services, supports, and health status of the individuals receiving services.”
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1. Be reviewed and updated at least annually;
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1. Establish measurable goals and objectives;
2. Update the provider’s quality improvement plan; and
3. Submit revised corrective action plans to the department for approval or continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies when reviews determine that a corrective action was fully implemented but did not prevent the recurrence of the cited regulatory violation or correct a systemic deficiency pursuant to 12VAC35-105-170.
Virginia Early Intervention Practice Manual Update (6502_Part C 09.pdf)
Post Office Box 1797 Richmond, Virginia 23218-1797
[FONT 2]Introduction / Opening Information[/FONT 2]July 9, 2021
After the most recent updates to selected sections were posted for public comment, the final version of the Early Intervention Practice Manual (Guidance Document Part C 9) is available at this link:
If you have any questions about the current Practice Manual, contact:
The final version of the Early Intervention Practice Manual (Guidance Document Part C 9) is posted for public access after recent updates.
[FONT 2]Contact Information[/FONT 2]For questions regarding the Practice Manual, please contact Catherine Hancock at the provided office number or fax.
Verification of Course Completion Certificates (7208_Verification of Course Completion Certificates Awa.pdf)
Verification of Course Completion Certificates Awa.pdf
Page 1 of 2
Guidance Document: Verification of Course Completion Certificates
Adopted May 12, 2022 | Effective Date: July 7, 2022
Guidance Document Board for Asbestos, Lead, and Home Inspectors
Virginia Board for Asbestos, Lead, and Home Inspectors
Page 1 of 2
I. Background
Board staff has received inquiries from other states regarding the validity of Virginia asbestos and lead training course completion certificates wherein the name of the course participant, the training manager, and the principal instructor are one and the same.
II. Issue
As training managers and principal instructors with asbestos and lead licenses are required to complete refresher training, to include an examination, and the Board’s regulations are silent on whether these individuals are permitted to sign their own completion certificates, it is necessary to develop means to verify whether a training manager and/or principal instructor has completed refresher training and the requisite examination.
III. Board Guidance
In accordance with § 2.2-4002.1 of the Code of Virginia, this proposed guidance document conforms to the definition of a guidance document in § 2.2-4101.
In order to limit confusion and verify the completion of refresher training and the passing of required closed-book, monitored examinations, the Board provides the following guidance:
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1. Course participants who are both the training manager and principal instructor of a training program must be monitored by another instructor if completing said program’s examination for the purpose of license renewal. The monitoring individual will sign the certificate of completion as the participant’s instructor.
2. Course participants who are either the training manager or the principal instructor must be monitored by the other if completing their own program’s examination for the purpose of license renewal. The monitoring individual will sign the certificate of completion as the participant’s instructor.
This policy applies to asbestos and lead refresher courses only. The Board will not accept initial training certificates of completion wherein the name of the course participant, training manager, and principal instructor are the same.
Polygraph Examiner Criminal History Review Guidelines (5720_Polygraph Examiner Criminal History Review Matrix.pdf)
Approved January 15, 2015
[SIZE 20.04]The following convictions will not be reviewed by the Board:[/SIZE 20.04]-
1. All felony convictions with no subsequent reportable convictions, unless the conviction resulted in incarceration where the release date is less than one year from the application date.
This does not include felony convictions.
Virginia Behavioral Health Funding Guidelines (7506_DD 07.pdf)
Contents
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I. Program Description
II. Program Eligibility Requirements
III. Prioritized Funding Categories
IV. Covered and Non-Covered Services and Supports
V. Application for Funding
VI. Application Review Criteria
VII. Funding Award Process
VIII. Requests for Reconsideration
IX. Post-Funding Review
X. Termination of Funding
12VAC35-230-20 Funding through the Virginia Department of Behavioral Health and Developmental Services’ (“department”) Individual and Family Support Program (“IFSP”) assists individuals on a waiting list for a Virginia Medicaid Home and Community-Based Services (HCBS) Developmental Disability Waiver (“DD Waiver Waiting List”) and their families with accessing resources, supports, and services.
The program supports the continued residence of individuals with developmental disabilities in their own homes or in the family home of the individual.
II. Program Eligibility Requirements12VAC35-230-35 To be eligible, applicants must meet all of the following criteria when funds are requested:
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1. Applicants must be on the Virginia DD Waiver Waiting List, and
2. Applicants must be living in their own homes or in a family home.
Applications may be submitted either by the individual who is on the DD Waiver Waiting List or a custodial family member applying on behalf of the individual(s) on the DD Waiver Waiting List.
A “custodial family member” is a family member who has primary authority to make all major decisions affecting the individual and with whom the individual primarily resides.
Individuals on the DD Waiver Waiting List who also receive assistance through other programs like the Commonwealth Coordinated Care Waiver (CCC Plus) or the Early and Periodic Screening Diagnosis and Treatment Program (EPSDT) may apply for funds if the request is for items that are not available through this or a similar program.
IFSP encourages all applicants to maximize assistance by accessing other supports and resources where appropriate.
As defined in 12VAC35-230-10, Operation of the Individual and Family Support Program.
III. Prioritized Funding Categories12VAC35-230-45 The amount each applicant may request is based upon the applicable prioritized funding category for the applicant. The program shall approve awards up to approximately $2.5 million in direct assistance to individuals on the DD Waiver Waiting List.
Prioritized Funding Categories-
Priority 1: Total Funds Available: Approximately 50% of funds will be awarded to applicants with Priority 1 status on the DD Waiver Waiting List.
Maximum Per Recipient: $1000.
Application Period: Open for one month.
Determination Process:
Funds will be awarded to applicants with the highest Critical Needs Summary scores (most at risk of institutionalization) as recorded in the Waiver Management System (WaMS) at the time of application submission, until funds are exhausted.
After all Priority 1 funds are allocated, any Priority 1 applicants who remain unfunded shall be included in the random selection process for the remaining funds in the group with Priority 2 and 3 applicants.
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Total Funds Available: Approximately 50% of funds will be awarded to applicants with Priority 2 and 3 status on the DD Waiver Waiting List.
Maximum Per Recipient: $500.
Application Period: Open for one month.
Determination Process:
All Priority 2 and 3 applicants and all remaining unfunded Priority 1 applicants shall be in the same group for random selection.
Funds shall be awarded to applicants in a random, unprioritized manner until all available funds are distributed, with the exception that new applicants and applicants who were denied in the previous year’s funding cycle will be prioritized.
The funding application schedule, including application deadlines, are posted on the My Life, My Community website at https://mylifemycommunityvirginia.org. All applications must be submitted via the department’s WaMS IFSP Funding Application Portal located at https://www.dbhds.virginia.gov/ifsponline.
Applications shall be reviewed by the department at the following intervals:
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Priority 1: Upon close of the application period.
Priorities 2 and 3: After all Priority 1 applications are reviewed and determinations are made. No later than one month from the close of the application period.
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12VAC35-230-55 The following items and services are eligible for funding as allowable expenditures under the IFSP. Please note: IFSP funds are one-time funds and are not guaranteed to be awarded in future years.
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Backup generator
Furniture, including beds, sofa, chairs, tables, lamps, and dressers
Adaptive furniture
Mattresses and bedding
Handrails and grab bars
Home modifications to improve accessibility, including door widening, additional flooring, kitchen or bathroom remodels, and driveway and window installation
Appliances
Heating, cooling, and plumbing systems conversion, installation, and repairs
General home repairs
Location devices and GPS trackers, including Project Lifesaver and AngelSense, personal alarms, locator services, and associated trainings
Respite
Fencing
Home security systems, including home alarms and cameras
Wheelchair ramp and other ramps
Stairlifts
Legal fees, including fees to establish guardianship, power of attorney, microboards, trusts, etc.
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Companion services, peer support, and mentoring
Childcare and afterschool care
Community activities/recreation
Conferences, family education, and trainings
Day support programs
Self-advocate education or training
Summer camp
Supported employment
Therapeutic activities and copays
Transportation services including Uber, Lyft, cabs, buses, etc.
Sports activities and lessons, including tournaments
Recreational and entertainment activities that support community integration
Recreational activities, including art classes, music lessons, dance lessons, gym memberships, etc.
Recreational equipment, including swings and playset equipment
In-state vacations
Passes for recreational activities
Tuition
Modifications to a vehicle, including wheelchair lifts
Reimbursement for transportation costs including gas, tolls, etc.
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Attendant care
Behavior therapy/applied behavioral analysis
Communication and assistive technology, including computers, tablets, laptops, iPads, apps, mobile phones, mobile phone services, warranties and repairs, internet services, speech applications, and speech products
Telecommunication services that enhance community access and involvement, including SIM cards, internet, mobile phone service, and applications that link individuals to community activities
Assistive technology repair
Dental care, procedures, and equipment
Hearing care, procedures, and equipment
Medical care copays
Medication
Equipment, including bikes, wheelchairs, strollers, car seats, and highchairs
Sensory items, including toys
Nutritional supports, including nutritional drinks like Boost, Ensure, formula, adult formula for feeding tubes, etc.
Therapies, including occupational therapy, physical therapy, speech therapy, massage therapy, and chiropractic therapy
Personal hygiene items, including incontinence supplies, skin ointments, wipes, specialized toothbrushes, and costs associated with professional grooming services such as haircuts, manicures, and pedicures
Therapeutic horseback riding/hippotherapy
Vision care, procedures, and equipment
Durable medical equipment, including clothing and compression garments and apparel that simplifies self-dressing and offers solutions to meet a multitude of physical challenges. Eligible clothing items include the following:
Bibs and clothing protectors
Soft clothing for sensory sensitivity
Clothing with velcro, snaps, or zipping closures
Orthopedic shoes
Eligible clothing items include the following:
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Bibs and clothing protectors
Soft clothing for sensory sensitivity
Clothing with velcro, snaps, or zipping closures
Orthopedic shoes
IFSP Funds may NOT cover the following costs:
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Clothing not related to the applicant’s disability;
Food (not related to special dietary needs associated with the disability or as part of a recreational experience);
Installment payments for automobiles and auto insurance; and
Any services or items not listed in these Guidelines or if covered by another entity.
12VAC35-230-65 The application can be found on the WaMS IFSP Funding Application Portal located at https://www.dbhds.virginia.gov/ifsponline.
IFSP funds may only be used to cover expenses incurred after the applicant receives the award approval notice.
All program funds will be issued by debit card. Applicants are expected to register the card immediately upon receipt. Failure to register the card may affect the applicant’s eligibility for future funds.
By applying, the individual or custodial family member agrees to:
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1. Maintain all receipts documenting items or services purchased with IFSP funds for three calendar years from the date of purchase and, upon request, provide the receipts to the department for auditing.
2. Acknowledge that failure to comply with the program’s policies may result in recovery of awarded funds and denial of future funding requests.
Upon receipt of a completed application and prior to issuance of funding, the department shall:
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1. Verify that the individual is on the waiting list for a Medicaid Home and Community-Based Services (HCBS) DD Waiver;
2. Confirm that the requested items or services are eligible for funding; and
3. If applicable, confirm that the applicant complied with program requirements in previous years.
Failure to provide all the requested application information shall result in an application denial.
3 IFSP stopped requiring receipts in 2020. However, applicants are still expected to maintain receipts documenting expenditures for eligible items and providing...
7506_DD 07.pdf
them as requested as part of a program audit.
DBHDS IFSP Funding Guidelines (DD 07) Rev. 09/12/2024
VIII. Funding Award Process
12VAC35-230-85
The department shall provide a written notice to the individual or custodial family member who submitted the application indicating whether the application was approved or denied.
Approvals
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Applications shall be approved according to criteria outlined in Sections I through VI of these guidelines.
Denials
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Applications may be denied if the department determines that:
The applicant does not meet the eligibility criteria.
The requesting individual or custodial family member did not comply with IFSP policies or regulations for previous funding awards. This includes failure in prior years to register debit cards for awards or failure to provide receipts for funds previously received, when requested for review.
After reviewing all applications, and following approval criteria outlined in the Prioritized Funding Categories Section III, the IFSP funding annual appropriation is expended.
An applicant in Priority 2 or Priority 3 (or remaining unfunded Priority 1) who received IFSP funding the year before may not receive funding again until all other eligible applicants in those priority categories have been awarded funding.
IX. Requests for Reconsideration
12VAC35-230-90
For applications denied for the reasons listed in Section VII, the department shall provide written notice via email stating the reason(s) for denial, and information on how to appeal the decision.
Requests for reconsideration must be submitted in writing using the directions provided in the written denial notice.
Reconsiderations must be submitted no later than 30 days after receiving the denial notice.
A determination shall be made within 30 days of receipt of the request and provided to the responsible party in writing. This decision will be final.
X. Review of Requests for Reconsideration
Process:
-
The department shall conduct a thorough review of (i) each application received for reconsideration and (ii) the determination process to identify potential errors that may have occurred.
If an error is identified that indicates the applicant should have received a funding award, the request for reconsideration will be approved.
XI. Post-Funding Review
12VAC35-230-100
Department staff may request documentation or verification that funds were used in accordance with the program guidelines to purchase only approved services or items as described in the application and approved by the department.
By receiving IFSP funds, recipients agree to provide all information requested by the department for three years following the funding cycle in which the funds were awarded.
Failure to provide information when requested may result in recovery of the awarded funds by the department or prohibition from receiving future funds.
XII. Termination of Funding
12VAC35-230-110
Funding through the IFSP shall be terminated when the individual is enrolled in a Medicaid HCBS DD Waiver, if the individual is found to be no longer eligible to be on a waiting list for a Medicaid HCBS DD Waiver in accordance with 12VAC30-122-90 and all appeals are exhausted, or if awarded funds are used for purposes not approved by the department in its written notice.
Any funds approved but not yet released to the awardee will be forfeited in such circumstances.
If you need answers to questions related to IFSP, please visit the DBHDS My Life, My Community website at https://mylifemycommunityvirginia.org.
Reporting Peer-on-Peer Aggressions as Potential Neglect (7654_OHR 01.pdf)
Effective: 02/01/2024
[SIZE=12]Introduction and Purpose[/SIZE=12]This guidance is intended to clarify the reporting requirements to the DBHDS Office of Human Rights (OHR) for peer-on-peer aggressions that occur in community provider settings licensed or funded by DBHDS.
It is intended to supersede guidance dated June 15, 2017, entitled “Office of Human Rights Peer-to-Peer Reportable Incidents.”
The impetus for clarification was a comprehensive review of neglect data entered by providers in the DBHDS Computerized Human Rights Information System (CHRIS), and collaborative conversations with key stakeholders.
[SIZE=12]Defined Terms[/SIZE=12]-
“Complaint” means an allegation of a violation of this chapter [the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services (“Human Rights Regulations”) or a provider’s policies and procedures related to the Human Rights Regulations.]
“Allegation” is not a defined term in the Human Rights Regulations; however, for purposes of this guidance and in practice, it is used interchangeably with the term “complaint” and refers to a claim or report of an alleged human rights violation.
“Individual” means a person who is receiving services. The term includes the terms “consumer,” “patient,” “resident,” “recipient,” and “client.” In this document, an individual is also referred to as a “peer.” See § 37.2-100 of the Code of Virginia.
“Internal review” is not a defined term in the Human Rights Regulations; however, when used in this guidance, it refers to the provider’s standard processes to review incidents to determine any further actions needed to identify and address potential harms to an individual and to reduce the likelihood of reoccurrence.
“Neglect” means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse.
See DBHDS, OHR 01, February 2024 Page 2 of 5 Neglect directly impacts the health and safety of an individual receiving services and has the potential to result in significant harm to the individual. “Peer-on-peer aggression,” for purposes of this guidance, means a physical act, verbal threat, or demeaning expression by an individual against or to another individual that causes physical or emotional harm to that individual.
Examples include hitting, kicking, scratching, and other threatening behavior.
Note: Incidents involving peer-on-peer aggression may constitute potential neglect when provider staff fail to follow internal policies and procedures, do not deliver supervision consistent with an individual’s individualized services plan (ISP), or do not act to prevent an individual from being harmed during the incident.
Physical harm resulting from peer-on-peer aggression may be evidenced by open wounds, bruises, black eyes, lacerations, or broken bones.
Emotional harm resulting from peer-on-peer aggression may be evidenced by an individual stating that they are feeling unsafe or afraid of certain peers, or documented changes in the individual’s behavior (i.e., becoming more withdrawn, avoidance of peer(s), or clinical documentation from a qualified professional). “Provider” means any person, entity, or organization offering services that is licensed, funded, or operated by the department.
See § 37.2-403 of the Code of Virginia. “Serious injury” means any injury resulting in bodily hurt, damage, harm, or loss that requires medical attention by a licensed physician, doctor of osteopathic medicine, physician assistant, or nurse practitioner.
See 12VAC35-115-30. “Services” means care, treatment, training, habilitation, interventions, or other supports, including medical care, delivered by a provider licensed, operated, or funded by the department.
See § 37.2-403 of the Code of Virginia.
Historically, the standard for reporting incidents of peer-on-peer aggressions to the OHR in CHRIS emphasized the occurrence of the incident in combination with either a complaint or provider suspicion of neglect.
The rationale was that requiring providers to report incidents of peer-on-peer aggressions where they “suspect” neglect, even in the absence of an actual complaint alleging neglect, increased the department’s ability to monitor provider trends and ensure appropriate actions to prevent and mitigate harm of individuals.
However, the requirement to report on this basis did not fully validate the fact that incidents of peer-on-peer aggressions can and do occur when neglect is not present.
It also deemphasized the fact that providers are ultimately responsible for identifying, monitoring, and mitigating risk patterns and trends.
(See 12VAC35-105-520.)
In Fiscal Year 2022, licensed community providers reported a total of 8,708 complaints alleging neglect via CHRIS.
Providers specifically coded 63% (5,542) of these complaints as alleged “Peer to Peer Neglect.”
Of these “Peer to Peer Neglect” reports, less than 2% (121) were ultimately determined to be a violation of an individual’s right to be free from neglect while receiving services.
The high volume of reports compared to the low number of substantiated neglect violations indicates that the vast majority of peer-on-peer incidents of aggression are not the result of neglect.
During the same time period, data on serious incidents reported via CHRIS to the DBHDS Office of Licensing indicate there were 513 incidents (out of 22,424) where the cause of the incident was peer-on-peer aggression.
In addition, the OHR became aware of another 300-plus complaints alleging neglect that were brought to its attention through means other than provider self-report.
1 These additional reports came to OHR’s attention through local departments of Social Services, the Office of the State Inspector General, and via the Office of Licensing online complaint process.
This illustrates additional concerns about provider compliance with the existing reporting requirements.
The goal of the oversight provided by the OHR and the reporting requirements in the Human Rights Regulations is to enable the department to monitor compliance with relevant laws and regulations to help ensure the rights and safety of individuals receiving services.
While notification to the OHR is a function of CHRIS, additional purposes include:
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documenting alleged abuse, neglect, or exploitation, and other human rights complaints;
documenting a summary of the provider’s investigation, findings, and any corrective action;
and allowing for review, monitoring, and verification of corrective action by the OHR.
Therefore, providers should only report incidents to the OHR in CHRIS that are alleged to have resulted in a human rights violation, whether that complaint is by an individual receiving services, by provider staff, or by other people outside the provider agency.
Even when the outcome is known or predictable to the provider, a CHRIS report and investigation of circumstances is required for all complaints.
A review of an incident where there is no complaint, identified pattern, or determination that a human rights violation may have occurred is not reportable to the OHR in CHRIS; however, these may still be reportable to the Office of Licensing if they meet the definition of a serious incident.
[SIZE=12]Internal Review of Peer-on-Peer Aggression[/SIZE=12]All incidents that meet the definition of “peer-on-peer aggression” in the Human Rights Regulations are to be reviewed by the provider, in accordance with the provider’s policies and procedures.
This internal review of incidents involving peer-on-peer aggression is expected to consider, at a minimum, whether provider staff followed internal policies and procedures, delivered supervision consistent with individual(s) needs and the ISP(s), and acted to prevent individuals from being harmed while receiving services.
In addition, the provider is expected to identify any programmatic issues that may have contributed to the opportunity for peer-on-peer aggression (e.g., policies, protocols, etc.).
Upon completion of this internal review, providers are expected to implement any identified proactive measures that may reduce the number of peer-on-peer aggressions and lessen the possibility of neglect, resulting in a safer treatment environment overall.
(See also 12VAC35-105-160 and 12VAC35-105-520 of the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services [“Licensing Regulations”] that specify various review and reporting requirements.)
Please note that the internal review is separate from the investigation that would occur if the review raised suspicion of abuse or neglect, or if the provider received a complaint.
The OHR may request to review provider information specific to their review of incidents involving peer-on-peer aggression because of identified trends, the possibility of neglect, complaints discovered by the OHR that were known to the provider but not reported, or in any situation that the OHR deems necessary to protect the rights of individuals receiving services from providers of mental health, developmental, or substance abuse services in Virginia.
-
(See 12VAC35-115-260.)
Providers must report to the OHR all incidents of peer-on-peer aggression that are alleged to have resulted in or from a human rights violation, whether the alleged violation is discovered by the provider or through a complaint.
These incidents of peer-on-peer aggression shall be entered in CHRIS within 24 hours of discovery of the incident or receipt of the complaint, in accordance with 12VAC35-115-230.
These incidents should be coded under the category “Neglect Peer-on-Peer Aggression.”
Examples of incidents of peer-on-peer aggression that should be reported:
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An incident that clearly occurred because staff were not engaged in appropriate supervision (e.g., provider staff willfully ignored the physical act, verbal threat, or demeaning expression of one peer to another; provider staff intervened but not in accordance with policy; provider staff failed to implement supervision or supports based on the specific needs identified in the ISP);
A pattern of three or more incidents of peer-on-peer aggression involving the same peers within a seven-day timeframe (e.g., Individual A was the victim of physical acts, verbal threats, or demeaning expressions by another individual or individuals during three or more separate incidents within the timeframe; Individual B performed physical acts, verbal threats, or demeaning expressions toward another individual or individuals during three or more separate incidents within the timeframe).
Entering Incidents of Peer-on-Peer Aggression in CHRIS
Incidents of peer-on-peer aggression that are determined to be reportable after a review by the provider shall be entered in CHRIS within 24 hours of the date of this
DBHDS Office of Human Rights (OHR) Reporting Peer-on-Peer Aggressions as Potential Neglect
determination, which is the date of discovery. These incidents should be coded under the category “Neglect Peer-on-Peer Aggression” and the description must indicate the reason for the report.
Introduction and Purpose
For instance, when the report is concerning three or more incidents of peer-on-peer aggression within a seven-day timeframe, the provider should indicate this as the “description,” along with a brief account of the three incidents.
Defined Terms
When the complaint alleges involvement of a known provider staff person, the provider staff name should be entered in the description of the incident on the Accusation Tab in CHRIS.
If the complaint indicates a possible programmatic failure, the provider should select “Other” and enter the provider’s name (e.g., ABC Residential) under the Accusation Tab in CHRIS.
Reporting Requirements and Procedures
Reports of peer-on-peer aggression should be entered in DBHDS, OHR 01, February 2024 Page 5 of 5 CHRIS under the name of the individual who was the alleged victim of the aggression.
If the aggression was mutual, a separate report must be entered for all individuals involved.
All incidents of peer-on-peer aggression that are reported in CHRIS must be investigated in full accordance with the Human Rights Regulations. (See 12VAC35-115-175.)
The complaint shall be substantiated when the provider determines, as a result of its investigation, that the incident of peer-on-peer aggression:
-
was the result of acts or omissions by provider staff or a programmatic deficit; and
resulted in an individual’s physical or emotional harm.
Providers are expected to take and document appropriate corrective actions for all substantiated complaints resulting in a human rights violation.
In addition to the provider’s reporting requirements to the department as outlined above, if at any time the provider has reason to suspect that an incident may be a crime, or is otherwise reportable to another entity, the provider shall report the incident to all appropriate authorities.
Such instances include but are not limited to an incident:
-
Between peers involving sexual assault, which is a form of violence and includes forced groping and rape;
Involving unwanted sexual activity between minors (e.g., intercourse, kissing, touching of private areas); or
Involving sexual intercourse or other sexual activity, physical assault, or exploitation between adult peers in which at least one individual is deemed to lack capacity based on an existing assessment that indicated the individual was at risk of exploitation.
Risk Management Guidance for Behavioral Health Providers (6874_LIC 21.pdf)
DBHDS, LIC 21 , August 2020
1. DBHDS Office of Licensing Guidance for Risk Management
Effective: August 27, 2020
Purpose
This document contains guidance to providers regarding the requirements for risk management adopted to address compliance with the Department of Justice's Settlement Agreement with Virginia within the Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services [12VAC35-105] (“Licensing Regulations”).
Regulations addressed
Note all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.”
12VAC35-105-20. Definitions
12VAC35-105-520. Risk management
Settlement Agreement indicators addressed
V.C.1.1, V.C.1.4, V.C.1.5, V.C.4.1, V.C.4.3, and V.C.4.4
Guidance 12VAC35-105-20. Definitions
The following definitions (pending final approval) are relevant to this guidance document:
-
"Risk management" means an integrated system-wide program to ensure the safety of individuals, employees, visitors, and others through identification, mitigation, early detection, monitoring, evaluation, and control of risks.
"Root cause analysis" means a method of problem solving designed to identify the underlying causes of a problem. The focus of a root cause analysis is on systems, processes, and outcomes that require change to reduce the risk of harm.
"Serious incident" means any event or circumstance that causes or could cause harm to the health, safety, or well-being of an individual. The term "serious incident" includes death and serious injury.
Guidance:
All providers are required to designate a qualified person with responsibility for the risk management function.
Qualifications for this position shall be obtained through the completion of department approved training in these enumerated areas of risk management responsibility:
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1. Individual risk screening;
2. Conducting investigations;
3. Root cause analysis; and
4. The use of data to identify risk patterns and trends.
Note that these are minimum qualifications. Providers may also provide training in additional areas relevant to the risk management function, which may include topics such as emergency preparedness, use of universal precautions to prevent infections, prevention of inadvertent release of protected health information (PHI), and other areas of potential risk to providers.
DBHDS will post information about approved training on its website. Providers that the Office of Licensing determines are non-compliant with risk management requirements for reasons that are related to a lack of knowledge will be required to demonstrate that they complete training offered by the Commonwealth or other training determined by the Commonwealth to be acceptable, as part of their corrective action plan (CAP). B. The provider shall implement a written plan to identify, monitor, reduce, and minimize harms and risk of harm, including personal injury, infectious disease, property damage or loss, and other sources of potential liability.
Guidance:
Providers must have a written risk management plan focused on identifying, monitoring, reducing, and minimizing harms and risk of harm through a continuous, comprehensive approach. This plan should include identifying year-over-year trends and patterns and the use of baseline data to assess the effectiveness of risk management systems.
The written risk management plan should be reviewed and updated at least annually, or any time that the provider identifies a need to review and update the plan based on ongoing quality review and risk management activities, such as during its quarterly reviews of all serious incidents.
As required by 12VAC35-105-620, a provider’s risk management plan may be a standalone risk management plan or it may be integrated into the provider’s overall quality improvement plan.
Risk management plans and overall risk management programs should reflect the size of the organization, the population served, and any unique risks associated with the provider’s business model.
In developing a risk management plan, the provider should consider how the following characteristics affect the provider’s level and types of risks:
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• How many individuals does the provider serve?
• What are the needs and characteristics of those served?
• What are typical risks associated with this population?
• What services does the provider offer; what risks are involved with these services?
• What is the location(s) where services are provided?
• What is the provider’s business model?
DBHDS will post information about approved training on its website. Providers that the Office of Licensing determines are non-compliant with risk management requirements for reasons that are related to a lack of knowledge will be required to demonstrate that they complete training offered by the Commonwealth or other training determined by the Commonwealth to be acceptable, as part of their corrective action plan (CAP). C. The provider shall conduct systemic risk assessment reviews at least annually to identify and respond to practices, situations, and policies that could result in the risk of harm to individuals receiving services.
The risk assessment review shall address at least the following:
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Guidance:
An annual risk assessment review is a necessary component of a provider’s risk management plan. This review should include consideration of harms and risks identified and lessons learned from the provider’s quarterly reviews of all serious incidents conducted pursuant to 12VAC35-105-160.C., including an analysis of trends, potential systemic issues or causes, indicated remediation, and documentation of steps taken to mitigate the potential for future incidents.
The risks enumerated in the regulation are not an exhaustive list. Other risks that providers should consider include:
• Financial risks including whether the provider has sufficient capital to support the business if revenue decreases or is delayed, per 12VAC-35-105-210; and whether the provider has instituted the appropriate checks and balances over financial transactions;
• Business risks; and
• Workforce related risks.
1. The environment of care Guidance:
The “environment of care” means the physical environment where services are provided, such as the building and physical premises.
A review of the environment of care should consider the results of the annual safety inspection conducted pursuant to 12VAC35-105-520.E, when applicable, but is broader than a safety inspection.
Examples of environmental considerations include such things as:
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• The location where services are provided (e.g., in individual’s own home, at a correctional facility, or at a location under the provider’s control);
• How the area where services are provided is arranged;
• Any special protective features that may be present;
• The location, amount, and condition of safety equipment, including:
• Fire extinguishers;
• First aid kits;
• Flashlights;
• Emergency egress routes and exit signs;
• Any other safety equipment that is or should be present.
• The condition and temperature regulation of refrigerators that store food or medications;
• Security of medication storage;
• Condition of electrical cords, outlets, and electrical equipment;
• The adequacy, suitability, and condition of lighting; and
• Any other physical features that could present safety risks if not properly arranged, secured, maintained, or otherwise addressed.
Environment of care considerations will be different when services are provided at a location that is not under the direct control of the provider, such as at an individual’s own home.
While providers are more limited in their ability to assess some of the factors listed above in these locations, providers should consider any unique risks associated with the provision of services in these locations during its risk assessment review.
In such cases the review does not need to consider each location (e.g., each home) individually, but should identify risks that may be common across the different locations or settings. 2. Clinical assessment or reassessment processes Guidance:
Examples of assessments include physical exams that are completed prior to admission or any time that there is a change in the individual’s physical or mental condition.
Reassessments include:
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(i) reviews of incidents in which the individual was involved, and
(ii) reviews of the individual’s health risks.
Persons designated as responsible for the risk management function need not be engaged in the clinical assessment or reassessment process, but should review these processes during the risk assessment review process. For example, are assessment processes effectively identifying and mitigating risks unique to each individual? 3. Staff competence and adequacy of staffing Guidance:
Examples of factors related to staff competency and adequacy of staffing include whether:
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• All employees meet minimum qualifications to perform their duties;
• All employees complete orientation training prior to being assigned to perform direct care work;
• All employees have undergone background checks;
• All employees have completed abuse and neglect training;
• All employees have up-to-date CPR certification;
• Employees who administer medications have received requisite training;
• Employees have completed additional training applicable to their job functions, such as initial and annual fire safety training;
• Staffing schedules are consistent with the provider’s staffing plan; and
• The staffing plan continues to be adequate to meet the needs of the individuals being served.
In addition to seclusion and restraint, examples of high risk procedures may include:
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• The administration of high risk medications;
• High risk methods of medication administration;
• Procedures used to transfer individuals who require assistance transferring from one location to another; and
• Any other procedure that may pose a greater than average risk to the health and safety of individuals, staff members, or third parties.
Examples of high risk procedure considerations include the following:
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• Whether the use of seclusion and restraint, and other high risk procedures are in compliance with the Regulations to Assure the Rights of Individuals Receiving Services from Providers Licensed, Funded, or Operated by the Department of Behavioral Health and Developmental Services [12VAC35-115] (“Human Rights Regulations”) and the Licensing Regulations and any other applicable laws and regulations that govern their use;
• Identification and review of procedures that are typically conducted by the provider which are potentially high risk;
• Whether staff who are permitted to implement high risk procedures have the requisite training, experience, and qualifications to do so safely and in accordance with regulation;
• Whether all high risk procedures are properly authorized and reviewed per policy, regulation, and law; and
• The findings from any root cause analysis conducted when a high risk procedure causes or is otherwise associated with a serious injury.
The provider’s systemic risk review shall evaluate serious incidents at least annually. Examples of considerations related to serious incidents include whether:
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• All Level I
DBHDS, LIC 21 , August 2020
serious incidents were reviewed at least quarterly to identify trends in accordance with 12VAC35-105-160;
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Any patterns or trends that have been identified require additional safeguards or risk mitigation strategies;
The provider has an updated policy that defines who has the authority and responsibility to act when a serious incident or a pattern of serious incidents indicates that an individual is at risk; and
Serious incidents and patterns of serious incidents are reviewed and appropriate follow-up is conducted or implemented to address individual or system-level risks.
D. Systemic Risk Assessment Review Process
The systemic risk assessment review process shall incorporate uniform risk triggers and thresholds as defined by the department.
Guidance:
DBHDS will disseminate information about uniform risk triggers and thresholds in separate guidance when they are developed.
E. Safety Inspection
The provider shall conduct and document that a safety inspection has been performed at least annually of each service location owned, rented, or leased by the provider.
Recommendations for safety improvement shall be documented and implemented by the provider.
Guidance:
An annual safety inspection must be completed at each service location. This inspection should evaluate the premises for safety concerns. Examples of safety concerns include the operability of fire safety equipment, emergency egress routes, any cooking and electrical devices on the premises, and trip hazards or other dangerous items or scenarios.
F. Documentation of Serious Injuries
The provider shall document serious injuries to employees, contractors, students, volunteers, and visitors that occur during the provision of a service or on the provider's property. Documentation shall be kept on file for three years.
The provider shall evaluate serious injuries at least annually. Recommendations for improvement shall be documented and implemented by the provider.
Guidance:
Failure to document serious injuries to employees, contractors, students, volunteers, and visitors will result in the issuance of a licensing report citing 12VAC35-105-520.F.
Documented serious injuries to employees, contractors, students, volunteers, and visitors shall be evaluated at least annually. This evaluation shall include the identification of recurring serious injuries, trends, any other indication of systemic safety deficiencies, and planned steps to remedy the same.
The evaluation and planned remediation steps should be incorporated into or aligned with the provider’s annual systemic risk assessment review process or both. *Please note that Level II incidents include “a significant harm or threat to the health or safety of others caused by an individual.” Therefore, if a serious injury was caused by an individual to an employee, contractor, student, volunteer, or visitor during the provision of services or on the provider’s premises, the serious injury should also be reported into CHRIS within 24 hours of discovery as a Level II serious incident.*
Incident Reporting Guidelines for Licensed Providers (6876_LIC 20.pdf)
To: DBHDS Licensed Providers
From: Jae Benz, Director, Office of Licensing
Date: August 22, 2020
RE: Guidance on Incident Reporting Requirements
PurposeThe purpose of this memorandum is to remind DBHDS licensed providers of the requirements and expectations for reporting serious incidents to the DBHDS Office of Licensing, pursuant to 12VAC35-46-1070.C. and 12VAC35-105-160.D.2., including the timeframe for reporting incidents; the process for reporting incidents; the allowable timeframe for adding to, amending, or correcting information reported to the Office of Licensing through the Computerized Human Rights Information System (CHRIS); and to inform providers of the processes that the Office of Licensing will follow for issuing citations, repeat citations, and sanctions for violations of serious incident reporting requirements.
In addition to ensuring all providers understand the regulatory requirements associated with reporting incidents, the processes outlined in this memo are central to the department’s efforts to address compliance indicators related to serious incident reporting as mandated by the US Department of Justice’s (DOJ) Settlement Agreement with Virginia.
1. Serious Incident Reporting Requirements REGULATIONS FOR CHILDREN’S RESIDENTIAL FACILITIES (“Children’s Residential Regulations”) [12VAC35-46]Pursuant to 12VAC35-46-1070.C., providers of children’s residential services shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other situations as required by the department.
DBHDS, LIC20, August 2020
RULES AND REGULATIONS FOR LICENSING PROVIDERS BY THE DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES (“Licensing Regulations”) [12VAC35-105]
Regulation 12VAC35-105-160.D.2. of the Licensing Regulations requires providers to report all Level II and Level III serious incidents using the department's web-based reporting application and by telephone to anyone designated by the individual to receive such notice and to the individual's authorized representative within 24 hours of discovery.
Although Level I serious incidents do not need to be reported to the Office of Licensing through the CHRIS system, regulation 12VAC35-105-160.C. requires all non-children’s residential providers to collect, maintain, and review all serious incidents, including Level I serious incidents at least quarterly as part of the provider’s quality improvement program.
Please note that these methods of reporting an incident in place of submitting an incident report into the CHRIS system will be deemed as non-compliant and the provider will be cited:
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Reporting a serious incident to the provider’s licensing specialist via e-mail or phone call;
Reporting a serious incident to the provider’s human rights advocate via e-mail or phone call;
Reporting the incident to any other representative of DBHDS by any means other than the serious incident reporting function in CHRIS; and
Reporting an allegation of abuse or neglect that also meets the criteria for a Level II or Level III serious incident only on the DBHDS Office of Human Rights (OHR) side of CHRIS instead of reporting the incident on both the OHR and the DBHDS Office of Licensing sides of CHRIS.
It is important to note that although providers use the CHRIS system to report serious incidents to the Office of Licensing, and to report allegations of abuse or neglect to OHR, these are two distinct reporting functions, which satisfy separate regulatory requirements.
Reporting an allegation of abuse or neglect to OHR does not remove the need to report a Level II or Level III serious incident to the Office of Licensing, even if the serious incident report involves the same underlying facts as the abuse or neglect allegation.
Please note that the Office of Licensing is working to ensure any future incident reporting system eliminates the need for double entry.
CHRIS System Errors and Network OutagesThere may be unusual circumstances when a provider is unable to report an incident through the CHRIS system because of a CHRIS system error or a network outage.
The ONLY valid reasons for not reporting a serious incident into CHRIS include:
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The CHRIS system was not functioning at the time the incident was discovered; or
The provider was unable to access the CHRIS system for reasons that were not in the provider’s control.
If a provider is unable to report a serious incident through the CHRIS system for one of these valid reasons, then the provider must notify the Office of Licensing’s Incident Management Unit (IMU) via e-mail (incident_management@dbhds.virginia.gov) of the provider’s inability to report the incident through the CHRIS system within 24 hours of the discovery of the incident.
In the rare circumstance when the provider is unable to access both the CHRIS system and e-mail for reasons outside of the provider’s control, then the provider may notify their regional Incident Management Unit (IMU) representative by telephone.
In such a circumstance, mark the e-mail to IMU with the following subject line: “Potential Late Entry-CHRIS complications for [NAME OF PROVIDER].”
Notification to other DBHDS employees or representatives, including the provider’s licensing specialist or human rights advocate, will not substitute for notification to the IMU.
Providers will be cited for a regulatory violation of 12VAC35-105-160.D.2. or 12VAC35-46-1070.C., as applicable, if they do not report serious incidents within the regulatory timeframe, unless they have notified the IMU of their inability to do so due to a system error in CHRIS or a network outage, even if they have notified their licensing specialist or human rights advocate.
DBHDS, LIC20, August 2020
Note on Authorized Users and Late SubmissionsI have noted in my October 1, 2019 memo and in subsequent CHRIS training that not having an authorized user for CHRIS is not a valid reason for late submission of a serious incident report in the CHRIS system.
It is the provider’s responsibility to ensure that an authorized user for CHRIS is available at all times.
Updates to Serious Incident ReportsIn some instances, a provider may need to update a serious incident report in CHRIS after its initial submission.
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A provider may be awaiting a medical report or other records related to an emergency room visit; or
IMU staff may request that the provider update an incident report in CHRIS when the IMU identifies information that should have been included in the report, but was not included.
When the provider must update an incident report in CHRIS after the initial submission, the provider must do so within two business days from the initial submission of the incident report, or from the time that the provider is informed by the IMU of the need to update the report, whichever is later.
If the provider is unable to obtain necessary information to update the incident report within the two business day period for reasons outside of the provider’s control, such as when the provider is awaiting pertinent laboratory results that are not received within the two business day period for updating the incident report, then the provider must communicate this to the provider’s regional IMU representative during the two business day timeframe.
Failure to update a serious incident report in CHRIS within two business days from the initial submission of the report, or from the time that the provider is informed by the IMU of the need to update the report, will be cited as a regulatory violation of 12VAC35-105-160.F. or 12VAC35-46-230.A., as applicable, unless the provider has communicated its inability to obtain the necessary information to the provider’s regional IMU representative within the two business day timeframe.
2. Office of Licensing Compliance Monitoring ActivitiesThe Office of Licensing conducts ongoing monitoring of provider compliance with serious incident reporting requirements.
The IMU within the Office of Licensing reviews serious incident reports for timeliness and compliance with all other regulatory requirements.
Each business day, the IMU CAP specialist will ‘pull’ a report to determine if any providers have not reported Level II and Level III serious incidents through the CHRIS system within the 24-hour timeframe.
The IMU CAP specialist will issue a licensing report for all late submissions of serious incident reports into the CHRIS system, except when a provider has notified IMU during the 24-hour reporting period, and the provider had a valid reason for not reporting the incident in the CHRIS system during the 24-hour reporting period, pursuant to 12VAC35-105-160.D.2. or 12VAC35-46-1070.C.
The Office of Licensing also monitors provider compliance with serious incident documentation and reporting requirements during all investigations and annual inspections.
Prior to conducting an annual inspection, the licensing specialist will review the provider’s history of compliance with 12VAC35-105-160.D.2. or 12VAC35-46-1070.C.
If a licensing specialist identifies a serious incident(s) during an annual inspection that should have been reported but was not reported at all or was not reported within 24 hours of the discovery of the incident, and for which a licensing report has not already been issued, then the licensing specialist will issue a licensing report citing the provider for late reporting pursuant to 12VAC35-105-160.D.2. or 12VAC35-46-1070.C., as applicable.
If a provider made an abuse or neglect report to OHR following a Level II or Level III serious incident, but did not report the serious incident to the Office of Licensing through the CHRIS serious incident reporting function, then the licensing specialist will instruct the provider to report the serious incident, and then will issue a licensing report citing the provider for late reporting.
When conducting an annual inspection of a provider, other than a provider of children’s residential services, the licensing specialist will also request evidence to verify the provider’s compliance with the documentation and quarterly review of all serious incidents.
If the licensing specialist determines that quarterly reviews of all serious incidents were not conducted, or identifies serious incidents that were not included in the provider’s quarterly reviews, then the licensing specialist will issue a licensing report for failure to conduct quarterly reviews citing 12VAC35-105-160.C.
Finally, when conducting an annual inspection of a provider, other than a provider of children’s residential services, the licensing specialist will review at least one randomly selected root cause analysis (RCA) that was conducted from a list of the serious incidents reported by the provider during the calendar year.
If the licensing specialist determines that the provider did not conduct an RCA within 30 days of discovery of one or more Level II serious incidents or any Level III serious incidents that occurred during the provision of a service or on the provider's premises, or that the provider’s RCA does not meet the regulatory requirements of 12VAC35-105-160.E., then the licensing specialist will issue a licensing report.
Corrective Action Plans (CAPs) - Minimum RequirementsCorrective action plans (CAPs) will be required for ALL identified violations of serious incident documentation and reporting requirements.
Providers must submit a CAP to the department within 15 business days of the issuance of the licensing report.
End of Document 6876_LIC 20.pdf MEMORANDUMThis memorandum provides guidance on the requirements for Corrective Action Plans (CAPs) and the progressive actions related to serious incident reporting violations.
PurposeThe purpose of a CAP is to prevent the recurrence of the regulatory violation by addressing the underlying cause(s) of the violation.
1. Serious Incident Reporting RequirementsThe provider may request an extension of up to 10 business days PRIOR to the due date for the CAP. Failure to submit a CAP or request an extension within 15 business days of the issuance of a licensing report will result in an additional licensing report citing the provider for failure to submit a CAP pursuant to 12VAC35-105-170.D. or 12VAC35-46-80.B., as applicable.
The Office of Licensing will only accept CAPs that meet the following minimum criteria:
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The proposed corrective actions are clearly articulated and reasonably calculated to address the underlying cause(s) of the violation and to prevent its recurrence.
The proposed CAP includes systemic actions to ensure future compliance with the regulation. Examples include the implementation of ongoing quality assurance systems and self-monitoring tools such as checklists, spreadsheets, tables, or forms.
There is a realistic completion date provided for each corrective action.
The CAP includes the means and processes by which evidence of completion of the corrective actions will be collected and provided to the Office of Licensing.
CAPs that do not meet these minimum criteria will be returned to the provider for revisions within 15 business days.
Progressive Actions for Repeat CitationsBeginning October 1, 2020, the Office of Licensing will implement progressive citation protocols to address repeat violations of serious incident documentation and reporting requirements at the service level. The purpose of these protocols is to ensure that providers who demonstrate regulatory noncompliance implement effective corrective actions and quality improvement activities to prevent future violations.
When a licensed service was previously cited for a regulatory violation, future violations within a one-year period (measured on a rolling basis) will result in the following progressive actions:
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First Citation: When related to reporting of serious incidents, deaths, or allegations of abuse or neglect within a one-year period, the provider will be issued a licensing report citing:
12VAC35-105-160.D.2. or 12VAC35-46-1070.C., as applicable, for noncompliance with reporting requirements.
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12VAC35-105-160.D.2. or 12VAC35-46-1070.C., as applicable, for systemic noncompliance with reporting requirements; and
12VAC35-105-170.G. or 12VAC35-46-80.B., if it is determined that the repeat violation was due to failure to implement a previously pledged CAP.
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12VAC35-105-160.D.2. or 12VAC35-46-1070.C., for systemic noncompliance; and
12VAC35-105-170.G. or 12VAC35-46-80.B., if it is determined that the violation was due to failure to implement a previously pledged CAP.
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Issuance of sanctions enumerated in § 37.2-419 of the Code of Virginia;
Denying license applications or renewals (Code of Virginia § 37.2-418);
Issuance of provisional licenses (Code of Virginia § 37.2-415);
Revocation or suspension of licenses due to repeated failure to submit or implement adequate CAPs (Code of Virginia § 37.2-418).
You are encouraged to sign up for the Office of Licensing’s recurring CHRIS trainings on Eventbrite for helpful information related to serious incident reporting.
If you have questions or concerns regarding this memo, please contact Stella Stith, Office of Licensing Incident Management Manager, at stella.stith@dbhds.virginia.gov.
Additional resources from DBHDS related to serious incident reporting include:
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DBHDS Office of Licensing Guidance for Serious Incident Reporting
Office of Licensing Serious Incident Reporting Training
CHRIS Reporting Expectations Memo
Revoking a User’s Delta Access
Restructuring Within the Office of Licensing
02.2020 CHRIS Modifications Training
04.2020 CHRIS Modifications Training
Note that all Office of Licensing guidance documents are posted on Town Hall and numbered beginning with ‘LIC.’ More information about the Settlement Agreement indicators tied to serious incident reporting, specifically indicators: V.B.3.b, V.B.3.a.i, V.B.3.a.ii, V.B.3.a.iii, V.B.3.b, V.C.6.4, V.C.6.5, V.C.6.6, and V.C.6.7, can be found within the Joint Filing of Complete Set of Agreed Compliance Indicators.
Guidance on Developing Corrective Action Plans (6875_LIC 19.pdf)
DBHDS, LIC1 9, August 2020
1
PurposeThis document provides guidance to DBHDS licensed providers on how to develop and implement an acceptable correcti ve action plan (CAP).
2
Regulations AddressedNote all regulatory language is formatted in italics while guidance language is in plain text located within boxes under the label “guidance.”
12VAC35-105-20. Definitions
12VAC35-105-170. Corrective Action Plan Settlement Agreement
3
Indicators AddressedV.C.4.8
Guidance12VAC35-105-20. Definitions. The following definitions are relevant to this guidance document:
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"Corrective action plan" means the provider's pledged corrective action in response to cited areas of noncompliance documented by the regulatory authority.
"Systemic deficiency" means violations of regulations documented by the department that demonstrate multiple or repeat defects in the operation of one or more services.
The development, implementation, and monitoring of CAPs are important components of a provider’s overall quality improvement process. Adequate CAPs address identified deficiencies on both an individual and systemic level.
12VAC35-105-170. Corrective action plan.
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A. If there is noncompliance with any applicable regulation during an initial or ongoing review, inspection, or investigation, the department shall issue a licensing report describing the noncompliance and requesting the provider to submit a corrective action plan for each violation cited.
B. The provider shall submit to the department a written corrective action plan for each violation cited.
C. The corrective action plan shall include a:
Detailed description of the corrective actions to be taken that will minimize the possibility that the violation will occur again and correct any systemic deficiencies;
Date of completion for each corrective action; and
Signature of the person responsible for oversight of the implementation of the pledged corrective action.
Guidance: Develop a CAP: CAPs must include a detailed description of planned corrective actions that are targeted to the mitigation or prevention of the recurrence of the regulatory violation that the CAP is intended to address, and must be sufficiently detailed to inform the Office of Licensing of the planned action steps that will be taken to fulfill the goals of the CAP.
Planned actions must be verifiable, with mechanisms for verifying the completion of the planned actions incorporated into the provider’s ongoing quality improvement activities, pursuant to *12VAC35-105-620*. If the provider’s pledged corrective action plan includes a one-time, permanent fix such as amending language within a form template, the provider will only need to verify completion of the planned activity once as part of its quality improvement activities.
When developing an acceptable CAP, the provider should review the citation received by the department to identify the problems that led to the issuance of the citation, including a determination as to whether or not the problem is systemic and occurring across different services, locations, or staff.
Providers are required to conduct a root cause analysis (RCA) on all Level II and Level III serious incidents that occurred within the provision of the provider’s services or on the provider’s property.
Therefore, if the citation was issued as the result of a serious incident, the RCA will assist the provider in identifying practices or underlying conditions that may have led to the occurrence of the serious incident.
Additional assistance related to RCA s can be found within the department’s “Guidance for Serious Incident Reporting.”
Providers may also become aware of remedies to systemic issues through the following processes:
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conducting quarterly reviews of all serious incidents, including Level I serious incidents, pursuant to *12VAC35-105-160.C.*;
annual and as needed risk assessments pursuant to *12VAC35-105-520.C.*; and
the use of standard quality improvement tools as part of the established quality improvement program pursuant to *12VAC35-105-620.B.*.
Providers should consider the following steps when writing a CAP:
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Address all problems documented in each violation by:
Identifying the root cause(s) of the violation;
Developing a systemic plan of action, if applicable, to address each problem, which may require updating policies, procedures, and forms, or conducting any needed training or retraining for staff, or other steps that could alleviate the problem and minimize the possibility that the violation will occur again;
Indicating the frequency for monitoring the plan, including how it will be monitored (Ex: monthly audits, weekly chart reviews, quarterly checklist).
If a CAP is not accepted in whole or in part, it will be returned to the provider within 15 business days, with clearly stated comments and questions that indicate the specialist’s concerns.
If a CAP is returned to the provider a second time for failure to meet all requirements within *12VAC35-105-170.C.*, the licensing specialist will offer to have a phone call with the provider to provide technical assistance related to the criteria needed to create an acceptable CAP.
If a CAP is returned to the provider a third time for failure to meet all requirements within *12VAC35-105-170.C.*, the CAP will be returned and the CAP dispute process will be initiated automatically as outlined in *12VAC35-105-170.F.*
Example for Creating a CAP:
After an unannounced inspection, Provider A receives a licensing report on August 1st that includes the second citation for late reporting of a serious incident within a one-year period.
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Address all problems documented in each violation by:
Identifying the root cause(s) of the violation. As this is Provider A’s second citation for the same regulatory violation within one year, Provider A conducts an analysis in accordance with the written quality improvement program, to determine the root cause of these repeat violations. The analysis reveals that two different staff members failed to report the serious incidents within 24 hours of discovery. Both staff members completed serious incident reporting training less than 10 months ago and one was recently promoted to a supervisor position with additional responsibilities related to serious incident reporting. Despite this training, and analysis of the reasons for not reporting indicated that staff had not fully understood the process or responsibilities for reporting. In addition, a survey of other staff responsible for incident reporting identified inconsistent understanding of reporting policy and procedure.
Developing a systemic plan of action to address each problem, which may require updating policies, procedures, and forms; or conducting any needed training or retraining for staff; or other steps that could alleviate the problem and minimize the possibility that the violation will occur again. Provider A decides to amend the agency-wide training policy to include a test that requires a 90% passing score, and amend the new supervisor training to include review of the incident reporting requirements. The training policy is revised to state that all employees will be trained on the serious incident reporting requirements and must pass a test with a score of 90% or higher within the first 30 days of employment and prior to working alone with individuals. Provider A recognizes that it is important to test staff understanding of the training and expectations related to incident reporting. Provider A also understands that it is important that supervisors receive additional training to enable them to monitor staff compliance with the serious incident reporting requirements. This corrective action will address the issue on both an individual and systemic level versus simply choosing to retrain the two employees who failed to report the incidents within the required timeframe.
Indicating the frequency for monitoring the plan to include how it will be monitored (Example: monthly audits, weekly chart reviews, quarterly checklist). Provider A includes within the CAP that the training manager will: (i) verify all current staff have passed the serious incident report training within 30 days of hire, and (ii) document the review within a written document, to be stored with the provider’s training policy.
Identify the position responsible for monitoring implementation of the approved CAP.
Provider A identifies the training manager position as the position responsible for monitoring implementation of the approved CAP. In this instance, the training manager will be responsible for updating the provider’s training policy and responsible for ensuring copies of the passing test scores are included in each employee’s file. In addition, the training manager will ensure employees receive both initial and retraining on serious incident reporting on the dates outlined within the revised training policy.
Include a date of completion for each corrective action. Providers should ensure that completion dates for planned activities are realistic, and the staff person(s) responsible for oversight of the CAP must monitor and verify the completion of the planned activities. Providers will need to submit evidence of compliance with their corrective action plans by their pledged completion dates for any violations of *12VAC35-105-160.E.* or *12VAC35-105-520*; or any violations which pose a threat to the health and safety of individuals served. Provider A decides the corrective action plan must be completed by September 1st. Provider A is confident that this date is a realistic amount of time to amend the training policy and retrain employees. Provider A’s training manager (as identified in #2 above) will monitor implementation and effectiveness of approved corrective actions as part of the established quality improvement program required by *12VAC35-105-620* (see below). This might include developing a quality assurance process to monitor and track the timeliness of all serious incident reporting to ensure that the corrective actions are having the intended effect.
D. The provider shall submit a corrective action plan to the department within 15 business days of the issuance of the licensing report.
One extension may be granted by the department when requested prior to the due date, but extensions shall not exceed an additional 10 business days.
An immediate corrective action plan shall be required if the department determines that the violations pose a danger to individuals receiving the service.
GuidanceExtensions to the 15 business day timeline for submitting a CAP may be granted to a provider only if requested by the provider PRIOR to the due date, and only for one additional period of up to 10 business days.
The new due date for the CAP will be up to 10 days from the date the CAP was due, and not up to 10 days from the date the extension was requested.
If a licensing specialist determines during an inspection or investigation that there is an immediate and substantial threat to the health,
DBHDS, LIC1 9, August 2020
safety, or welfare of the individuals receiving services, the licensing specialist will immediately address the concerns with the provider and will request that the provider develop and commit to a CAP during the onsite inspection.
If the provider fails to suggest a CAP during the inspection, the specialist will suggest one.
E. Receipt and Review of Corrective Action Plan (CAP)
Upon receipt of the corrective action plan, the department shall review the plan and determine whether the plan is approved or not approved.
The provider has an additional 10 business days to submit a revised corrective action plan after receiving a notice that the department has not approved the revised plan.
If the submitted revised corrective action plan is not approved, the provider shall follow the dispute resolution process identified in this section.
Guidance:
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The Office of Licensing will respond to CAPs within 15 business days of receipt of the provider’s CAP.
CAPs will be approved if they include:
detailed and verifiable corrective actions targeted to remedying and preventing the recurrence of identified regulatory violations;
realistic planned completion dates for each of the planned actions;
and the signature of the identified responsible person for monitoring the implementation of the planned actions.
F. Disagreement with Citation or Disapproval of CAP
When the provider disagrees with a citation of a violation or the disapproval of a revised corrective action plan, the provider shall discuss this disagreement with the licensing specialist initially.
If the disagreement is not resolved, the provider may ask for a meeting with the licensing specialist's supervisor, in consultation with the director of licensing, to challenge a finding of noncompliance.
The determination of the director is final.
Guidance: CAP Dispute Resolution Process:
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Providers should promptly communicate disagreement with a citation directly to the specialist who issued the citation (licensing specialist, IMU specialist, or investigator). If a provider does not communicate his disagreement with the specialist before the CAP is due, a citation will be issued for not submitting the CAP on time.
Per the regulation, the provider must reach out to their licensing specialist to discuss the disagreement prior to reaching out to the licensing specialist’s supervisor.
If a provider disagrees with a citation, and is not able to resolve the disagreement with their specialist, the CAP dispute resolution process will be initiated.
The CAP dispute resolution may be initiated by the provider or the specialist if the two parties are not able to come to an agreement related to the issued citation(s).
The purpose of the CAP dispute resolution process meeting is fact-finding and will include open discussion of the dispute issues to promote understanding of the provider’s position on citations issued. Accordingly, the provider and specialist are encouraged to present information relevant to the grievance at this meeting.
While the parties may question one another regarding disputed facts and issues, the meeting should not be adversarial or treated as a hearing.
The specialist’s supervisor is charged with presiding over the meeting and will serve as a neutral party to the dispute.
No decisions will be made at the time of this meeting and the information will be gathered from the meeting and discussed with the Office of Licensing Assistant Director and Director to make a final decision.
After the CAP dispute meeting, the specialist’s supervisor will make a recommendation to the Office of Licensing Director or the director’s designee.
The Office of Licensing Director or designee will issue a final decision in writing regarding the citation within 10 business days from the CAP dispute meeting. The Office of Licensing Director’s decision is final.
If the citation is upheld, the provider will have 10 business days to submit the CAP.
If the citation is not upheld, the Office of Licensing will remove the violation from the licensing report.
Nothing in this procedure will prevent the Office of Licensing from requiring immediate corrective action when the violation presents a threat to the health, safety, or welfare of individuals served.
G. Implementation of Corrective Action Plan
The provider shall implement their written corrective action plan for each violation cited by the date of completion identified in the plan.
Guidance: Implement the Plan:
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For serious injuries and deaths that result from substantiated abuse, neglect, or health and safety violations (“Health and Safety CAPs”), the Office of Licensing verifies that CAPs are implemented within 30 business days of the date the corrective action plan was approved.
Failure to implement a written CAP will result in a licensing report citing *12VAC35-105-170.G*.
H. Monitoring Implementation and Effectiveness of Corrective Actions
The provider shall monitor implementation and effectiveness of approved corrective actions as part of its quality improvement program required by *12VAC35-105-620*.
If the provider determines that an approved corrective action was fully implemented, but did not prevent the recurrence of a regulatory violation or correct systemic deficiencies, the provider shall:
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Continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies; or
Submit a revised corrective action plan to the department for approval.
Guidance: Monitor CAP:
In order to demonstrate compliance with this regulation, each provider must show proof of monitoring all CAPs for implementation and effectiveness.
If after completion of the planned activities the provider determines that the issue that led to a citation occurred again, then the provider shall implement the provider’s own policies and procedures for updating the provider’s quality improvement plan, if applicable, or submitting revised corrective action plans, pursuant to *12VAC35-105-620.D*.
This may include determining whether or not the CAP was implemented as intended.
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If the CAP was not fully implemented as intended, the provider should evaluate and address any barriers to implementation.
If the CAP was fully implemented, the provider should assess the reasons that the issue recurred and make a determination as to whether changes to the corrective action plan are necessary.
While prevention of a second regulatory violation may not always be possible, prevention is the goal.
If a second regulatory violation occurs, the provider should always analyze whether the current CAP is the most effective means of preventing reoccurrence or if additional steps could be taken.
A provider may determine after review that the recurrence of a regulatory violation was not due to the insufficiency of the implemented corrective actions, and that the planned corrective actions remain the most effective means of preventing or substantially mitigating future recurrences.
If this is the case, then the provider should clearly document through the quality improvement program the basis for this conclusion and continue implementing the planned corrective actions without additional measures.
I. Revising and Continuing Corrective Actions
If the provider determines that revisions to the CAP are necessary, those revisions should be submitted to the licensing specialist for review and approval.
The provider should document through the quality improvement program, if applicable, when it is determined that an issue has been corrected and monitoring may be discontinued.
Example Continued:
Provider A successfully implements the CAP by revising the training policy and ensuring all employees passed the test with a score of 90% or higher by the completion date outlined in the CAP.
However, on January 1st, the provider self-identifies the failure to report a serious incident in a timely manner through the quality assurance process implemented as a result of the initial corrective action.
The provider’s quality assurance process involved tracking the timeliness of reporting each serious incident on a quarterly basis.
A review of the data identified three instances (out of 25 serious incidents) when reports were not made within 24 hours.
Provider A determines that the approved CAP was fully implemented.
However, it did not correct the identified systemic deficiency.
Provider A has two options:
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1) to continue implementing the CAP and put into place additional measures to prevent the recurrence of the cited violation and address systemic deficiencies; or
2) submit a revised CAP to the department for approval.
If the provider determines that the approved corrective actions are the most effective means of addressing the issue, then this rationale should be documented through the quality improvement program and the provider may continue implementing the approved corrective actions.
In accordance with the provider’s quality improvement policy, Provider A conducts an analysis into why the CAP was not effective.
Provider A’s analysis determines that while the staff pass a test, applying the knowledge to real-life situations is more difficult.
As a result, Provider A determines that the CAP will continue to be implemented, but also will make sure to talk through real-life scenarios and examples during each staff meeting.
Provider A also implements a motto with all staff, “When in doubt, talk it out,” to encourage staff to call a supervisor if they have any questions about whether an occurrence may be considered a Level II or Level III serious incident.
After one year, the provider determines through quarterly monitoring that 100% of serious incidents were reported within 24 hours.
Based on attaining the objectives of the CAP, the provider determines that this issue was successfully addressed and closes it as a quality improvement goal, consistent with the policies and procedures.
Case Management Guidelines 2022 (7531_DD 08.pdf)
Introduction and Background
December 2022 - Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 1 of 8
COMMONWEALTH of VIRGINIA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES
Post Office Box 1797 Richmond Virginia 23218-1797 Telephone (804) 786-3921 Fax: (804) 371-6638 www.dbhds.virginia.gov
Case Management Operational Guidelines 2022
People with developmental disabilities who are most at risk benefit from more frequent case manager/support coordinator face-to-face visits due to the complexity of their support needs.
The “Case Management Operational Guidelines” were developed by a committee of community services boards (CSB), DD Waiver staff, and advocacy community representatives.
The guidelines provide historical information, including two additional updates from April 2014 and January 2017.
This document is designed to incorporate past guidance in a simplified, redesigned format.
These operational guidelines are intended to assist CSB DD case managers (hereafter referred to as support coordinators or SC/CM) in implementing the case management requirements of enhanced case management. [Section]
Enhanced Case Management Requirements
Enhanced case management requires the following:
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1. For individuals receiving case management/support coordination services, the individual’s SC/CM shall meet with the individual face-to-face on a regular basis and shall conduct regular visits to the individual’s residence, as dictated by the individual’s needs.
2. At these face-to-face meetings, the case manager/support coordinator shall:
observe the individual and the individual’s environment to assess for previously unidentified risks, injuries, needs, or other changes in status;
assess the status of previously identified risks, injuries, needs, or other change in status;
assess whether the individual’s support plan is being implemented appropriately and remains appropriate for the individual; and
ascertain whether supports and services are being implemented consistent with the individual’s strengths and preferences and in the most integrated settings appropriate to the individual’s needs.
If any of these observations or assessments identifies an unidentified or inadequately addressed risk, injury, need, or change in status, a deficiency in the individual’s support plan or its implementation, or a discrepancy between the implementation of supports and services and the individual’s strengths and preferences, the SC/CM shall report and document the issue, convene the individual’s service planning team to address it, and document its resolution.
To “report and document the issue” and meet requirements, the SC/CM must take the following actions:
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a. Document in the record the specific unidentified or inadequately addressed risk, injury, need, or change in status, including the report to and the response of the designated provider(s).
b. Convene and mobilize person-centered planning (PCP) team members needed to address the issue and revise the ISP as needed. The meeting will include the individual, guardian/authorized representative (AR), if applicable, case manager/support coordinator, and applicable providers. The meeting can be in person, a video meeting, a formal scheduled conference call, and/or an informal SC/CM initiated telephone call with the relevant parties.
c. Report suspected abuse, neglect, or exploitation to Adult Protective Services (APS) or Child Protective Services (CPS) and the DBHDS Office of Human Rights (OHR) according to agency policies and regulations.
d. Report to the DBHDS Office of Licensing (OL) serious incidents or injuries as defined in licensure according to agency policies and regulations.
e. Report the individual’s PCP team’s inability to achieve resolution within a reasonable time (2 weeks) by following SC/CM agency policies and by contacting the CRC and the DBHDS Office of Licensing as needed.
f. Document the issue and resolution of the issue in the case manager/support coordinator record.
g. When an issue is related to a health or crisis event, the SC/CM monitors implementation of the ISP (including safety and risk mitigation protocols) to ensure the ISP is implemented as written to reduce the potential of a future crisis event. Any crisis event includes the need for the SC/CM to document the issue, convene relevant team members, revise the ISP, report suspected abuse, neglect, and/or exploitation to APS/CPS/OHR/OL as defined in regulations, and document the resolution. SC/CMs also communicate concerns to their supervisors and follow their agencies’ policies and procedures in responding.
3. The individual’s case manager/support coordinator shall meet with the individual face-to-face every 90 days. For individuals that are receiving enhanced case management (ECM), these visits must occur at least once per calendar month, with no more than 40 days between visits.
For example, if an ECM visit occurs on March 2, the next visit is due on or before April 11th. There are 40 days from March 2nd to April 11th, and this timeframe enables one visit in both calendar months.
At least one such visit every two months must be in the individual’s place of residence for any individuals who:
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1. Have transitioned from a training center within the previous 12 months;
2. Receive services from providers having conditional or provisional licenses;
3. Have an interruption of service greater than 30 days (excludes a break in employment when the individual is in supported employment and remains with the same supported employment provider);
4. Have an inability to access needed therapeutic services, assistive technology, environmental modification, or behavioral consultation;
5. Encounter the crisis system, criminal justice system, or have APS involvement;
6. Reside in congregate settings of 5 or more individuals**;
7. Have any items under 1a or 1b scored with a 2 on the Supports Intensity Scale® (SIS®)**
** exceptions described in the chart below
To assist with determining when to initiate and cease the provision of ECM, DBHDS has developed, in collaboration with CSBs, an automated ECM Worksheet that is available on the DBHDS website at https://dbhds.virginia.gov/wp-content/uploads/2022/09/CM-Worksheet-FINAL-11.3.21-1.xlsx.
The On-site Visit Tool (OSVT) must be completed at one face-to-face visit monthly for people receiving ECM and once quarterly for people receiving targeted case management (TCM) and uploaded into the Waiver Management System under the Person’s Information attachments section.
This form provides a means to ensure that consistency is applied when assessing for any “change in status” and to confirm that the services are “implemented appropriately.”
Based on observation and report, include specific, detailed notes in the person’s record about the findings and any actions that will be taken (including the need for any additional assessments, such as behavioral and/or medical reviews, or root cause analysis, to understand and address identified concerns).
If the person has lost a service as a result of behavioral or medical issues or a provider’s perception of increased needs, additional assessment from a qualified professional or the exploration of alternate services/providers are necessary to determine how the individual’s needs can be met.
Case managers/support coordinators must ensure that there is a corresponding note in the individual’s record that includes additional actions or follow-up as identified on the OSVT.
When scoring each section (Change in Status and Services Implemented Appropriately), if there is a concern noted on any of the questions in each of these two sections, this affects final scoring.
For example, if there is an answer of ‘yes’ to any of questions 1 - 5 in “Change in Status,” this indicates a change in status.
Similarly, an answer of ‘no’ to any of questions 7 - 13 under “Services Implemented Appropriately” indicates services are not appropriately implemented.
Information from the completion of the OSVT should be incorporated into the quarterly Person-Centered Review. [Section]
Explanation of Population Served
All individuals with developmental disabilities who receive HCBS waiver services and who meet the criteria established in this guidance require more frequent face-to-face visits at least every thirty (30) days.
Individuals receiving HCBS waiver services include Building Independence (BI), Family and Individual Support (FIS), Community Living (CL) waiver recipients, as well as people receiving Commonwealth Coordinated Care (CCC) Plus Waiver who are on the DD Waiver wait list and have targeted case management.
Thus, the CSB DD case manager/support coordinator must provide the more frequent face-to-face visits at least every thirty (30) days to individuals who are on the DD waiver or the DD waiver wait list with Commonwealth Coordinated Care (CCC) Plus waiver, AND meet any of the criteria one through seven above.
Table 1 below shows which groups must receive face-to-face visits at least every thirty (30) days if they meet any of the criteria. [Section]
Inability to Complete Required Visits
If the case manager/support coordinator cannot complete the required face-to-face contact, he/she must document the reason(s) and all attempts.
After two consecutive 30-day periods of no contact, the CSB case manager/support coordinator will notify their supervisor to determine if further steps are needed (such as contacting the licensing specialist, DMAS, CRC, etc.).
The CSB case manager/support coordinator must also comply with the established Waiver “Request to Retain Slot” process as appropriate.
Compliance with these standards will be through routine Licensing reviews of case management services, quality service reviews, and as part of the investigation review process for both Licensing and Human Rights. [Section]
Exceptions
The following chart provides a description of the removal of ECM criteria to include exceptions where applicable.
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Table 1: Population 30-day visits required IF any of the criteria are met:
BI Waiver Recipients: Yes
FIS Waiver Recipients: Yes
CL Waiver Recipients: Yes
Individuals on DD Waiver Wait List who are receiving CCC+ Waiver Services and who have Targeted Case Management: Yes
Individuals on the DD Waiver Wait List who do not have CCC+: No
Individuals in Training Centers: No
Individuals in Community-Based ICFs: No
Individuals in NFs: No
Enhanced Case Management Criteria and Considerations
When to Begin ECM | When to Stop ECM | Considerations
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A. The person left a training center in the last 12 months. The person has been stable in their new home for at least 12 months. SC/CMs can complete a post-move monitoring report or send their notes from the visits that occur at 30, 60, and 90 days detailing their review of the provision of essential supports and notes for the first year to the post-move monitor. Post-move monitor should be notified of a change in provider if it occurs during the first year for individuals with SIS level 1-4 or during the first 2 years for individuals with a SIS level of 5-7 because that's how long DBHDS actively follows people who are discharged from a training center.
B. The person receives services from any provider w/ conditional or provisional license. 90 days have passed since the removal of the conditional or provisional status. License type can be located through the Office of Licensing Provider Search, by selecting License Type from the drop down menu here.
C. An interruption of 30 days or longer for any DD waiver service (excludes a break in employment when the individual is in supported employment...
Case Management Operational Guidelines 2022
Introduction and Background
and remains with the same supported employment provider). When services have resumed. An individual choosing not to attend or participate in a service is not considered an interruption. This means a break in an authorized service due to factors beyond the individual's control such as programmatic issues, staffing, or medical events that led to the break in services for any of the following waiver services:
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i. Congregate residential (including supervised [group home] and sponsored residential)
ii. In-home residential
iii. Personal assistance (agency-directed or consumer-directed)
iv. Supported employment (Change in SE job site but not provider does not constitute interruption in service)
v. Day services (e.g., group day support, community engagement, community coaching, and workplace assistance)
December 2022 - Case Management Operational Guidelines Revised, Eff. 3/2/23 (DD 08) Page 6 of 8
Enhanced Case Management Requirements
D. Service Interruptions and Exceptions
There is an inability to access needed therapeutic services, adaptive equipment, or environmental modifications that have been recommended by a professional. Needed services have been identified/obtained. N/A
E. Crisis and Medical System Encounters
E1. The person encounters the crisis system and/or the medical health system for admission or assessment (for unplanned and emergency related events). When the person has recovered from the crisis and/or medical concerns and has been stable † for at least 90 days or there are unique circumstances that a supervisor confirms* warrants an exception to ECM. Crisis services include: REACH Crisis Therapeutic Home (CTH), Adult or Child Crisis Stabilization Unit (CSU), unplanned crisis stabilization services (if mobile crisis comes out once and doesn’t refer to consultation or other REACH services, then ECM is not required), emergency services, children’s crisis or REACH services, hospital (other than for routine or elective procedures) and ER visits, hospitalization followed by an admission to a long-term rehabilitation or skilled nursing facility or unplanned stay. ECM is initiated upon admission to the facility. A stay in a state facility such as Central State Hospital is different and ECM would not be provided during this stay. SC/CM must document the reason ECM is not provided in any instance. Some known causes of unplanned medical emergencies include: aspiration pneumonia, bowel obstruction, seizures, decubitus ulcer (pressure sore), UTI, seizure, falls, and sepsis.
E2. There has been APS or CPS involvement. The APS/CPS case has been closed without further risk to the person for at least 90 days or there are unique circumstances that a supervisor confirms* warrant an exception to ECM. N/A
E3. The person has encountered the criminal justice system or has been incarcerated. Criminal charges have been resolved with no additional concerns for at least 90 days or there are unique circumstances that a supervisor confirms* warrant an exception to ECM. ECM is not required during periods of incarceration other than for the 60 days immediately prior to release to assist with reintegration efforts.
F. Living in a Group Home with 5 or More Beds
This is the only ECM criteria met and the person has been medically and behavioral stable † with successful supports for the past 12 months with no new risks (medical and/or behavioral) identified in the last 12 months. Safety protocols/mitigation plans (health and safety outcomes/risk protocols/behavior plans) are in place as evidenced by:
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1. The ISP includes safety protocols and mitigation plans for identified intensive medical and behavioral needs. The ISP is updated appropriately.
2. Safety protocols/mitigation plans are followed by the provider.
3. SC/CM reviews provider documentation of safety protocols and mitigation plans to ensure they are implemented as written.
4. The safety protocols/mitigation plans (health and safety outcomes/risk protocols/behavior plans) are reviewed quarterly and revised as needed.
If the individual were to meet any other ECM criteria, this exemption does not apply and ECM would continue. If someone moves from a 5-bed home to another 5-bed home and they were stable before the move and remain stable for 12 months with no new risks identified, then ECM is not required. Please note ECM criteria is based on the number of people for which the home is licensed and not the number of people actually living in the home. Licensed home size can be confirmed by contacting the DBHDS Office of Licensing as needed.
G. Items on the SIS® and Clinical Documentation
Any item(s) under 1a or 1b on the SIS® are scored with a 2. There is clinical documentation that establishes that items no longer meet 1a or 1b since the completion of the SIS® and no new needs have been identified that meet the same criteria or this is the only ECM criteria met (from A through G) and the person experienced no concerns related to the identified health conditions in the past 12 months. Alternatively, the person only receives Therapy Services as identified on 1a of the SIS® with no other items under 1a or 1b scored a 2, or the only item identified is "Fall Risk" with no injury in the last 90 days. If the individual has experienced an injury as a result of an adverse event in the context of lifting or transferring in the past 90 days, then ECM is required and will continue for 90 days after the individual is stabilized.
*It is expected that these situations will be infrequent and should clearly document supervisory review and why an exception is being made. If an exception is appropriate, the SC must still review all criteria before determining if the individual qualifies or not for ECM.
†Stability is defined as pre-injury/illness condition/functioning or the individual has reached post-injury/illness, condition, or optimum functioning as determined by a licensed medical professional (primary care provider (PCM), nurse practitioner (NP), registered nurse (RN), physician assistant (PA)). While in writing from the professional would be preferable, documentation by the SC/CM is sufficient when it includes the details of the conversation with those involved and confirms that a professional made the determination. DBHDS has provided a training video available at https://vimeo.com/manage/videos/673185115/22a1ae3289, as well as a Frequently Asked Questions document to assist with specific scenarios that have been encountered. This document is available online at https://dbhds.virginia.gov/wp-content/uploads/2022/09/ECM-Question-Answers-Final-9.26.22-1.pdf. Additional guidance is available in the DD Support Coordination Handbook at https://dbhds.virginia.gov/assets/doc/sccm/dd-sc-manual-12202021-rev-2-final.pdf or by contacting your Provider Development System Team Community Resource Consultant (CRC). CRC contact information is available online at https://dbhds.virginia.gov/developmental-services/provider-development/.
DSP Orientation and Competency Protocol (6823_DD 04.pdf)
Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol
Introduction
Direct Support Professionals (DSPs) and their supervisors who provide services and supports for people with developmental disability (DD) in Virginia are required to complete an orientation training process established by the Department of Behavioral Health and Developmental Services (DBHDS) per Medicaid Waiver regulations (12VAC30-122-180). This process was initiated in 1997 and has seen various revisions and updates since that time.
It is designed with three purposes in mind: so people get quality services, to build skills and confidence, and to enhance the supervisor-DSP relationship.
This protocol serves as a resource to providers in understanding the competency-based training requirements of Virginia’s Developmental Disabilities Waivers (i.e., the Building Independence Waiver, the Family and Individual Supports Waiver, and the Community Living Waiver).
This process does not replace the requirements for providers to meet DBHDS training and orientation requirements under the DBHDS Office of Licensing, which are described in the DBHDS Licensing Regulations (12VAC35-105-440, 450) or other regulations or accreditation standards.
Defining Direct Support Professional (DSP)
Direct Support Professional (DSP) is defined under the DD waivers as: "Direct support professional," "direct care staff," or "DSP" means staff members identified by the provider as having the primary role of assisting an individual on a day-to-day basis with routine personal care needs, social support, and physical assistance in a wide range of daily living activities so that the individual can lead a self-directed life in his own community.
This term shall exclude consumer-directed staff and services facilitation providers.
Any agency employee, regardless of credentials, who provides Medicaid Waiver reimbursable support as described above, must complete the DBHDS DSP Orientation process.
This process also applies to supervisors who oversee the work of DSPs.
Providers may elect to employ agency trainers in delivering training content to DSPs and their supervisors, which is acceptable, but the use of a trainer does not supplant conversations between DSPs and supervisors about the content of the training or the application of that content within the provider setting.
This process does not apply to professional staff who provide consultative or specialized medical and behavioral support, such as Therapeutic Consultation, Skilled Nursing, and Private Duty Nursing.
Providers of Individual and Group Supported Employment services were previously excluded due to operating within organizations that met Commission on Accreditation of Rehabilitation Facilities (CARF) standards.
Employment Service Organizations are now required to complete orientation training, testing, and to observe and document basic competencies per Settlement Agreement (SA) negotiations with the Department of Justice, which occurred in January of 2020.
In addition, DMAS enrolled Home Care Organizations licensed by the Virginia Department of Health who are providing Personal Assistance, Respite, and Companion services under any DD Waiver must implement the process of observing and documenting competencies as described in this protocol in addition to completing the training and testing requirements per the same SA negotiations.
Regulatory and Licensing Context
There is a set of requirements that affect all providers of specified waiver services and one additional set of advanced competency requirements for DBHDS-licensed providers only, which are dependent upon who is being supported.
Training and Implementation Details
DSP and DSP Supervisor Orientation Training; Testing; Assurances
Agencies providing direct support to individuals on the Developmental Disabilities' waivers are required to complete the DSP Orientation training. This includes both non-DBHDS licensed providers (such as Home Care Organizations licensed by the Virginia Department of Health and Employment Services Organizations under the Department of Aging and Rehabilitative Services) in addition to DBHDS-licensed providers.
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The following services are covered:
Agency-Directed Personal Assistance
Agency-Directed Companion
Agency-Directed Respite
Center-based Crisis Services
Community-based Crisis Services
Crisis Support Services
Community Engagement
Community Coaching
Group Day Services
Group Home Residential
Group Supported Employment
Independent Living
In-Home Support Services
Individual Supported Employment
Sponsored Residential
Supported Living Residential
Workplace Assistance
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DSP supervisors in agencies providing any of the above services must complete online training and testing through the Commonwealth of Virginia Learning Center (VLC), which is a web-based application that delivers self-study training topics to Virginia employees, Community Services Boards, and community providers.
The VLC provides supervisors with the online supervisor’s training and competency test.
This online training provides information about the role of a DSP supervisor under these requirements, the expectations for implementing the orientation process, and provides a certificate of completion that must be retained in the personnel file for programmatic review by the DBHDS Office of Licensing and the Department of Medical Assistance Services.
Supervisors can access the required supervisor training and take the test through the Virginia Learning Center (VLC).
Access the VLC online by following this guide: DBHDS External Entities Domain Guide.
The supervisor training can be located in the VLC by searching with the key word “DSP”.
Once a supervisor has completed online training and testing through the VLC, they may request a copy of the DSP test answer key by sending a copy of their VLC certificate to their assigned Community Resource Consultant with DBHDS: Provider Development Contact Chart.
Linked resources are maintained online at: http://www.dbhds.virginia.gov/developmental-services/provider-development.
Orientation Manual and Training Materials
DSPs follow a different process from supervisors in completing orientation training and competency testing.
DSPs receive training from their agency supervisor or designated agency trainer. They may also access the training materials through a public-facing website, which includes a manual, training slides for agency use, and various forms and checklists related to these requirements.
Use of the materials is encouraged as they contain content that is freely available to providers and align with Virginia’s principles, values, and expectations for providing support under the DD waivers.
The Orientation Manual and training slides that may be used in equipping DSPs with necessary knowledge, skills, and abilities are available online at: https://partnership.vcu.edu/DSP_orientation/index.html.
The Orientation Manual Test is divided across the six areas contained in the DSP Orientation Manual:
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Section I: The Values that Support Life in the Community
Section II: Introduction to Developmental Disabilities
Section III: Waivers for People with Developmental Disabilities
Section IV: Communication
Section V: Positive Behavioral Support
Section VI: Health and Safety
The Orientation Manual was designed to:
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Outline the current values and best practices associated with providing Developmental Disability Waiver services and supports
Provide DSPs and supervisors with practical tips on how to apply these values and better support individuals with intellectual and other disabilities
Prepare DSPs and supervisors who come with varying degrees of experience for the work ahead of them
Promote person-centered service delivery
Assurances
DSPs (and DSP supervisors) must also confirm through a signed assurance that they have met the competency-based training requirements and passed the “Orientation Manual Test” with at least 80% success prior to providing reimbursable supports in the absence of other staff who have successfully completed requirements.
The signed assurance confirms the receipt of instruction in the characteristics of developmental disabilities and Virginia’s DD Waivers, person-centeredness, positive behavioral supports, effective communication, DBHDS-identified health risks and the appropriate interventions, and best practices in the support of individuals with developmental disabilities.
Assurance documents are specific to agency role. There are two versions, and DSPs and DSP supervisors complete the version that matches their role within the organization.
A copy of the Orientation Manual test and these assurance documents are available online at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html.
The assurances include confirmation of the use of observational competency checklists, which will be covered in the next sections of this protocol.
DSP & DSP Supervisor Basic Competency Checklist
All DSPs and DSP Supervisors providing the services described in this document (see page 2) must complete an observed competency checklist that records DSP and DSP supervisors’ ability to be proficient in three established competencies.
Each competency has a set of skills that are observed and documented during the 180-day orientation period for new DSPs and DSP Supervisors.
The skills under the third competency must be confirmed at a “competent” level of ability prior to providing these supports in the absence of staff who have been deemed proficient with these skills.
The three competencies are:
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Demonstrates person-centered skills, values, and attitudes
Understands and follows service requirements
Demonstrates abilities that improve or maintain the health and wellness of those they support
These competencies and the type (i.e., 1:1, group, and/or formal education) of any related training (such as reviewing the DBHDS provider DSP training manual and slides) are documented on a standard checklist (DMAS #P241a).
Observation of DSPs applying their knowledge and skills is documented by DSP Supervisors.
DSP supervisors’ observation and documentation are completed by the agency Director or designee.
This checklist is introduced with two pages of instruction to assist in consistent application across DSPs and DSP Supervisors.
Levels of ability recorded on the checklist are defined as follows:
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Basic understanding: The individual is able to communicate a fundamental knowledge of the skill or action; high level of supervision needed.
Developing: The individual is in the process of establishing the ability or is showing some, but not all, aspects of the skill or action in practice; moderate level of supervision needed.
Competent: The individual demonstrates all applicable skills or actions in column two, but not on a routine basis as appropriate to the skill or action; low level of supervision needed.
Proficiency: The individual demonstrates all aspects of the skill or action on a routine basis in practice as appropriate to the skill or action; minimal supervision needed.
Competency refers to the minimum required for acceptability.
Direct Support Professional (DSP) and DSP Supervisor DD Waiver Orientation and Competencies Protocol
Introduction
The checklist instructions contain critical information about the process including:
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DSPs and supervisors are deemed proficient once all related skills and behaviors have been observed and documented on the checklist, including noting as not applicable (NA) if an action related to any skill does not apply in the current role in any of the skills included on the checklist.
Proficiency is established when the skills are observed over time and each area must be confirmed as proficient within 180 days of hire.
To ensure the health and wellness of people receiving services, Competency 3 and all related skills must be confirmed as competent prior to providing support in the absence of paid staff who has demonstrated proficiency with this competency.
Competency refers to the bare minimum required for acceptability where proficiency establishes an ongoing level of ability that is above the minimum.
If at any time a DSP or DSP Supervisor is found to be deficient in any competency area, billing by the agency must cease related to those services rendered by that person.
The provider must document actions taken and the date that restoration of ability is confirmed.
Once proficiency has been demonstrated, the provider may resume billing for services provided by the DSP or supervisor from that date forward.
DMAS shall not reimburse for those services provided by DSPs or DSP supervisors who have failed to pass the orientation test or demonstrate competencies as required.
The initial completion of the checklist and annual updates, as well as confirmation of training, must be maintained and available for review by the Department of Behavioral Health and Developmental Services, the Department of Medical Assistance Services, and other reviewers as required.
Virginia’s Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities checklist is available online at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html
DBHDS DSP and DSP Supervisor DDW Orientation and Competencies Protocol
3.6.20 Page 8 of 11
DSP & DSP Supervisor Advanced Competency Checklists and Training for DBHDS-licensed Agencies Only
While Virginia’s Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities checklist applies to DBHDS-licensed agencies supporting people from Supports Intensity Scale (SIS©) tiers one through four, there are additional training requirements and competency checklists when providers support people most at risk and identified as having support needs defined through the SIS© at tier four.
DBHDS established training and competency requirements as described in the 2016 DMAS Medicaid Memo to include a higher level of skill when providers offer services and supports to people with tier four support needs.
Included in DD Waiver regulations (12VAC30-122-180) and the Medicaid Memo 9.1.16, are the requirements that providers supporting individuals at SIS© tier four complete training in the areas of autism, complex health supports, and complex behavioral supports.
Training in these areas can be developed or reviewed and approved by a qualified professional in each area as described in the DBHDS Advanced Competencies Training Topics 9.25.17 document available online here: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html.
Training may be accessed through a variety of means as long as it is nationally recognized or developed or approved by a qualified professional in each competency area.
Health professionals include:
Autism professionals include:
Behavioral professionals include:
The following topics must be included in training provided to DSPs and their supervisors when supporting individuals at SIS© tier four:
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Health: Confidentiality; Professional collaboration; Communicating health information; Documenting health information; Relationship between physical and mental health; Common risk factors for DD-related health conditions; Universal precaution procedures; Performing delegated tasks; Supporting Virginia’s identified risks for people with DD including: skin care (pressure sores; skin breakdown), aspiration pneumonia, falls, urinary tract infections, dehydration, constipation & bowel obstruction, sepsis, and seizures; Providing direct care to individuals with complex health care needs (e.g., ADLs, positioning, care of Durable Medical Equipment, and specialized supervision with appropriate responses to health parameters set by the health professional).
Behavior: Ethical Practices (practicing within scope); Function and Purpose of Behavior; Replacement Behavior Training; Positive Behavior Supports; Behavioral Prevention; Dual Diagnosis; Data Collection (goal and purpose); Ruling out medical concerns for behavior.
Autism: General Characteristics of Autism; Dual Diagnosis; Environmental Modifications/Assessments; Communication Supports and Strategies; Social skills, Peer Interactions, and Friendship; Sensory Integration; Life Span Supports.
There are three corresponding advanced competency checklists that must be completed in DBHDS-licensed programs (see page 2 for included services) where individuals with SIS© tier four support needs receive services and supports from DSPs and DSP supervisors based on individual needs.
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Virginia’s Autism Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P201)
Virginia’s Health Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P244a)
Virginia’s Behavioral Competencies for Direct Support Professionals and Supervisors who support individuals with Developmental Disabilities (DMAS #P240a)
Criteria for Requiring Advanced Competencies at SIS® Tier Four
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Health: The presence of a complex health condition that necessitates specific supports and instructions indicates that Health Competencies (DMAS P244a) must be met.
Autism: A diagnosis of autism indicates that Autism Competencies (DMAS P201a) must be met.
Behavior: The need for behavioral supports either in the ISP or in a formal behavioral plan indicates that Behavioral Supports Competencies (DMAS P240a) must be met.
These advanced competency checklists are available online at: https://partnership.vcu.edu/DSP_orientation/Competencies-Assurances-Tests.html
These checklists must be initiated by DBHDS-licensed providers and DSPs and DSP supervisors confirmed as proficient within 180 days of hire or within 180 days of assisting a person with related SIS© tier four support needs, whether that person is new to the program or receives an updated SIS© confirming Tier Four, which corresponds with SIS© levels 5, 6, and 7.
The checklists would be limited to those that are relevant to the needs of the individual(s) supported.
DBHDS Licensing regulations require that providers admit only those individuals whose service needs are consistent with the service description, for whom services are available, and for which staffing levels and types meet the needs of the individuals served receiving services (12VAC35-105-580).
These advanced competencies build on these requirements and are designed to increase consistency in the support offered through these programs.
Compliance, Data, and Provider Remediation
Provider agencies are reviewed by DMAS Quality Management Review (QMR) for compliance with DSP and DSP Supervisor competency training requirements.
If upon review a provider does not have documentation to demonstrate that DSPs and DSP Supervisors have met the requirements set forth in this protocol per DD Waiver regulations, the provider will be cited for a lack of compliance with waiver requirements.
Providers must respond through a corrective action plan when deficiencies are identified by DMAS that details the methods that will be employed to ensure ongoing, sustained implementation of these requirements.
A provider’s inability to demonstrate compliance can result in a provider having its DMAS participation agreement or DBHDS license suspended or revoked.
DBHDS and DMAS collect data around compliance and remediation activities related to this process, which is part of Virginia’s overall approach to compliance under the waivers per approval by the Centers for Medicare and Medicaid Services at the federal level.
The established measures included in DD Waiver Quality Assurance Reporting for these requirements and that are currently tracked for compliance are stated as:
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Number and percent of provider agency staff meeting provider orientation training requirements.
Number and percent of provider agency direct support professionals (DSPs) meeting competency training requirements.
Completed at Level 1 DBHDS DSP and DSP Supervisor DDW Orientation and Competencies Protocol 3.6.20 Page 11 of 11
Through these measures, DBHDS and DMAS report to CMS the number of providers who meet and do not meet provider orientation training requirements. This is one means of determining Virginia’s success with operating the Building Independence, Family & Individual Supports, and Community Living Waivers.
Portability
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DSPs who move employment from one agency to another and have documentation of having completed training and passed the 2016 Orientation Manual Test there do not have to be retrained, although the new agency would still discuss the values and concepts as they pertain to their agency’s policies with the new employee.
The new provider would ensure that receipt of a copy of the DSP’s scored test or supervisor’s VLC certificate and assurance and keep it on file.
Competencies where required must be confirmed at each agency within 180 days of hire and reconfirmed at least annually.
Questions about these requirements can be directed to your assigned Community Resource Consultant.
A contact list and linked documents are available online at the DBH DS Provider Development Webpage: http://www.dbhds.virginia.gov/developmental-services/provider-development
Documentation Requirements Overview
2021 Person-Centered Support Plan Guidance (6379_DD 01.pdf)
In response to the need for quality Person-Centered Individual Support Plans (PC ISPs) that meet all regulatory requirements and expectations, DBHDS is issuing the included guidance for writing and reviewing PC ISPs.
The methods and practices described here are expected to lead to more success with person-centered planning. Specifically, the measurability of plans is needed for agreement with the Centers for Medicare and Medicaid Services (CMS) Home and Community Services (HCBS) Settings Regulations, the Settlement Agreement, and DBHDS licensing and developmental disability (DD) waiver regulations.
This paper details changes in thinking and writing to improve outcomes for people with DD Waivers in Virginia.
[SIZE=12]Measuring ProgressIn 2009, the principles of Person-Centered (PC) Practices became the foundation of Virginia’s Individual Support Plan in DD waivers.
Over the past ten years, people with DD have been increasingly supported to make decisions about fundamental aspects of living in ways that matter most to them personally.
With the introduction of PC Practices, many providers and Support Coordinators (SCs) expressed appreciation for system changes that more fully implemented practices they had long valued.
The benefits of person-centered practices are evident, but we have struggled to develop person-centered plans that are specific to each person, retain the basics of accountability, and ultimately lead to meaningful changes in a person’s life.
At the center of the issue is a philosophical shift in how we plan with people.
In moving from a deficit-based planning model to person-centered supports, the ability to show progress through planning has been strained.
We have received reports from the independent reviewer for Virginia’s Settlement Agreement, from our state Medicaid agency, and from our licensing specialists that plans are not measurable.
We can do better.
To address these concerns, but maintain the core values of person-centered practices, we have to find an effective and simple way to bring measurability to the plans we write with people.
This paper has been written to detail how we believe planning can be both measurable and person-centered.
It is offered as a means to establish common ground around person-centered planning for all DD stakeholders in Virginia. “A test for something being person-centered is that it works for humans.” – Michael Smull
[SIZE=12]Virginia’s Person-Centered Individual Support PlanVirginia’s Person-Centered Individual Support Plan can be divided into three primary sections:
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I. The assessment: Part I Personal Profile and Part II Essential Information
II. The plan for a desirable future: Part III Shared Planning and Part IV Agreements
III. The action steps: Part V Plan for Supports
When reviewing the PC ISP, it’s important to look across all parts to gain an understanding of how the plan supports the life the person wants.
While it is an integrated whole where each section supports the others, the focus of this paper is on sections II and III listed above.
[SIZE=12]Shared Planning and Outcome DevelopmentPerson-centered planning seeks to identify and achieve changes that bring a person more fully into his or her community and increase quality in the person’s life.
In changing how we plan with people, we want to keep our values in place, which includes the person directing his process to the extent possible and being surrounded by people of his choosing.
The person’s vision of a good life is what teams seek to uncover through conversations and in preparations for planning.
In the development of outcomes, it is important not to lose sight of the purpose of planning, discovering and setting in place plans to pursue the life the person wants.
In shaping outcome statements, we recommend three considerations.
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Meaningful outcomes can support a person in achieving independence, integration, or an increased quality of life.
As outcomes are developed, teams may benefit from asking if the outcome speaks to one of these three areas in determining if the outcome supports the person in a meaningful way.
We recognize that outcomes should be clearly stated and personally meaningful.
For example, the idea that a person “increases independence in his life” is at the center of person-centered practices, but as an outcome it is not specific to an individual or easily observed.
Planning teams should ask “how will this person increase independence in his life?” and “What does this mean to him?”
Individual’s desired outcomes should be based on what is important to the person with regards to their personal preferences.
As such, outcomes that stop with what’s important to the person often do not result in observable statements that are specific to the person.
For example, having more spending money might be important to a person, but in no way establishes what this means in measurable terms.
In addition to being observable, a few additional considerations can increase measurability of outcomes — the frequency of the outcome, the target date, and the steps that lead to the outcome.
For example, the statement “John has more money” can be improved by considering how this could describe an achievement that John would find meaningful such as: “John saves 50 dollars per month so that he can go on vacation next year” or “John earns at or above minimum wage for 12 months so that he has more shopping money.”
Each outcome in the PC ISP will have a target date noted as “by when,” which indicates that the outcome is expected to be accomplished or will be reassessed by that date.
When desired, a frequency should be included in the wording of the outcome statement.
Additional examples of measurable outcomes:
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Not measurable [SIZE=11.04] | [SIZE=11.04] Measurable
John does things. | John uses the post office in order to send a friend a card each month. | 10/31/21
John goes places. | John vacations at the beach this year in order to see the ocean. | 8/31/21
John meets people. | John goes to coffee shops weekly so that he meets new people. | 10/31/21
John goes out to eat. | John dines at a local restaurant at least weekly in order to enjoy a meal. | 10/31/21
John feels good. | John uses his nebulizer as prescribed so that his breathing improves. | 10/31/21
The next step for planners and teams to increase measurability is to describe the basic steps that lead to the outcome.
These steps are shared across the planning team to contribute to achieving the outcome.
To make an outcome more measurable, we would ask what are the “key steps to get there.”
These steps layout the plan to pursue the achievement, which is in line with action planning, a foundational practice in person-centered planning.
These steps should be logical and, when considered together, be expected to result in the time-bound achievement that is defined in the outcome.
Each step identifies the support or service that will assist with its accomplishment.
For example:
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Outcome | End Date | Key steps and services to get there …
John vacations at the beach this year in order to see the ocean. | 8/31/21 | John chooses a location (day support), saves money (John’s brother), purchases supplies (day support), makes reservations (day support), and travels to the beach to see the ocean (in-home supports).
For support teams who struggle with forming outcomes, we have previously utilized a formula, which has been noted as helpful and should remain an option to support meaningful outcomes.
This formula has been slightly modified as follows for the examples provided.
The asterisk* is a reminder to include a frequency when desired:
The following examples demonstrate the concept of formula use to develop outcomes:
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Important TO: Earning money | Outcome (measurable achievement): John earns at least minimum wage monthly so that he has more shopping money. | Key steps and services to get there: Complete referral to DARS (SC), complete job development (supported employment), secure employment and learn job (supported employment).
Important TO: Cooking dinner for family | Outcome (measurable achievement): Jenny cooks Italian dinners for her family monthly in order to spend time with her family. | Key steps and services to get there: Menu planning, grocery shopping, inviting family, preparing and serving dinner (supported living).
Important TO: Having more friends | Outcome (measurable achievement): John goes to coffee shops weekly in order to meet new people. | Key steps and services to get there: Planning and going to coffee shops, sharing contact information, maintaining contact, developing comfort talking with new people (therapeutic consultation and community engagement).
Each of these examples shows movement from what’s important to the person to a more specific achievement that is time bound.
Without this time-bound element, there is decreased focus on making what is desired happen and it is more difficult to track success or progress toward the achievement.
For example, if Jenny’s outcome was just to “prepare Italian dinners for her family,” how would we know she is accomplishing this to the degree she wants?
By including the time-bound measure she wants as monthly, we have better defined what Jenny hopes to accomplish and what is considered by her and her support team to be achievable.
Outcomes may be changed or removed during the person-centered planning process; however, if the outcome is part of what’s needed for the person to have the life he or she wants, there is no requirement to remove or change the outcome.
Some supports will be needed across the lifespan whether they are provided by paid staff or natural supports.
We need a planning process that brings about the positive changes desired by the person, while maintaining what is working and ensuring he or she is well supported in the routine course of daily life.
[SIZE=12]Balancing Important TO and Important FORWhen developing outcomes, the team, which includes the person, should discuss the person’s preferences and the things that are important to them, as identified in the Personal Profile.
In some instances, an outcome will directly reflect what is important for a person in addition to what is important to them.
This helps to assure the whole support team is aware of identified behavioral and/or health needs in order to address associated risk factors and appropriately mitigate risk.
Identified health and behavioral support needs must be clearly included in planning.
The inclusion of identified risks or “all essential supports” in plans is an additional concern identified by the Independent Reviewer for the Settlement Agreement in the 10th and 11th report (p.43).
Adapting the completion of the Shared Plan as described above with “key steps to get there” listed under the “Key steps and services to get there …” section of the plan should help meet this requirement and reduce the chances key information is lost.
The following example shows how multiple, related health supports can be addressed under a single outcome in the Shared Plan.
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Important FOR: Insulin use, diabetic diet, blood sugar monitoring
Important TO: Feeling good
Outcome: Jill follows diabetic care each day so that she feels good.
Key steps and services to get there: Preparing diabetic
friendly meals and snacks (group home), taking insulin as prescribed, monitoring blood sugar, comfort check-ins (group home and skilled nursing). In this example, the activities needed to support Jill with diabetes are all included alongside the outcome.
This method helps with grouping related supports and better ensures their inclusion in the component plans prepared by providers following the meeting. While these steps will be reflected in the support activities found in each of the support plans, not every provider will be expected to assist with each step.
The support coordinator will assure that all steps are addressed across the support team in the various support plans.
[SIZE=12]Support Plans and Support ActivitiesSupport activities should be identified in the planning process as the basic steps in supporting the achievement of the outcomes, but will be more fully developed by providers following shared planning.
Support activities can be defined as being routine, for skill development, for health and safety, or to explore new opportunities before deciding on the specific nature of the activity.
Support activities are developed with individuals by providers, and include action verbs that indicate what specific activities will be supported.
Support activities may be groupings of activities (e.g., morning routine), but should also be written as individual activities when skills are being built, or when specific medical or behavioral protocols are being used (see examples below).
A basic formula for writing an activity statement is provided below. Each activity should use an action verb and be observable.
Rev 6.7.21
Where skill-building is not being attempted, adding “how often” to the activity statement makes routine activities measurable.
Where skill-building is being attempted, more information is needed to determine that the person is developing skills as desired.
Notice in the following examples, “countable achievement” is used to describe the measure that will be used for each activity, and each measure includes both how often and how long to help define the measure.
Rev 6.7.21
[SIZE=12]Criteria for Support Removal and Activity MonitoringCriteria for the removal of supports for health and safety are based on healthcare guidelines, medical orders, or documented plans for removal.
When a measure is met, a new learning activity should be considered, explored, and attempted either by changing the skill or changing the measure.
It is important to note that activities and sometimes outcomes may end simply because the person is no longer interested in pursuing the activity, or their needs may change such that the activity is no longer appropriate due to unforeseen circumstances.
It is also possible — and actually likely — that some activities may be expected to last indefinitely, and the person will continue to need the supports.
[SIZE=12]Support Instructions and Data CollectionSupport instructions detail how the supports will be provided, in accordance with the individual’s needs and preferences, and how the individual will participate in the provision of supports.
Ongoing noting in accordance with Medicaid requirements, along with simplified data collection, can assist providers with ongoing changes and quarterly reporting.
While some support instructions may be “standard practice,” individualized person-centered instructions should also be woven throughout the plan.
In addition to Medicaid-required noting, the following demonstrates data collection for each type of support:
Rev 6.7.21
[SIZE=12]Example: Addressing Health and Safety in PlanningTo illustrate how health and safety can be adequately addressed in planning, consider the following example:
During the planning meeting, the team discusses Sophie’s diabetes. While the team all agrees that daily monitoring of her diabetes is absolutely necessary (important FOR), Sophie is only concerned with the fact that daily finger sticks are painful and what she wants is to be more comfortable (important TO).
Outcome: Sophie is more comfortable while testing her blood sugar each day so that she has less pain.
Key steps and services to get there… :
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Explore a new glucometer, test glucose daily (group home supports).
Support Activity: Sophie’s blood sugar levels are tested daily.
I no longer need or want support when (measure by providing a clearly stated achievement): Sophie’s physician removes the order for daily finger sticks.
Support Instructions: Staff conduct finger sticks every morning according to Sophie’s diabetes protocol (attached).
Rev 6.7.21
[SIZE=12]Supporting Sophie During TestingStaff gently remind Sophie that “it is time.” That is all that needs to be said, and she will know.
Saying “finger stick” upsets her.
Sophie chooses where to sit; some days she prefers being on her bed, and some days she prefers being on the lounge chair in the living room.
Staff puts smooth jazz music on the radio or tells a joke or a story to distract her during the finger stick.
If upon testing, Sophie’s blood sugar is lower than 80 mg/dl or higher than 120 mg/dl, take health and safety steps described in her protocol (attached).
What to record: Was Sophie’s blood sugar tested and recorded as stated in her plan (record any concerns in a note)? Yes; No
It is clear in this example that the outcome is truly what is very important to Sophie to have in her life.
The support activity addresses the health need, and is clearly measurable, and the instructions are clear and reflective of both what Direct Support Professionals and Sophie will do.
Simply put, the outcome is “WHERE” we want to be, the support activities are “WHAT” we are doing to get there, and the support instructions are the “HOW” we are doing it.
In a person-centered planning process, the person is at the center of planning.
They let us know about the things they want in their lives; it is our role to support them in achieving what they want.
CMS specifically indicates in their guidance that person-centered planning is not about “paper completion.”
To that end, it may be helpful to envision the process out of order—that is, we are providing the supports (support activities) in this specific manner (support instructions) in order for the person to achieve what they want in their life (outcomes).
This guidance is offered as the basis of expectations as we move forward.
Person-centered plans can be measurable, and measurability helps to ensure that we are accountable to the people we support.
For people to have more independence, more integration, and a better quality of life, we must live up to the promises we make in the planning process.
We hope these adjustments lead to better planning and better lives for those we support.
Rev 6.7.21
[SIZE=12]Background Resources-
DBHDS Office of Provider Development: https://dbhds.virginia.gov/developmental-services/provider-development
DBHDS Office of Licensing: http://www.dbhds.virginia.gov/quality-management/Office-of-Licensing
Helen Sanderson Associates: http://helensandersonassociates.co.uk/
Independent Reviewers 10th and 11th report and the DOJ Settlement Agreement: http://www.dbhds.virginia.gov/doj-settlement-agreement
The Learning Community for Person-Centered Practices: http://www.tlcpcp.com
The Oregon ISP: https://oregonisp.org/
UMKC Institute for Human Development: http://www.lifecoursetools.com
Vision Care Services and Limitations (7720_Vision Manual - Chapter 4.pdf)
7720_Vision Manual - Chapter 4.pdf
Chapter IV: Covered Services and Limitations
________________________________________________________________________________
CHAPTER IV TABLE OF CONTENTS
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General Information 1
Member Copay Policy 1
Freedom of Choice of Provider 1
Service Authorization 2
Submitting Request for Service Authorization 3
Covered Services and Limitations 6
Diagnostic Examinations and Other Optometric Treatment Procedures 6
Lenses (Under 21 Years of Age) 6
Eyeglass Frames 7
Repair of Eyeglass Frames And/Or Replacement Of Broken Lenses 7
Professional Ophthalmic Dispensing Service 8
Ocular Prostheses 8
Vision Care Provider's Role in the Prescription Drug Program 8
Coverage and Limitations 9
Copayment on Drugs 10
Multiple Source Drugs - Payment Basis 10
Client Medical Management 11
Medicare Catastrophic Coverage Act of 1988 11
QMB Coverage Only 11
QMB Extended Coverage 12
All Others 12
Early Periodic Screening Diagnosis and Treatment Service Authorization 13
How to Determine if Services Require Service Authorization 14
Exhibits 16
________________________________________________________________________________
GENERAL INFORMATION
The Department of Medical Assistance Services covers the following vision care services for Medicaid members:
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Services Member Age Limit
Diagnostic examinations and optometric treatment procedures and services - All Ages
Eye exercises (Orthoptics) - Only under 21
Lenses - Only under 21
Frames - Only under 21
Repair of lenses or frames - Only under 21
Professional ophthalmic dispensing fees - Only under 21
Medically necessary contact lenses (must be preauthorized) - Only under 21
Eye Prostheses - All Ages
MEMBER COPAY POLICY
All members are liable for copayments for vision services except for those under age 21 and individuals receiving long-term care services or hospice care.
[FREEDOM OF CHOICE OF PROVIDER
Virginia Medicaid members are free to choose any participating vision provider licensed by the State Regulatory Agency to provide a particular vision service.
[Introduction
Service authorization (Srv Auth) is the process to approve specific services for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement.
[
The purpose of service authorization is to validate that the service requested is medically necessary and meets DMAS criteria for reimbursement. [
Service authorization does not guarantee payment for the service; payment is contingent upon passing all edits contained within the claims payment process, the individual’s continued Medicaid eligibility, the provider’s continued Medicaid eligibility, and ongoing medical necessity for the service. [
Service authorization is specific to an individual, a provider, a service code, an established quantity of units, and for specific dates of service. [
Service authorization is performed by DMAS or by a contracted entity.
General Information Regarding Service Authorization
[Provider manuals are located on the DMAS and KePRO websites. [
The contractor’s website has information related to the service authorization processes for programs identified in this manual. [
You may access this information by going to http://dmas.kepro.com and clicking on the Forms tab for fax forms to request services. [
A service specific checklist may be found by clicking on “Service Authorization Checklists” on KePRO’s website. [
For educational material, click on the Training tab and scroll down to click on the General tab. [
The Srv Auth entity provides communication and language needs for non-English speaking callers free of charge and has staff available to utilize the Virginia Relay service for the deaf and hard-of-hearing. [
Updates or changes to the Srv Auth process for the specific services outlined in this manual will be posted in the form of a Medicaid Memo to the DMAS website. [
Changes will be incorporated within the manual.
SUBMITTING REQUESTS FOR SERVICE AUTHORIZATION
Effective April 1, 2012
[Certain services previously reviewed by DMAS’ Medical Support Unit (MSU) will be reviewed by Keystone Peer Review Organization (KePRO), DMAS’ service authorization contractor. [
KePRO will begin accepting requests, regardless of the dates of service, on April 1, 2012. [
KePRO will allow retroactive reviews for service requests submitted through June 30, 2012. [
Refer to the DMAS Medicaid Memo dated March 9, 2012, titled “Services Currently Reviewed by DMAS’ Medical Support Unit Moving to KePRO for Review, effective April 1, 2012 and New Procedures Codes Requiring Service Authorization, effective April 1, 2012”. [
Effective July 1, 2012, KePRO will not authorize requests retroactively for these procedure codes, regardless of the dates of service. [
The only instance KePRO will approve services retroactively on and after July 1, 2012, is when the provider demonstrates retroactive Medicaid eligibility determination for members. [
KePRO will accept requests through direct data entry (DDE), fax, telephone, or US Mail. [
The preferred method is by DDE through KePRO’s provider portal, Atrezzo Connect. [
To access Atrezzo Connect on KePRO’s website, go to http://dmas.kepro.com. [
For direct data entry requests, providers must use Atrezzo Connect Provider Portal. [
Provider Registration is Required to use Atrezzo Connect [
The registration process for providers happens immediately online. [
From http://dmas.kepro.com, providers not already registered with Atrezzo Connect may click on “First Time Registration” to be prompted through the registration process. [
Newly registering providers will need their 10-digit National Provider Identification (NPI) number and their most recent remittance advice date for YTD 1099 amount. [
The Atrezzo Connect User Guide is available at http://dmas.kepro.com : Click on the Training tab, then the General tab. [
Providers with questions about KePRO’s Atrezzo Connect Provider Portal may contact KePRO by email at atrezzoissues@kepro.com. [
For service authorization questions, providers may contact KePRO at providerissues@kepro.com. [
KePRO can also be reached by phone at 1-888-827-2884, or via fax at 1-877-OKBYFAX or 1-877-652-9329.
Faxing Requests to KePRO
[KePRO’s website has information related to the service authorization processes for all Medicaid programs they review. [
Fax forms, service authorization checklists, trainings, and more are available on KePRO’s website. [
Providers may access this information by going to http://dmas.kepro.com.
Timeliness of Submission by Providers, Effective July 1, 2012 and Forward
[This grace period only applies to the procedure codes attached to the DMAS Memo dated March 9, 2012. [
Effective July 1, 2012, there will be no retroactive authorization. [
This means that if the provider is untimely submitting the request, KePRO will review the request and make a determination from the date it was received. [
The days/units not submitted timely will be denied, and appeal rights will be provided.
Processing Requests at KePRO
[KePRO will approve, pend, reject, or deny requests for service authorization. [
When a final disposition is reached, KePRO notifies the member and the provider in writing of the status of the request through the Medicaid Management Information System (MMIS) Letter generation process. [
For organ transplants, an additional letter will be faxed to the provider. [
Providers who have received an approved service authorization prior to April 1, 2012, from DMAS’ Medical Support Unit will receive an additional letter generated by the MMIS. [
This letter is to ensure that all approved service authorizations are accessible to KePRO. [
These letters will be mailed between March 9, 2012, and April 1, 2012. [
If there is insufficient medical]
7720_Vision Manual - Chapter 4.pdf
Chapter IV: Covered Services and Limitations
necessity information to make a final determination, KePRO will pend the request back to the provider requesting additional information.
If the information is not received within the time frame requested by KePRO, the request will automatically be sent to a physician for a final determination with all information that has been submitted.
In the absence of clinical information, the request will be submitted to the supervisor for review and final determination.
Providers and members are issued appeal rights through the MMIS letter generation process for any adverse determination.
Instructions on how to file an appeal is included in the MMIS generated letter.
Specific Service Type Information
0304 Medical Device, services/maintenance
Provider must submit requests to KePRO within 14 business days of the need and prior to rendering services.
As of July 1, 2012, there will be no retroactive authorization. The only exception will be member retroactive eligibility determination.
This means that if the provider is late submitting the request, KePRO will review the request and make a determination from the date it was received.
The days/units that were not submitted timely will be denied and appeal rights will be provided.
KePRO will review completed requests within 3 business days of receipt and make a final determination.
Out of State Providers
Out of state providers (non-participating, enrolled) are held to the same service authorization processing rules as in-state (participating, enrolled) providers and must be enrolled with Virginia Medicaid prior to submitting a request for out-of-state services to KePRO.
If the provider is not enrolled with Virginia Medicaid, the provider is encouraged to submit the request to KePRO, as timeliness of the request will be considered in the review process starting July 1, 2012.
KePRO will pend the request back to the provider for 12 business days to allow the provider to become successfully enrolled.
Providers will not be penalized if DMAS does not process the enrollment request within 12 business days.
If KePRO receives confirmation of the provider’s enrollment with Virginia Medicaid within 12 business days, the request will then continue through the review process and a final determination will be made on the service request.
If the request was pended for no provider enrollment and KePRO does not receive confirmation of the provider’s enrollment within the 12 business days, KePRO will reject the request back to the provider, as the service authorization cannot be entered into MMIS without the provider’s National Provider Identification (NPI).
Once the provider is successfully enrolled, the provider must resubmit the entire request.
Timeliness from the prior submission will not be considered with the re-submission.
Any provider not enrolled with Virginia Medicaid may do so by going to https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollment.
At the toolbar at the top of the page, click on “Provider Services” and then “Provider Enrollment” in the drop-down box.
It may take up to 10 business days to become a Virginia participating provider.
Review Criteria to be Used
DMAS criteria for medical necessity will be considered if a service is covered under the State Plan and is reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve functional disability.
Coverage may be denied if the requested service is not medically necessary according to this criteria or is generally regarded by the medical profession as investigational/experimental or not meeting the standard of practice.
DMAS criteria may include CMS’ Nationally Recognized Criteria (NRC).
Therefore, all approvals must meet these agency criteria.
All other criteria, including McKesson InterQual®, SIMplus®, or other McKesson review products, EPSDT, and physician review criteria are used for guidelines and reference purposes only.
Covered Services and Limitations
The following reflects Virginia Medicaid covered services and coverage limitations related to vision service.
Diagnostic Examinations and Other Optometric Treatment Procedures
-
A routine comprehensive eye examination as defined under Comprehensive Ophthalmological services in the American Medical Association CPT Code Book, is allowed only once every 24 months.
The National Standard Code for this service is found in Appendix B.
For extenuating medically indicated circumstances where less than 24 months have elapsed since the last examination, explain the situation on an attachment to the CMS-1500 (12-90).
For non-routine eye examinations and other optometric treatment procedures, which the provider is qualified by his or her license to perform, use CPT five-digit codes found in the AMA CPT code book. These books may be purchased from:
Order Department: OP 054192
American Medical Association
Post Office Box 10950
Chicago, IL 60610-0946
Eye Exercises (orthoptics) are covered only for persons under 21 years of age under Virginia Medicaid's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program.
Reimbursement will be provided for medically indicated orthoptics based on an EPSDT referral to a Medicaid participating EPSDT provider: an ophthalmologist or an optometrist.
All orthoptic sessions must be medically necessary.
If more than six sessions are required, the seventh and subsequent sessions billed to Medicaid require written documentation supporting the continuing need. This documentation must be attached to the CMS-1500 (12-90).
The CMS-1500 (12-90) will be reviewed by DMAS medical consultants and be approved for payment as appropriate.
The appropriate CPT/HCPCS code for orthoptics is 92065 - orthoptic and/or pleoptics training, with continuing medical direction and evaluation.
Lenses (Under 21 Years of Age)
-
Lens charges must reflect only the provider's laboratory costs; they may not exceed the average and reasonable wholesale costs.
HCPCS procedure codes for lenses are found in Appendix B.
Attach the supplier's invoice where possible.
For more expensive lenses, place a "22" modifier in Locator 24D of the CMS-1500 (12-90) and explain the medical justification on an attachment.
Each lens is considered a separate procedure and should be billed as "1" or "2" in Locator 24G of CMS-1500 (12-90).
Ophthalmic lenses may be made of either: (1) plastic with scratch-resistant coating or (2) glass.
Tinted lenses are covered only when they can be medically justified (e.g., photophobia, albinism).
Photogray lenses and lenses for cosmetic purposes are not covered by the Program.
Contact lenses are not covered by Virginia Medicaid except through service authorization by DMAS’ Service Authorization contractor. Authorization will be based on medical necessity and that eyeglasses cannot accomplish the optometric treatment.
Eyeglass Frames
-
Frame charges must reflect only the provider's actual laboratory cost; they may not exceed the average and reasonable wholesale cost.
The appropriate HCPCS procedure code for frames is found in Appendix B.
For special medically justified frames, place a "22" modifier in Locator 24D of the CMS-1500 (12-90) and explain the medical justification on attachment.
The entire eyeglass frame is billed as one procedure.
Eyeglass frames should be durable ZYL frames (plastic), such as Opti-Colors. Wire frames are covered, however, Medicaid will not reimburse the provider any more for wire frames than the provider would receive for plastic frames. The provider cannot balance bill the member for any difference in cost.
Repair of Eyeglass Frames And/Or Replacement Of Broken Lenses
-
The appropriate HCPCS procedure codes are found in Appendix B.
The repair of frames and lenses is normally limited to once every 12 months. If a repair is made in less than 12 months, place "22" modifier in Locator 24D of CMS-1500 (12-90) and explain the medical justification on an attachment.
Attach a medical justification statement and a detailed repair statement including the costs.
The repair or replacement of non-covered services is not covered by the Program.
Professional Ophthalmic Dispensing Service
-
Professional services, such as measuring, fitting, verifying, and adjusting the eyeglasses and providing an eyeglass case, are covered services.
There are no corresponding national codes to bill for the lens or frames dispensing fees.
The frames dispensing fee will be included in the frames purchasing fee.
The lens dispensing fee will be added to the HCPCS code billed for the lens.
Note: Provider charges should include the lens dispensing fee. If a lens HCPCS code is priced for individual consideration (HCPCS codes V2100 to V2118, V2200 to V2220, V2300 to V2309, and V231), the provider should submit their actual invoice cost.
Ocular Prostheses
Eye prostheses are provided when eyeballs are missing regardless of the age of the member or the cause of the loss of the eyeball.
Eye prostheses are provided regardless of the function of the eye.
Service authorization is not required, but post-payment review is conducted.
VISION CARE PROVIDER'S ROLE IN THE PRESCRIPTION DRUG PROGRAM
Ophthalmologists and optometrists licensed by a state regulatory agency to prescribe drugs may prescribe legend drugs for Medicaid members.
The provider's normal procedure for prescribing drugs should be followed. However, the prescriber's Medicaid provider number must be included on all prescriptions for Medicaid members.
The prescribing of drugs should be in accordance with community standards of medical and pharmacological practices and consistent with economy.
Physicians are expected to write generic prescriptions, specifying a brand name only when it is medically necessary.
In acute illnesses, prescribed drugs should be limited to the quantity needed for the course of treatment for the illness.
Maintenance drugs for chronic illnesses should be prescribed in quantities reflecting at least a 30-day supply or 100 units/doses, except when contraindicated by the patient's physical or psychological condition.
Coverage and Limitations
Prescription services are provided to Medicaid members as described below.
Legend drugs are covered except for the following:
-
• Anorexiant drugs prescribed to suppress appetite; however, service authorization may be requested if the medical indication is to treat attention deficit disorders or narcolepsy.
• If approved, reimbursement is allowed for the prescription only from one pharmacy selected by the patient and when prescribed by one designated provider.
• Utilization is monitored.
• DESI (Drug... (text cut off)](/LIST)
Chapter IV: Covered Services and Limitations
Efficacy Study Implementation) drugs considered by the Food and Drug Administration (FDA) to be less than effective. Compound prescriptions, which include a DESI drug, are not covered.
A current list of the DESI drugs is provided in Appendix C of this manual and will be updated by periodic replacement pages to this manual.
EXCEPTION:
Dipyridamole, under the brand name Persantine only, is covered when prescribed for the FDA-approved indication: as an adjunct to Coumarin anticoagulants in the prevention of postoperative thromboembolic complications of cardiac valve replacement.
Physicians must indicate the diagnosis on the prescription. The pharmacist may submit a claim for reimbursement only when the approved diagnosis is documented, and the documentation must remain on file in the pharmacy.
Dipyridamole products other than the brand name Persantine are classified as DESI drugs and are not covered by Medicaid. Investigational/experimental drugs and drugs which have been recalled. Food services and dietary or nutritional supplements that do not constitute a legend/schedule drug under Virginia law EXCEPT when preauthorized and EXCEPT as provided for in a hospital or nursing facility and included in the overall cost of inpatient care. Supplements will be preauthorized through home health only when the supplements are required as the sole source and are administered via mechanical device. Supplements may be authorized through EPSDT or the technology-assisted or AIDS waiver when the supplements are required as the primary nutritional source.
NOTE: Retrovir is covered to treat patients with symptomatic HIV (Human Immunodeficiency Virus) infections (AIDS and advanced ARC, AIDS-Related Complex). No special procedures are required for prescribing this drug.
Non-legend drugs (over-the-counter) are only covered as described below:
-
Coverage is allowed for the following:
Family planning drugs and supplies
Insulin
Syringes and needles, except for members residing in nursing facilities
Diabetic test strips for members under 21 years of age
Specific therapeutic categories, which are covered for nursing facility members:
Analgesics
Antacids
Antidiarrheal
Antivertigo preparations
Cough and cold preparations
Dermatologicals
Hemorrhoid preparations
Laxatives
Ophthalmic preparations
Vitamins, minerals, and hematinics
Copayment on Drugs
Members are required to pay the dispensing pharmacy $1.00 for generic drugs and $3.00 for brand name drugs for each original and refill legend drug prescription, insulin, syringes, and needles.
This copayment does not apply to members under age 21, institutionalized patients, hospice patients, and pregnancy-related or family planning drugs and supplies.
Multiple Source Drugs - Payment Basis
Under the authority of 1902 (a) (30) (A) and the regulations in 42 CFR 447.332, the Centers for Medicare and Medicaid Services (CMS) establishes a specific upper limit for certain multiple source drugs if the following requirements are met:
-
All of the formulations of the drug approved by the Food and Drug Administration (FDA) have been evaluated as therapeutically equivalent in the current edition of the publication *Approved Drug Products With Therapeutic Equivalence Evaluations* (including supplements or in successor publications).
At least three suppliers list the drug, which has been classified by the FDA as category "A" in its publication *Approved Drug Products With Therapeutic Equivalence Evaluations* (including supplements or in successor publications) and in the current editions (or updates) of published compendia of cost information for drugs available for sale nationally (e.g., *Red Book*, *Blue Book*, *Medi-Span*).
The upper limit for multiple source drugs for which a specific limit has been established does not apply if a physician certifies in his or her handwriting that a specific brand is "medically necessary" for a particular member.
The handwritten phrase "brand necessary" or "brand medically necessary" must appear on the face of the prescription.
A dual line prescription form does not satisfy the certification requirement.
A checkoff box on a form is not acceptable.
The "brand necessary" documentation requirement applies to telephoned prescriptions.
CLIENT MEDICAL MANAGEMENT
As described in Chapters III and VI of this manual, the State may designate certain members to be restricted to specific physicians and pharmacies.
When this occurs, it is noted on the Medicaid member's ID card.
A Medicaid-enrolled physician who is not the designated primary provider may provide and be paid for services to these members only:
-
In a medical emergency situation in which a delay in treatment may cause death or result in lasting injury or harm to the member.
On written referral from the primary physician, using the Practitioner Referral Form (DMAS-70). This also applies to covering physicians.
For other services covered by DMAS which are excluded from Client Medical Management Program requirements.
Routine vision care services (routine diagnostic exams for members of all ages and eyeglasses for members under age 21) provided to restricted members are excluded from the requirement for a written referral.
These are services billed using codes listed in Appendix B of the Vision Care Manual.
Medical treatment for diseases of the eye and its appendages requires a written referral or may be provided in a medical emergency.
Ophthalmologists and other physicians skilled in the treatment of diseases of the eye and its appendages must coordinate medical treatment with the primary care physician.
The primary care physician must complete a Practitioner Referral Form (DMAS-70) when making a referral to another physician or clinic.
The referral physician must follow special billing instructions found in this manual to receive reimbursement for restricted members.
MEDICARE CATASTROPHIC COVERAGE ACT OF 1988
The Medicare Catastrophic Coverage Act of 1988 and other legislation require state Medicaid programs to expand the coverage of services to certain low-income Medicare beneficiaries, known as Qualified Medicare Beneficiaries (QMBs).
QMB Coverage Only
Members in this group are eligible for Medicaid coverage of Medicare premiums and of deductible and coinsurance up to the Medicaid payment limit less the member's copayment on allowed charges for all Medicare-covered services.
The Medicare coinsurance is limited to the Medicaid fee when combined with the Medicare payment.
QMB Extended Coverage
Members in this group will be eligible for Medicaid coverage of Medicare premiums and of deductible and coinsurance on allowed charges for all Medicare-covered services plus coverage of all other Medicaid-covered services listed in Chapter I of this manual.
This group’s Medicaid verification provides the message, “QUALIFIED MEDICARE BENEFICIARY --QMB EXTENDED.”
These members are responsible for copay for pharmacy services, health department clinic visits, and vision services.
All Others
Members without ANY of these messages at the time of verification will be eligible for those covered services listed in Chapter I of this manual.
Early Periodic Screening Diagnosis and Treatment Service Authorization (EPSDT) is Medicaid's comprehensive and preventive child health program for individuals under the age of 21.
Federal law (42 CFR § 441.50 et seq.) requires a broad range of outreach, coordination, and health services under EPSDT, distinct from general state Medicaid program requirements.
EPSDT is geared to the early assessment of children’s health care needs through periodic screenings.
The goal of EPSDT is to ensure that health problems are diagnosed and treated as early as possible, before the problems become complex and treatment more costly.
Examination and treatment services are provided at no cost to the member.
Any treatment service which is not otherwise covered under the State’s Plan for Medical Assistance can be covered for a child through EPSDT as long as the service is allowable under the Social Security Act Section 1905(a) and the service is determined by DMAS or a DMAS-contracted managed care organization as medically necessary.
Therefore, services may be approved for persons under the age of 21 enrolled in Medicaid, FAMIS Plus, and FAMIS Fee For Service (FFS) if the service/item is physician ordered and is medically necessary to correct, ameliorate (“make better”), or maintain the individual’s condition. (Title XIX Sec. 1905 .[42 U.S.C.1396d] (r)(5)).
All Medicaid and FAMIS Plus services that are currently service authorized by the Service Authorization contractor are services that can potentially be accessed by children under age 21.
However, in addition to the traditional review, children who are initially denied services under Medicaid and FAMIS Plus require a secondary review due to the EPSDT provision.
Some of these services will be approved under the already established criteria for that specific item/service and will not require a separate review under EPSDT; some service requests may be denied using specific item/service criteria and need to be reviewed under EPSDT; and some will need to be referred to DMAS.
Specific information regarding the methods of submission may be found at the contractor’s website, DMAS.KePRO.com.
Click on Virginia Medicaid. They may also be reached by phone at 1-888-VAPAUTH or 1-888-827-2884, or via fax at 1-877-OKBYFAX or 1-877-652-9329.
EPSDT is not a separate Medicaid program. EPSDT is distinguished only by the scope of treatment services available to children under age 21.
Because EPSDT criteria (service/item is physician ordered and is medically necessary to correct, ameliorate (“make better”), or maintain the individual’s condition) must be applied to each service that is available to EPSDT-eligible children, EPSDT criteria must be applied to all service authorization reviews of Medicaid services.
Service requests that are part of a community-based waiver are the sole exception to this policy.
Waivers are exempt from EPSDT criteria because the federal approval for waivers is strictly defined by the state.
The waiver program is defined outside the parameters of EPSDT according to regulations for each specific waiver.
However, if services are not covered under traditional Medicaid FFS or under a waiver program, then EPSDT may be an alternative.
Examples of EPSDT Review Process: The following is an example of the type of request that is reviewed using EPSDT criteria: A durable
Chapter IV: Covered Services and Limitations
A medical equipment (DME) provider may request coverage for a car seat for a child who is 7 years old and has a diagnosis of cerebral palsy.
DME policy indicates that DMAS only purchases equipment for use in the member’s home.
This child’s spasticity and contractures require the child to have a special car seat to be transported safely in the car.
The contractor would not approve this request under DME medical necessity criteria because the equipment is for use outside the home.
However, this may be reviewed under EPSDT because the car seat does ameliorate his medical condition and allows him to be transported safely.
The review process as described is to be applied across all non-waiver Medicaid programs for children.
A request cannot be denied as not meeting medical necessity unless it has been submitted for physician review.
DMAS or its contractor must implement a process for physician review of all denied cases.
When the service needs of a child are such that current Medicaid programs, including waivers, do not provide the relevant treatment service, then the service request will be sent by the service authorization contractor directly to the DMAS Maternal and Child Health Division for consideration under the EPSDT program.
All service requests must be a service that is listed in (Title XIX Sec. 1905 .[42 U.S.C. 1396d] (r)(5)).
Requests may be sent to:
-
EPSDT Service Authorization Coordinator
Fax: 804-612-0043
Phone: 804-225-3231
How To Determine If Services Require Service Authorization
In order to determine if services need to be service authorized, providers should go to the DMAS website: http://dmasva.dmas.virginia.gov and look to the right of the page and click on the section that says Procedure Fee Files, which will then bring you to this: http://www.dmas.virginia.gov/pr-fee_files.htm.
You will now see a page entitled DMAS Procedure Fee Files. The information provided there will help to determine if a procedure code needs service authorization or if a procedure code is not covered by DMAS.
To determine if a service needs Service Authorization, next determine whether you wish to use the CSV or the TXT format.
The CSV is comma separated value and the TXT is a text format.
Depending on the software available on your PC, you may easily use the CSV or the TXT version.
The TXT version is recommended for users who wish to download this document into a database application.
The CSV Version opens easily in an EXCEL spreadsheet file.
Click on either the CSV or the TXT version of the file. Scroll until you find the code you are looking for.
The Procedure Fee File will tell you if a code needs to be prior authorized as it will contain a numeric value for the PA Type, such as:
-
00 - No PA is required
01 - Always needs a PA
02 - Only needs PA if service limits are exceeded
03 - Always need PA, with per frequency.
To determine whether a service is covered by DMAS, you need to access the Procedure Rate File Layouts page from the DMAS Procedure Fee Files.
Flag codes are the section which provides you with special coverage and/or payment information.
A Procedure Flag of “999” indicates that a service is non-covered by DMAS.
EXHIBITS
Please use this link to search for DMAS Forms: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderFormsSearch
Provider Manual Title: Vision Services
Revision Date: TBD
Chapter IV: Covered Services and Limitations
Page: 14
PRACTITIONER REFERRAL FORM (DMAS-70)
1. Formatted: Justified
Virginia Child Outcomes and Program Effectiveness (3793_Part C 05.pdf)
Virginia’s Child Outcomes Booklet
Introduction
An outcome is a benefit experienced as a result of services and supports provided for a child and their family. The effectiveness of any program requires knowing if children are making progress and if the services and strategies utilized are making a difference and improving outcomes for children and their families.
OSEP requires all state early intervention and preschool special education agencies to report data on three child outcomes:
-
Children have positive social-emotional skills (including social relationships).
Children acquire and use knowledge and skills (including early language/communication and early literacy).
Children use appropriate behaviors to meet their needs.
Although the federal government is the driving force behind the child outcomes data requirement, the data serve other important purposes as well. Understanding the child’s functioning in the three child outcome areas initially and ongoing and across routines and settings allows teams to use this information for effective service planning.
Local programs and state agencies need data on how children are doing to know how well programs are serving children and families and how to help programs improve. Families and other community members also need to know how programs are doing. We need to have the same information on all children in a program to form an overall picture of how all programs are doing.
Thoughtful analyses of data on child outcomes are the key to making good decisions about how to improve services for children and families.
Good Teaming Leads to Great Decisions
“Teaming and collaboration practices are those that promote and sustain collaborative adult partnerships, relationships, and ongoing interactions to ensure that programs and services achieve desired child and family outcomes and goals.”
Division for Early Childhood’s Recommended Practices, 2014
Determining Child Outcome Summary (COS) Ratings in Virginia
Part of an effective Child Outcomes Summary Process is effective teaming which includes engaging all members of the team including families when discussing a child’s current level of functioning compared to same age peers.
A Child Outcomes Summary team needs a complete picture of the child’s functioning to decide on outcomes ratings. Different members of the team contribute different information to this picture. Professional team members are skilled at picking up on varying levels of typical and atypical patterns of development. Family members know what the child does in different settings and with different people.
By sharing what they know about the child, each member of the team helps establish a complete picture of the child’s functioning, which helps to ensure that the outcomes ratings accurately reflect what the child can and cannot do.
With good teaming comes good decision-making. Good decision-making leads to objective and accurate ratings.
Virginia’s Child Outcomes Booklet, Team Engagement in the Child Outcomes Summary Process identifies the required components for Virginia’s Child Outcome Summary Ratings Process. Included in this booklet are the necessary resources to assist team members in being fully prepared to participate in the process.
If the process outlined in this booklet is followed properly, a high measure of inter-rater reliability will be achieved.
When implemented fully the required components will lead to a consistent Child Outcome Summary Process resulting in Virginia’s expected outcomes:
-
Families are included as full participants throughout the COS process;
Families’ cultural values, beliefs and practices are taken into consideration;
Substantial functional information is collected that will inform the assessment for service planning, aid in the selection of IFSP outcomes, and help to determine child outcome ratings (i.e., initial, ongoing and exit ratings);
A high measure of inter-rater reliability is achieved.
This booklet is intended as a companion guide to the Practice Manual where you will find specific requirements for timelines, assessment, and data entry for initial, annual and exit ratings.
Virginia’s Child Outcomes Booklet - Functional Assessment
CHAPTER ONE - Functional Assessment
A critical characteristic of the three child outcomes is that they are functional.
Functional outcomes refer to skills and behaviors that are meaningful to the child in the context of everyday living.
In addition, the three outcomes are broad. They reflect how the child functions throughout the day at home and wherever the child spends time.
The outcomes cross developmental domains to capture how children integrate the skills and behaviors needed to participate in everyday activities.
The three child outcomes reflect this emphasis on functioning, which is consistent with recommended practice for identifying individualized outcomes.
Functional assessment helps teams understand a child’s functional abilities, determine functional IFSP outcomes based upon family priorities, and inform the identification of intervention strategies and implementation.
When using the three global child outcomes as a framework for summarizing assessment results, practitioners assist families in thinking about how their child brings together his or her skills across domains to function in specific situations, rather than talking about skills from a particular domain in isolation.
Practitioners should ensure that conversations about these three global child outcomes focus on the child’s performance in the context of the activities and routines assessed.
This promotes conversations about possible IFSP outcomes to support participation and enhanced competence in the everyday activities that were prioritized by the parent.
Involving families in functional assessment is more than asking questions, going over questionnaires, or developmental profiles.
To truly involve families providers must:
-
Listen to the family story,
Observe and ask about the child’s everyday routines and activities related to the three child outcomes,
Ask parents to show or describe what happens in everyday routines and activities,
Observe parent/caregiver/child interactions, and
Observe the child playing.
Virginia defines functional assessment as a continuous collaborative process that combines observing, asking meaningful questions, listening to family stories, and analyzing individual child skills and behaviors within naturally occurring everyday routines and activities across multiple situations and settings.
To learn more about Virginia’s Definition of Functional Assessment see chapter seven.
To assign an accurate rating at entry, annual and exit, the team needs to (1) obtain a complete picture of the child’s skills and behaviors across multiple settings and situations and (2) understand typical child development.
1. Obtaining a complete picture of the child’s skills and behaviors across multiple settings and situations
means that, in addition to gathering information through ongoing assessment and assessment tools, teams must have other mechanisms for getting information about the child in other places and with other people.
It is especially important to get a picture of the child in places where the child spends time, including at home, in child care, and in other community settings.
The team needs to know how the child interacts with adult family members, siblings, extended family, and other significant people in the child’s life.
This information can come from talking with those familiar with the child, such as family members, grandparents, and/or care providers, or from observations in places where the child spends time.
2. Since the child outcome ratings are based on a comparison of a child’s functioning to that of same-aged peers
it is important to use a comprehensive assessment tool as an anchor to typical development.
The Infant & Toddler Connection of Virginia strongly recommends the MEISR (Measure of Engagement, Independence and Social Relationships) as an anchor tool.
Unlike more traditional assessment tools that focus on developmental domains and isolated skills in a testing situation, the MEISR assesses functional skills in the context of the child’s everyday activities and routines and is anchored not only by developmental domains but also by the three child outcome areas.
A link to the MEISR-COSF (2010) is included in Attachment A for informational purposes and to illustrate what functional skills fall into what child outcome area(s).
Virginia’s Child Outcomes Booklet - Understanding the 7-Point Rating Scale
CHAPTER TWO - Understanding the 7-Point Rating Scale
The 7-point scale is used to indicate a child’s status on each of the three outcomes at a given point in time.
In Virginia, these points always include entry, annual and exit from early intervention.
The process involves team members using the information gathered about a child to rate his or her functioning in each of the three outcome areas on a 7-point scale.
Using the 7-point rating scale requires the team to compare the child’s skills and behaviors with those expected for his or her age.
On the 7-point scale, a 7 represents age-expected functioning and lower points represent the degree of distance from age expectations.
Virginia requires the use of the Decision Tree when determining ratings for all children.
It is important to note that the decision tree was not written as a script for individuals to read during the meeting.
The decision tree is a guide to help teams reflect on the questions they need to answer to reach a rating and
Virginia’s Child Outcomes Booklet
Introduction
helps the team use the criteria consistently to decide between ratings.
Important Reminders: The next area of knowledge needed by the team is the age at which children typically acquire different kinds of skills.
The rating process requires an understanding of the timing and sequences of development that enable children to have positive social relationships, acquire knowledge and skills, and take action to meet their needs.
For example, children typically play next to their peers before they meaningfully interact with them.
In addition to child development occurring in typical sequences, we also know that children typically acquire skills within a certain time frame.
For example, most children learn to walk around 12 months of age.
The rating process requires that team members understand both the sequence in which children acquire skills and the age range in which they are acquired.
Team members will be asked to think about how the child’s functioning compares with what would be expected for a child his age.
It is important to note that each of the 7 points on the scale is defined by specific criteria.
These criteria are grounded in three categories of functional levels: age-expected, immediate foundational, and foundational.
Categories of Skills
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Age-expected skills are exactly what the phrase says: They are the skills and behaviors that are seen in children of a particular chronological age. For example, if a child is 24 months old, age-expected skills are what a 24-month-old would be expected to do. We would describe a 24-month-old with 24-month-old skills as showing age-expected skills.
Immediate foundational skills and behaviors are those that come just before age-expected skills in development. To understand immediate foundational skills, let’s consider the example of walking. When we think about the skills that come just before children become proficient in walking, we see that they are cruising from one piece of furniture to another and taking a few unsteady steps on their own. These are examples of immediate foundational skills for walking. If a child is not showing age-expected skills but is showing the skills that come immediately before the skills expected for the age, we would describe the child as showing “immediate foundational skills.”
Foundational skills occur much earlier in the developmental progression of skills. They are called foundational because they form the foundation for later skill development. When considering our example of walking, we would think about the skills needed for children to eventually learn to walk—those that come even before cruising and initial wobbly steps. Examples include pulling to stand, crawling or scooting, going from a sitting position to all fours in preparation for crawling, or, in younger infant development, pushing up while in tummy time. Children who are not yet showing age-expected skills but are showing skills that come much earlier in development would be described as showing “foundational skills.”
Use of Descriptor Statements
It is also important to note that in Virginia, we use the descriptor statements as reflected on the IFSP and the Decision Tree instead of numbers when discussing ratings with families. The numbers are used for data entry only.
Understanding the 7-Point Rating Scale
Let’s look at the definitions of each of the 7 points of the scale. In addition to the description, the corresponding descriptor statements from Virginia’s IFSP and Decision Tree are included for each of the 7 points.
Rating of 7
“Child has all the skills that we would expect in this area.”
A rating of 7 indicates that, in all or almost all everyday settings and situations, the child shows skills and behaviors that are expected for his or her age.
A rating of a 7 also indicates that at this time, no one on the team has concerns about the child’s development.
Rating of 6
“Child has the skills that we would expect in this area. There are some concerns with [including documenting area of concern/ quality/ lacking skill].”
A rating of 6 also indicates that in all or almost all everyday settings and situations, the child shows skills and behaviors that are expected for his or her age.
However, a rating of 6 indicates that the team has some concerns about the child’s functioning in the outcome area.
These concerns are substantial enough to suggest keeping an eye on the child’s development to determine the need for additional support in the future.
Examples of concerns where a rating of 6 would be appropriate are concerns about the child’s development potentially not keeping pace with age-expected development in the future or a child who is showing early signs of a possible developmental problem.
On the other hand, examples of concerns where a rating of 7 would be appropriate instead of 6 might include: shyness, a 15-month-old child may be very shy, but the behavior is expected for the age; or temper tantrums, a parent may be worried about a 2-year-old’s temper tantrums.
The team will want to help the parent address these behaviors, but the team can also help the parent understand that tantrums are to be expected given the child’s age.
Rating of 5
“Child shows many age expected skills. He also continues to show some skills that might describe a younger child in this area.”
A rating of 5 indicates that a child shows some functioning that is expected for his or her age in some settings and situations or some of the time.
This means that at other times or in some settings, the child is showing some functioning that is not age-expected.
This mix of age expected and not age-expected functioning is the main differentiation between a rating of 5 and ratings of 6 or 7.
Children who receive a rating of 5 have functioning that might be described as that of a slightly younger child because, developmentally, they present with some skills and behaviors that we would expect to see earlier in development.
Rating of 4
“Child shows occasional use of some age expected skills. He has more skills of a younger child in this area.”
A rating of 4 also indicates that there is a mix of age-expected and not age-expected skills, but in the case of a rating of 4, the child shows more functioning that is not age-expected.
Children who receive a rating of 4 show only occasional age-expected functioning across settings and situations; they show mostly functioning that is not age-expected.
The functioning that is not age-expected could be described as immediate foundational or foundational functioning, or both.
Rating of 3
“Child uses many skills that are necessary for development of more advanced skills; he is not yet showing skills used by other children his age in this area.”
The key feature of a rating of 3 is the lack of any age expected functioning in the outcome area.
A rating of 3 means the child is showing immediate foundational skills almost all the time and across settings and situations and possibly some foundational skills, but no skills or behaviors that are age-expected in the outcome area.
Children who receive a rating of 3 have functioning that might be described as that of a younger child when comparing their functioning with what is expected at their age because their skills and behaviors are those that we might see earlier in the developmental progression.
Rating of 2
“Child is beginning to show some of the early skills that are necessary for development of more advanced skills in this area.”
In a rating of 2, we see fewer immediate foundational skills compared with a 3.
A rating of 2 indicates that a child only occasionally uses immediate foundational skills across settings and situations and primarily has more of the foundational skills we see earlier in development.
Rating of 1
“Child has the very early skills in this area. This means that child has the skills we would expect for a much younger child.”
Finally, a rating of 1 means the child does not yet show any age-expected or immediate foundational functioning in the outcome area.
A child with a rating of 1 is showing all skills at the foundational level of development.
Important Note
Early intervention programs serve children with a wide range of abilities, including those with mild developmental delays and those with significant disabilities and regressive disorders.
Some children have a delay in only one of the outcomes areas and will show age expected functioning in the other two outcomes.
It’s important to remember that children with more significant developmental delays and disabilities will receive ratings at the lower end of the 7-point scale, and that’s okay.
It’s an accurate picture of the child’s functioning at that point in time.
Understanding the criteria for the 7-point scale is extremely important for deriving an accurate rating.
To assign an accurate rating at entry, annual and exit, the team needs to obtain a complete picture of the child’s skills and behaviors across multiple settings and situations.
This means that in addition to gathering information through ongoing assessment and assessment tools, teams must have other mechanisms for getting information about the child in other places and with other people including the child’s parents and other caregivers.
Please refer to the following chart for assessment considerations and documentation to support each rating statement.
Documenting Outcome Ratings
Rating Outcome Ratings: Child’s Development in Relation to Other Children The Same Age
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Age Expected Skills
Provide examples of child’s age expected functioning 6
Provide examples of the child’s age expected functioning
Provide specific information about the concern that led to the rating of 6
If there is evidence of functioning that is not age expected, a rating of 6 or 7 should not be assigned Decreasing Degree of Age Expected Skills
5
Provide examples of child’s age expected functioning
Provide examples of the child’s functioning that is NOT age expected 4
Provide examples of age expected functioning
Provide examples of the child’s functioning that is NOT age expected
Evidence should show more functioning that is NOT age expected than functioning that is age expected No Age Expected Skills
3
Provide examples of the child’s functional skills
Provide information about functional skills expected at this age, but not yet demonstrated
There should be no functioning that is age expected to receive this rating 2
Provide examples of the early functional skills the child is beginning demonstrating that are necessary for more advanced functioning
Provide information about the next skills necessary for child to move toward age expected functioning
There should be no functioning that is age expected to receive this rating 1
Provide examples of the child’s functional skills
Provide information about the next skills necessary for child to move toward age expected
Virginia’s Child Outcomes Booklet
Introduction
This booklet provides guidance on assessing and rating child outcomes in early intervention. It emphasizes the importance of thorough preparation, collaboration, and accurate documentation throughout the process.
CHAPTER ONE - Functional Assessment
Details about functional assessment are included in Chapter One.
CHAPTER TWO - Understanding the 7-Point Rating Scale
Information about the 7-point rating scale is covered in Chapter Two.
CHAPTER THREE - Determining Initial Ratings
Preparing Families
It is important that everyone participating in the Child Outcome Summary (COS) Process not only understands the required components of functional assessment and the 7-point rating scale but also understands why this information is collected.
Team members, including the family, must be well prepared to participate in the discussion. The Intake meeting is the ideal opportunity to introduce families to functional assessment and the COS.
It is important for the service coordinator to explain to the family that parents and caregivers are the most important members of the team since they know their child best.
In fact, doing so helps families understand how invested service coordinators and early intervention providers are in learning about and understanding their child and family.
The service coordinator and family may use this time to prepare by observing the child doing something that he enjoys or does often.
The service coordinator should reflect her observations on the Child Outcome Guiding Questions Checklist found in Chapter Seven: Important Documents when Completing the COS Process.
While this form is not “required,” it is strongly recommended as a way to capture functional information in preparation for eligibility determination and assessment for service planning.
Assessment Process
The initial assessment for service planning is conducted by a multidisciplinary team and includes use of a comprehensive assessment tool as an age anchor.
In addition to information from assessment tools, information is gathered from multiple sources:
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Observation;
The family, including information about the child’s performance across situations and settings and with different people;
Any other source (e.g., child care provider, medical records, etc.)
See Chapter 6 of the Infant & Toddler Connection of Virginia Practice Manual for more detailed requirements related to the initial assessment for service planning.
Team Collaboration & Family Engagement in Determining Ratings
Using the Decision Tree and considering the information above and the functional skills of same-aged peers, the team determines the appropriate rating statement for each of the three child outcomes.
A printed or electronic copy of the Decision Tree must be used by the team, which includes the family, at the assessment for service planning or the IFSP meeting to make the rating determination for each outcome.
Families are fully involved as team members in using the Decision Tree.
The service coordinator and service provider team members support family engagement by preparing families as described above and encouraging participation at each question and decision point in the Decision Tree.
CHAPTER FOUR - Determining Annual Ratings
Preparing Families
Similarly to the initial rating, family members need to be prepared to fully participate in the summary of the child’s functional status on the three child outcomes and strengths and needs when the annual IFSP is developed.
The service coordinator should remind the family about the three outcome areas, the purpose of the Child Outcomes Summary Process, and the Decision Tree.
Preparation should include informing the family what to expect during the meeting and providing an opportunity for questions.
Stress how important it is for family members to contribute information about what they have seen their child do.
To assist in preparing families, service coordinators are expected to share the parent’s guide to “Child Outcome Summary Process,” a two-page handout explaining the global child outcomes and the Decision Tree Process (see Chapter Seven: Important Documents when Completing the COS Process) prior to the annual assessment.
Assessment Process
Because service providers observe the child’s functioning and skills across all developmental domains and in relation to the three child outcomes routinely, there is generally enough information from ongoing assessment to complete the summary when the annual IFSP is developed.
Re-assessment at the time of the annual IFSP is only necessary in specific circumstances, such as if the child is receiving service coordination only, if there has been no ongoing assessment for an extended period, or if a major event (e.g., surgery) has recently impacted development.
When a re-assessment is needed, it must be conducted by a multidisciplinary team.
See Practice Manual Chapter 8 for details on special circumstances.
Team Collaboration & Family Engagement in Determining Ratings
Using the Decision Tree and considering the information above and the functional skills of same-aged peers, the team determines the appropriate rating statement for each of the three child outcomes.
A printed or electronic copy of the Decision Tree must be used by the team, including the family, at the assessment for service planning or the IFSP meeting to make the rating determination.
Families are fully involved as team members in using the Decision Tree.
The service coordinator and team members support family engagement by preparing families and encouraging participation at each decision point in the Decision Tree.
Virginia’s Child Outcomes Booklet - Determining Exit Ratings
Preparing Families
Explain to families that exit ratings on all three child outcomes are done prior to exit for children who had an entry rating and have been in the system for 6 months or longer since their initial IFSP (i.e., 6 months between initial IFSP and exit assessment).
The rating must be completed no more than 6 months prior to exit from early intervention.
Similarly to the initial rating, family members need to be prepared to fully participate in summarizing the child’s functional status and strengths and needs when exit ratings are determined.
The service coordinator should explain the three outcome areas, the purpose of the Child Outcomes Summary Process, and the Decision Tree.
Preparation should include informing the family what to expect during the meeting and providing an opportunity for questions.
Stress how important it is for family members to contribute information about what they have seen their child do.
To assist in preparing families, service coordinators are expected to share the parent’s guide to “Child Outcome Summary Process,” a handout explaining the global child outcomes and the Decision Tree Process (see Chapter Seven: Important Documents when Completing the COS Process) prior to the exit rating discussion.
Assessment Process
Exit ratings on all three child outcomes are done prior to exit for children who had an entry rating and have been in the system for 6 months or longer since their initial IFSP.
The rating must be completed no more than 6 months prior to exit from early intervention.
In determining exit ratings, the team should NOT review entry ratings; each rating should reflect the child’s current functioning.
Looking at entry ratings may bias the team’s decision; they are not relevant for the exit discussion.
A formal assessment is not required; ongoing assessment by providers determines the child’s functional status.
Providers document abilities using assessment instruments (e.g., HELP, ELAP, MEISR, etc.).
Documenting observations from ongoing assessment serves as an anchor for the assessment and helps determine the child’s status relative to same-age peers.
Completing the ASQ does not meet the assessment requirement.
It is not necessary to use the same instrument as for the entry assessment.
Since ratings reflect current status, it is important to time the exit assessment as close to the actual exit as possible.
Using ongoing assessment information just before exit can update ratings even if last annual IFSP was within 6 months.
If insufficient ongoing assessment data is available (e.g., the child has not been seen for a long time and the family leaves unexpectedly), it may be impossible to complete ratings.
In most cases, contact notes can provide enough information to determine the child’s exit status.
If ratings cannot be completed, this must be documented in a contact note.
Team Collaboration & Family Engagement
Although exit ratings are not always determined during a full IFSP team meeting, those determining ratings must refer to a paper or electronic Decision Tree.
Families should be engaged in the process whenever possible.
The team will answer the progress question: “Has the child shown any new skills or behaviors related to this outcome since entry?”
This “progress question” indicates whether the child has made progress compared to their own previous status.
Virginia’s Child Outcomes Booklet
Introduction
This booklet provides guidance on assessing and rating child outcomes in early intervention, emphasizing the importance of culturally sensitive, functional, and comprehensive assessment methods.
CHAPTER ONE - Functional Assessment
The functional assessment process involves observing children in everyday settings to determine their skills and behaviors. It requires considering cultural and linguistic differences, using multiple sources and methods, and focusing on the child's actual functioning rather than solely on standardized test results.
CHAPTER TWO - Understanding the 7-Point Rating Scale
The rating scale ranges from 1 to 7, with 1 indicating the lowest level of functioning and 7 indicating age-appropriate skills. Ratings should reflect the child's typical performance in natural environments, considering assistive technology and cultural factors.
CHAPTER THREE - Determining Initial Ratings
Initial ratings are based on the child's current skills at entry into early intervention. Team members should gather comprehensive information from various sources to accurately assess the child's starting point.
CHAPTER FOUR - Determining Annual Ratings
Annual ratings evaluate the child's progress over the year. The team considers gains in skills, regression, and the child's functioning across different settings. Progress is measured relative to the child's previous level, not solely against peers.
CHAPTER FIVE - Determining Exit Ratings
Exit ratings reflect the child's skills at the conclusion of early intervention. The team assesses whether the child has achieved age-appropriate functioning or made sufficient progress to meet expected outcomes.
CHAPTER SIX - Special Circumstances in Functional Assessment and the COS Process
1. The Inclusion of the Family’s Cultural Values, Beliefs and Practices
When assessing young children, practitioners must be sensitive to cultural and linguistic differences. A quality Child Outcomes Summary (COS) process involves using assessment methods that observe children in everyday settings.
Most formal assessment tools are not culturally sensitive, so family-centered and function-based assessments are essential. Multiple methods and sources help obtain a comprehensive picture of the child's functioning.
Assessment strategies should be tailored to each child, considering the family’s culture, beliefs, and values. It is critical to obtain an unbiased view of the child's abilities to distinguish between developmental delays and cultural or linguistic differences.
Team members need to understand how cultural practices influence the development of certain skills. For example, some cultures do not expect independence in feeding or sleeping arrangements, which should not be viewed as delays.
For more information, a study from Canada, *Cross-Cultural Lessons: Early Childhood Developmental Screening and Approaches to Research and Practice*, highlights cross-cultural lessons and factors influencing screening outcomes for immigrant and refugee children.
2. The Use of Assistive Technology
Assistive technology includes devices used by individuals with disabilities to participate in routines and activities. This ranges from adaptations like spoons and sippy cups to specialized devices such as switch interfaces and wheelchairs.
Ratings should reflect the child's functioning with the assistive technology used in daily routines. If technology is available in some environments but not others, the child's functioning should be rated accordingly, based on actual use across settings.
For example, consider a child who wears glasses, uses hearing aids, or uses a walker. The child's functioning should be assessed with these devices in place, acknowledging variability across environments.
3. Prematurity
In Virginia, children born prematurely are assessed using their *adjusted age* for eligibility and service planning. However, the Child Outcomes Summary ratings are based on chronological age.
Using chronological age provides a clearer picture of the impact of early intervention, showing how prematurely born children catch up over time.
4. Toilet Training
Determining age-appropriate toileting skills can be complex, especially considering cultural differences. The assessment tools, such as ELAP, typically begin scoring toileting at 18 months, but expectations vary.
The American Academy of Pediatrics (AAP) states there is no specific age to start toilet training. Most children achieve bowel and daytime bladder control by 3-4 years, with nighttime control often taking longer.
In 2003, the average age for toilet training in the U.S. was 37 months. Despite this, outcome ratings should not be influenced by toilet training status, as per current guidelines, to ensure accurate reflection of age-appropriate skills.
Providers may record toileting progress but must not factor it into outcome ratings. Toilet training may still be a family concern and addressed in IFSP outcomes.
5. Atypical Functioning
Some children display behaviors that are not delays but are atypical, such as self-stimulation, perseveration, or strict rituals. These behaviors are uncommon and markedly different from peers.
The team must evaluate how these behaviors impact the child's functioning across settings. For example, excessive self-stimulation may interfere with social interactions and learning.
It is important to consider both atypical behaviors and the child's strengths. For instance, a child may be overly focused on cars but still interact well with books and puzzles.
End of Document
Virginia’s Child Outcomes Booklet
Introduction
provide good descriptions of past events. When deciding a rating in an outcome area, the team needs to examine the entire repertoire of the child’s skills and determine which are and are not age-appropriate.
CHAPTER ONE - Functional Assessment
This professional development resource is supported by the Integrated Training Collaborative (ITC), with grant funding support from the Virginia Department of Behavioral Health and Developmental Services (DBHDS), Part C Early Intervention.
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CONTINUOUS from referral throughout the early intervention experience
COLLABORATIVE PROCESS building and maintaining rapport and relationships among early intervention team members including the service providers and family members/caregivers
OBSERVING observations, including videos, of the child in the home and in other natural environments
ASKING MEANINGFUL QUESTIONS promoting a conversation with the family using open-ended questions to convey respect that enhances family-centered services
LISTENING connecting with the family to gain a comprehensive understanding of their priorities and concerns based on their resources, values and culture
ANALYZING putting together information about the child from all sources (parent report, observation, age-anchored assessment tool, etc.) in order to understand the child’s functioning compared to same age peers
NATURALLY OCCURRING the activities and routines the child participates in that are unique to the family’s culture, community, and values
MULTIPLE SITUATIONS AND SETTINGS a skill becomes mastered when a child is able to do it in multiple places with multiple people
Functional Assessment
Functional assessment is a continuous collaborative process that combines observing, asking meaningful questions, listening to family stories, and analyzing individual child skills and behaviors within naturally occurring everyday routines and activities across multiple situations and settings.
Role of the Family in Outcome Summary Discussions
The family plays several important roles in Virginia’s Child Outcome Summary Process, including team member, child information provider and decision tree participant.
Infant & Toddler Connection of Virginia Child Outcomes Summary Process
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Team Member: Just as families are members of IFSP teams, they are critical to the assessment team.
Information Provider: Child Outcome ratings rely on information about a child’s functioning across situations and settings. Parent input is crucial: family members see the child in situations that professionals do not. The rest of the team will need to learn what family members know about the child—what the child does at home, at grandma’s house, in the grocery store, etc.
Participant in Summary Discussions: As members of the IFSP team, families are natural participants in the outcome summary discussion. Their role in the summary discussion is child expert, while other members of the team will know child development and the skills and behaviors expected at various age levels.
The Decision Tree
The decision tree is a guide to help teams reflect on the questions they need to answer to reach a summary statement and helps the team use the criteria consistently to decide between summary statements.
Virginia’s Child Outcomes Booklet - Summary and Important Documents | 17
Definition of Functional Assessment
This professional development resource is supported by the Integrated Training Collaborative (ITC), with grant funding support from the Virginia Department of Behavioral Health and Developmental Services (DBHDS), Part C Early Intervention.
CONTINUOUS from referral throughout the early intervention experience
COLLABORATIVE PROCESS building and maintaining rapport and relationships among early intervention team members including the service providers and family members/caregivers
OBSERVING observations, including videos, of the child in the home and in other natural environments
ASKING MEANINGFUL QUESTIONS promoting a conversation with the family using open-ended questions to convey respect that enhances family-centered services
LISTENING connecting with the family to gain a comprehensive understanding of their priorities and concerns based on their resources, values and culture
ANALYZING putting together information about the child from all sources (parent report, observation, age-anchored assessment tool, etc.) in order to understand the child’s functioning compared to same age peers
NATURALLY OCCURRING the activities and routines the child participates in that are unique to the family’s culture, community, and values
MULTIPLE SITUATIONS AND SETTINGS a skill becomes mastered when a child is able to do it in multiple places with multiple people
Functional Assessment
Functional assessment is a continuous collaborative process that combines observing, asking meaningful questions, listening to family stories, and analyzing individual child skills and behaviors within naturally occurring everyday routines and activities across multiple situations and settings.
Role of the Family in Outcome Summary Discussions
The family plays several important roles in Virginia’s Child Outcome Summary Process, including team member, child information provider and decision tree participant.
Infant & Toddler Connection of Virginia Child Outcomes Summary Process
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Family Member: Just as families are members of IFSP teams, they are critical to the assessment team.
Information Provider: Child Outcome ratings rely on information about a child’s functioning across situations and settings. Parent input is crucial: family members see the child in situations that professionals do not. The rest of the team will need to learn what family members know about the child—what the child does at home, at grandma’s house, in the grocery store, etc.
Participant in Summary Discussions: As members of the IFSP team, families are natural participants in the outcome summary discussion. Their role in the summary discussion is child expert, while other members of the team will know child development and the skills and behaviors expected at various age levels.
The Decision Tree
The decision tree is a guide to help teams reflect on the questions they need to answer to reach a summary statement and helps the team use the criteria consistently to decide between summary statements.
Virginia’s Child Outcomes Booklet - Summary and Important Documents | 19
Documenting Outcome Ratings
These questions can be used to guide the discussion with the family from the initial contact through the completion of the assessment for service planning. This is not intended to be comprehensive, and not all statements will apply to all children.
Familiarity with child development is necessary in order to understand the statements and how to apply them to each child and family.
Sample Questions for Child Outcome Ratings
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Tell me how (child): Provide Functional Examples
• communicates his/her feelings
• interacts with parents
• interacts with other known adults
• interacts with siblings
• interacts with other children
• responds to new people/strangers
• uses greetings (hi/bye)
• engages others in play
• responds to new places
Does parent have any concerns in this area?
• plays with toys (what toys and for how long)
• imitates what he/she sees others do
• imitates what he/she hears others say
• learns new skills and uses these skills in play
• responds to directions
• understands language (including prepositions)
• communicates (from cooing to using sentences)
• solves problems/figures things out
• remembers familiar play routines
• interacts with books
Does parent have any concerns in this area?
• moves around to get what he/she wants (toys, family, etc.)
• uses hands to play with toys
• uses hands to feed him/herself
• participates in feeding/eating (including utensils)
• participates in dressing
• sleeps
• uses the potty
• communicates wants and needs (requests)
• follows rules related to safety (holds hands, stops, understands “hot,” etc.)?
Does parent have any concerns in this area?
Decision Tree for Child Outcomes Summary Process
Based on All Assessment Information
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Is the child using functional skills that are close to age expected functioning?
Is the child showing age expected functional skills in all aspects of this outcome and across all settings and situations?
NO
YES
NO
YES
To what extent does the child use functional skills that are close to age expected across settings and situations?
To what extent is the child using age expected skills across settings and situations?
Are there any concerns about the child’s function with regard to this outcome area?
Child is beginning to show some of the early skills that are necessary for development of more advanced skills in this area.
Child uses many important skills that are necessary for more advanced skills.
Child shows many age expected skills. He also continues to show some skills that might describe a younger child.
Child shows occasional use of some age expected skills - or only some aspects of the skills.
YES
NO
Consider statements 1-3
NO
YES
Consider statements 4-7
NOTE: Performance of an age expected skill that emerges at a younger age is not sufficient by itself to answer yes to this question.
Does the child ever function in ways that would be considered age expected with regard to this outcome?
Let’s think about some examples
1. Child has the very early skills in this area. This means that child has the skills we would expect for a much younger child.
2. Child is beginning to show some of the early skills that are necessary for development of more advanced skills in this area.
3. Child uses many important skills that are necessary for development of more advanced skills; he is not yet showing skills used by other children his age in this area.
4. Child shows occasional use of some age expected skills. He has more skills of a younger child in this area.
5. Child shows many age expected skills. He also continues to show some skills that might describe a younger child in this area.
6. Child has the skills that we would expect in this area. There are some concerns with [area of concern/ quality/ lacking skill].
7. Child has all the skills that we would expect in this area.
Virginia’s Child Outcomes Booklet - Resources
The Early Childhood Technical Assistance Center (ECTA) provides an array of resources on quality practices for the Child Outcomes Summary. Specific resources include checklists and a video library.
Virginia’s Child Outcomes Booklet
Introduction
http://ectacenter.org/eco/pages/costeam.asp Age Anchoring Guidance for Determining Child Outcomes Summary (COS) Ratings is available from ECTA to answer commonly asked questions about age anchoring and examples of how the guidance applies in practice.
http://ectacenter.org/~pdfs/eco/COS_Age_Anchoring_Guidance.pdf
The Measure of Engagement, Independence and Social Relationships-Child Outcome Summary Form (MEISR-COSF) is available from ECTA. The MEISR-COSF assesses functional skills in the context of the child’s everyday activities and routines and is anchored not only by developmental domains but also by the three child outcome areas.
http://ectacenter.org/~pdfs/meetings/data2014/MEISR_May-2014-DNC.pdf
Definition of Functional Assessment
https://veipd.org/main/pdf/def_of_func_assess_9.10.18.pdf
Functional Assessment: Examples of Questions to Ask Families
This handout provides examples of questions an EI practitioner might ask a parent/caregiver to gather detailed information about a child’s functional abilities during different routines.
https://drive.google.com/file/d/1rGOdI0QuV37P8sVlmnNg06KkdKxMWazl/view
Assessment for Service Planning Notes Template
This template can be used to collect information during the assessment that will assist team members when reporting the results to the family according to the global child outcomes while using a functional assessment approach.
https://veipd.org/main/doc/asp_notes_template.docx
Videos
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http://ectacenter.org/eco/pages/costeam-videolibrary.asp
Child Outcomes Step-by-Step http://ectacenter.org/eco/pages/videos.asp
This video offers a consistent way to describe the three child outcome areas for providers and parents.
Parent Reaction to Engaging in the Process https://www.youtube.com/watch?v=lB9hiIoegCw&feature=youtu.be
Providers’ Reactions Engaging Families in the COS Process https://www.youtube.com/watch?v=j5pdmyTs4co&feature=youtu.be
CHAPTER EIGHT Resources
Virginia’s Child Outcomes Booklet - Resources | 23
ATTACHMENT A: Functional Skills by Outcome
The ITCVA strongly recommends the MEISR as an anchor tool since it assesses functional skills in the context of the child’s everyday activities and routines and is anchored not only by developmental domains but also by the three child outcome areas.
The MEISR-COSF Tool is a revision of the MEISR with functional skills organized by the three child outcomes and then by routine and age ranges. The MEISR-COSF, therefore, provides an opportunity for consistency and shared understanding about what functional skills fall under each outcome area … even if you are using a different assessment instrument.
Please click on this link to review the functional skills by outcome area: MEISR-COSF
Once you click on the link, since the purpose of including the MEISR-COSF in this booklet is to consistently define the functional skills that fall into each outcome area, you can focus on the skills column and the “Age in Months” column.
Please note that the ages included are beginning ages. They are not norm referenced - rather they are derived from other tools and sources.
24 | Virginia’s Child Outcomes Booklet - Resources
Adult Outpatient Competency Restoration Guidelines (6311_FOR 04.pdf)
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
Developed by Virginia’s Department of Behavioral Health and Developmental Services Office of Forensic Services February 2017
Introduction / Overview
If a criminal court finds that a defendant is incompetent to stand trial pursuant to Virginia Code section § 19.2-169.1, the court will order that the defendant receive treatment to restore their trial competence.
The Code requires that the court first consider ordering restoration services on an outpatient basis unless the court specifically finds that the defendant requires inpatient hospital treatment.
"Outpatient" and "community-based" are terms used interchangeably to describe restoration services that take place in a setting other than an inpatient hospital, including both the jail and larger community setting.
With the addition of this language regarding the court’s consideration of the “least restrictive” setting for competency restoration, came the need for a system for the provision of restoration services in the community.
The Department of Behavioral Health and Developmental Services (DBHDS), in partnership with Community Services Boards (CSBs)/Behavioral Health Authorities (BHAs), created a mechanism for courts to refer appropriate restoration cases to the local CSB/BHA for outpatient restoration.
As a result of this new process, DBHDS has also developed a training course for CSB/BHA staff who will be assigned to provide restoration services in their locality.
This manual is provided to the CSB/BHA staff as a tool for working with defendants who have been ordered to participate in outpatient competency restoration.
We encourage you to take advantage of the forensic expertise available at the DBHDS Forensic Services Office and in each of our DBHDS facilities.
A list of these individuals is provided in this reference manual.
The Office of Forensic Services will be offering Adult Outpatient Competency Restoration Training for CSB/BHA staff in conjunction with the dissemination of this manual.
Please contact Sarah Shrum (804-786-9084 or sarah.shrum@dbhds.virginia.gov) at the DBHDS Forensic Services Office if you are interested in training or a copy of this training manual.
Section 1: Restoration Training Presentations
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Session 1 - Competency to Stand Trial: History, Law, & Clinical Practice Pg. 1
Session 2 - Beginning Services: Assessment & Case Management Pg. 10
Session 3 - Creating a Restoration Plan Pg. 19
Session 4 - Practical Strategies for Overcoming Barriers to Restoration Pg. 29
Session 5 - Concluding Restoration: Knowing When It’s Over Pg. 36
Section 2: Small Group Work & Case Studies
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Small Group Work Instructions Pg. 53
Case Study #1 Pg. 55
Case Study #2 Pg. 65
Case Study #3 Pg. 75
Restoration Case Plan Format Pg. 85
Restoration Case Planning Sample Language Pg. 86
Section 3: Orientation for CSB/BHA Restoration Counselors
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Current Legal & Professional Criteria for Competency Pg. 87
Practical Tips Pg. 87
Steps in the Outpatient Restoration Process Pg. 89
Getting Started - Working with the Defendant Pg. 90
Pre-Test for Competency Pg. 92
Confidentiality Pg. 93
Section 4: Competency Restoration Court Orders
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Sample Restoration Order #1 Pg. 95
Sample Restoration Order #2 Pg. 97
Section 5: Providing Restoration Services to the Defendant
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Explaining the Purposes of Restoration Pg. 99
Explaining Legal Rights Pg. 99
Explaining Charges, Penalties, and Evidence Pg. 100
Explaining Pleas and Plea Bargains Pg. 101
Explaining Criminal Penalties and Plea Outcomes Pg. 104
Explaining Courtroom Personnel Pg. 107
Assisting Your Defense Attorney Pg. 108
Explaining the Trial Process Pg. 111
Explaining Appropriate Courtroom Behavior Pg. 112
Courtroom Diagram Pg. 114
Section 6: When is Restoration Over & What’s Next?
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Assessing Restoration Services Completion: Restoration Counselor Pg. 115
Next Steps for the Restoration Coordinator Pg. 116
Next Steps for CSB Executive Director/Designee Pg. 116
Post-Test for Competency Pg. 118
Section 7: Letters to the Court
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Sample Letter 1: Defendant is Competent Pg. 121
Sample Letter 2: Defendant is Incompetent but Restorable Pg. 122
Sample Letter 3: Defendant is Unrestorable Pg. 123
Sample Letter 4: Defendant is Unrestorable and Needs SVP Evaluation Pg. 124
Sample Letter 5: At Assessment Defendant Needs Inpatient Restoration Pg. 125
Sample Letter 6: Started Restoration but Defendant Needs Inpatient Pg. 126
Sample Letter 7: Unable to Locate Defendant Pg. 127
Sample Letter 8: Defendant is Too Sick to Complete Outcome Evaluation Pg. 128
Section 8: Relevant Virginia Code Sections
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Raising the Question of Competency to Stand Trial & Initial Evaluation Pg. 129
Disposition When Defendant is Found Incompetent Pg. 131
Disposition of an Unrestorably Incompetent Defendant Pg. 132
Certification to Training Centers for Unrestorable Defendants Pg. 134
Involuntary Commitment for Unrestorable Defendants Pg. 136
Relevant Code Definitions Pg. 138
Disposition of Unrestorable Defendants with Sexually Violent Offenses Pg. 139
Registration of Defendants with Sexually Violent Offenses Pg. 141
Charges Considered Sexually Violent Offenses Pg. 142
Section 9: Tools and Resources Summary and Supplements
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Summary of Tools & Resources Pg. 143
“Going to Court” Motion Graphic Video & English/Spanish Lesson Plans Pg. 144
Using “DJ and Alicia” Interactive Video on CD-ROM Pg. 193
Section 10: Guidelines for Restoration Services Payments
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Definitions for Outpatient Restoration Services Pg. 195
Outpatient Restoration Services Flow Chart Pg. 198
Outpatient Restoration Payment Guidelines Pg. 199
Adult Outpatient Competency Restoration Services Report Pg. 201
Section 11: Glossary & Helpful Contacts
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Glossary of Legal Terminology Pg. 203
DBHDS Facility & Central Office Staff Pg. 210
Section 1: Restoration Training Presentations (Repeated Section Title for Emphasis)
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Session 1 - Competency to Stand Trial: History, Law, & Clinical Practice Pg. 1
Session 2 - Beginning Services: Assessment & Case Management Pg. 10
Session 3 - Creating a Restoration Plan Pg. 19
Session 4 - Practical Strategies for Overcoming Barriers to Restoration Pg. 29
Session 5 - Concluding Restoration: Knowing When It’s Over Pg. 36
Section 2: Small Group Work & Case Studies (Repeated Section Title for Emphasis)
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Small Group Work Instructions Pg. 53
Case Study #1 Pg. 55
Case Study #2 Pg. 65
Case Study #3 Pg. 75
Restoration Case Plan Format Pg. 85
Restoration Case Planning Sample Language Pg. 86
Exercise #1 - Training Day 1
Your class will be divided into equal groups, and each group will be assigned to work on one of the case samples in this section.
In the first breakout session, your group should review your assigned case sample and discuss the areas that a competency restoration counselor will be focused on when providing restoration services.
You will be provided a pad for recording your thoughts about the topics below.
Each group should assign a reporter who will share the outcomes of the exercise when the larger group reconvenes on day 2 for report-out.
The small group should address the following issues:
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What are the potential challenges for this individual?
Behavioral health issues
Motivational issues
Impediments to competency
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Psychiatric
Educational
Case management
Obtaining and reviewing collateral
Collateral Interviews
Exercise #2 - Training Day 2
Using the same case example, your small group will now start the process of developing a more detailed restoration plan, including the tools and resources that you might use in the provision of restoration services to that individual.
Once again, you will be provided a pad of paper to record your responses.
At the end of the second small group exercise, each group will report out on its findings and restoration plan.
Make sure to address the following questions in the second small group exercise:
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With regard to interventions, how frequently would you meet, what types of interventions, which modalities (video, role play, “lecture”)?
How would you go about assessing progress?
How would you know when you had achieved treatment goals?
Any other unique challenges/barriers they foresee in working with this individual?
A sample restoration plan format is included in Section 3 of your binder; please use that format as a guide for developing your restoration plan and answering the questions above.
Your small group will work for 45 minutes on this exercise.
One faculty member will be assigned to your group to help guide, answer questions, etc.
Sample Competency Evaluation #1
April 8, 2014
The Honorable Judge Ima Nutral
Anytown Circuit Court
Anytown, VA
RE: Commonwealth v. Cecil Doe
Dear Ms. Fender:
Pursuant to your court order dated March 25, 2013, we have completed an evaluation of Cecil Doe’s competency to stand trial.
As you know, Mr. Doe is a 59-year-old male who has been charged with five counts of simple assault.
We met with Mr. Doe on April 1, 2013, for approximately four hours.
At the beginning of the evaluation, we informed Mr. Doe about the nature, scope, and purpose of the evaluation, including the relevant limits of confidentiality and privilege.
He was told that the evaluation was being conducted on motion of the Defense, and that a copy of the ensuing report will be sent to defense counsel, the Commonwealth’s Attorney, and the court (as required by Virginia Code Section 19.2-169.1).
Mr. Doe appeared able to demonstrate a rudimentary understanding of these arrangements and the limits to confidentiality.
He then agreed to participate in the evaluation.
SOURCES OF INFORMATION
During the evaluation, Mr. Doe participated in a general clinical interview as well as an interview specifically addressing competency to stand trial.
In addition, we relied on the following sources of information:
[Source list omitted for brevity]
RELEVANT BACKGROUND INFORMATION
[Note: Report is shorter than usual to facilitate training exercise] Family, Developmental, and Social History
Cecil Doe was born on January 1, 1955, in Abingdon, Virginia, where he remained through adulthood.
He was the eighth of nine children in his family.
He reported that he and his siblings had good relationships as children; however, he stated that he has had little contact with them as an adult, with the exception of the sister with whom he lives.
Beyond this basic information, Mr. Doe appeared to be a poor historian who tended to report few details and described his history, relationships, and school performance as “so-so.”
He stated several times that “there was nothing to complain about…because what’s the point of complaining.”
Therefore, the accuracy of the early history and relationships he described is unclear.
Mr. Doe reported that he has lived with family his entire life.
He indicated that he lived at home with his parents until he was approximately 19 or 20 years old, at which time he moved to live with an older sister, and continued living with her for several decades until his arrest.
He stated that he did not pay rent, but when he was employed he would give his income to his aunt to help with expenses.
However, Mr. Doe indicated that he has never taken primary responsibility for shopping for groceries or other necessities nor has he ever had responsibility for managing family money and bills.
Regarding education and career, Mr. Doe reportedly attended school only into the ninth grade.
During our interview, he stated that he had no history of special education or special services.
However, the available records indicate that Mr. Doe attended special education classes.
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
throughout most of his schooling, due to his unusually low performance on intelligence tests and his poor ability to achieve academically. Specifically, records suggest that Mr. Doe was retained for a second year in the first grade, then transferred to the second grade, but was recommended for special education.
Records indicate that he transferred to a “trainable mentally retarded” status rather than remaining in an “educable mentally retarded” class. His teachers often described him as pleasant, hardworking and helpful, but talkative and unable to make noticeable academic progress.
After leaving high school, Mr. Doe reportedly continued living at home with his parents and did not initially obtain a job. Only after he moved into his sister’s home as an adult did Mr. Doe obtain a job, working at a lumber company saw mill for approximately nine years.
According to Mr. Doe, he was fired after arguing with his employer about an instance of equipment malfunction, then eventually obtained another job working with his nephew at a landfill.
In short, Mr. Doe appeared to have much less formal employment than other men his age, and his two instances of employment ended unsuccessfully.
According to Mr. Doe, he has not held a job since working at the landfill, but he does not receive SSDI.
When asked how he provides for himself financially, he reported that he does not need money because he does not pay rent to his sister, his sister provides groceries, and he generally does not spend money.
Mr. Doe reported that he has never had his own bank account and has never had primary responsibility for shopping for groceries or clothing, although he did sometimes accompany his aunt or wife on shopping trips. 1
Only a small portion of his school records were available, because school policy requires destruction of certain records five years after a student leaves the school district. Nevertheless, those that were available consistently indicated substantial deficits in intellect and school performance.
Medical History
Mr. Doe reported a limited medical history. He stated that he never had any serious illnesses or injuries requiring lengthy treatment or hospitalization.
He reported sustaining a head injury that led to unconsciousness when he was thrown from a horse while in his twenties, but received only brief medical care thereafter.
Mental Health History
Mr. Doe denied any history of mental health services. He reported never undergoing outpatient or inpatient psychiatric care.
With regard to alcohol use, Mr. Doe reported that he started drinking in his late twenties. He stated that he typically drank beer, approximately a pint at night when he could not sleep, and infrequently drank liquor.
He maintained that his drinking had never led to loss of memory or consciousness, or caused other significant problems.
He reported no illegal drug use, and there was nothing in records to contradict this account.
CURRENT CLINICAL STATUS
Mr. Doe arrived, escorted by jail staff, in a standard issue striped jumpsuit, with adequate grooming.
He appeared older than his chronological age. Although generally cooperative with the interview, his interpersonal and response styles were curt and abrupt, though not overtly rude.
He often answered quickly with, “I don’t know,” and he rarely gave answers longer than a few words.
When asked about the quality of experiences or relationships, he gave brief, neutral replies such as “so-so” or “alright.”
With encouragement and further questioning, he was able to provide additional details in some instances, but in others he maintained that he simply could not recall with any specificity.
Mr. Doe was oriented to person and generally oriented to time (he correctly identified the month, but not the day or date).
He demonstrated difficulty with orientation to place, although it appeared that some of his answers were due to poor understanding rather than disorientation (e.g., he confused the distinction between country, state, and city).
Mr. Doe’s statements were linear, logical, and goal-directed, but unusually concrete in content.
He demonstrated difficulty with understanding and explaining abstract concepts throughout the interview.
Mr. Doe’s speech was normal in rate, given his brief response style, and loud in volume.
Mr. Doe described his current mood as “so-so,” explaining that he has “up and down days.”
He became tearful and reported that he was feeling sad during the interview because it was difficult talking about family.
Mr. Doe reported that he rarely experienced a sad mood in the past. He stated that he has had thoughts about harming himself infrequently, but could not provide insight into his thinking around those times, and denied current suicidal ideation.
He denied symptoms of mania (i.e., elevated highly-energized mood).
Mr. Doe denied experiencing delusions (i.e., fixed, false beliefs) and demonstrated no evidence of paranoia or suspiciousness.
He also denied auditory and visual hallucinations (i.e., unusual sensory experiences), and did not appear to be responding to internal stimuli during the current interview.
Overall, interview revealed little indication of psychiatric illness other than depressed mood.
But interview revealed much more evidence of serious intellectual deficits, consistent with his records.
Based upon Mr. Doe’s reported symptoms, records, and presentation during the current interview, he does not appear to meet criteria for any psychiatric illnesses.
Although he has periods of sad mood currently, he denied other symptoms of major mood disorders (e.g., poor sleep, restlessness, elevated mood and energy).
In contrast, information gathered from Mr. Doe’s self-report, records, and presentation appeared consistent with intellectual disability (formerly called mental retardation).
It is important to note that formal intellectual and adaptive functioning testing were not undertaken during the current assessment; these would be necessary to assign a formal diagnosis of mental retardation.
Nonetheless, Mr. Doe’s educational history reveals significant intellectual deficits, and his overall history appears to demonstrate deficits in adaptive functioning (e.g., dependency upon family for housing and needs, limited employment history, limited social interaction outside his family, lack of basic financial skills).
Moreover, intellectual impairments are documented from his childhood, consistent with the criterion of onset before age 18 years.
Given these data, it appears quite likely that Mr. Doe has intellectual deficits that rise to the level of intellectual disability.
COMPETENCE TO STAND TRIAL
Generally, Mr. Doe’s interview addressing trial competence was shorter than similar interviews with other defendants because of his brief and concrete response style.
As in other portions of the interview, Mr. Doe tended to respond quickly with short, equivocal replies, and he tended not to provide much additional detail with further questioning.
He repeated several times that he did not know much about court because he had never been to court.
In general, he appeared able to handle simple and concrete information, but less able to understand, explain and discuss abstract questions or concepts.
Factual and Rational Understanding
Overall, Mr. Doe appeared to have a marginal factual understanding of the charges against him.
When asked about his charges, he responded, “they said I hit them boys.”
Mr. Doe provided only the most basic description of the circumstances surrounding the allegations against him, and seemed confused about some basic facts (e.g., the location and date of the alleged offense).
He stated that the charges were serious, although he could not articulate a reason why they were serious, repeating, “they said I got six charges against me.”
When asked if he could think of a charge that would be more serious than assault, he replied that he did not know, though when asked whether murder would be more serious than rape, he stated, “I reckon, but I never did that.”
He continued to emphasize throughout the interview the seriousness of his current charges in the general sense that they have resulted in his involvement in the legal system, and that he had no prior involvement with the legal system.
Mr. Doe was able to recall being in court twice pertaining to his current charges but could not convey even basic explanations for those appearances, instead posing questions such as “why didn’t they fix all this already back then?”
Through direct, close-ended questions, Mr. Doe was able to state the pleas available to him.
He defined guilty as meaning “you done it” and not guilty as meaning “you ain’t done it.”
When asked if a defendant can plead not guilty even though he did the crime, Mr. Doe answered that the defendant cannot do so.
Mr. Doe recognized that pleading guilty in a case like his could lead to imprisonment; however, when asked if he would have a trial if he pled guilty, he stated that he did not know.
When asked if he thought a trial would be needed when a defendant pleads guilty, he appeared confused and stated, “no…yes…they always make you go to a trial.”
He did, however, recognize that a trial would follow a plea of not guilty.
We re-explained the pleas and their consequences to Mr. Doe at this point, and he appeared to understand the basic procedural information.
But after discussing other competence-related subjects, we asked Mr. Doe about these details again and he still appeared to have difficulty recalling when a trial occurs or does not occur.
It appeared that Mr. Doe was able initially to understand new information, but had difficulty retaining it amid discussion of other matters.
At a basic level, Mr. Doe recognized the concept of sentencing, stating that the type of punishment a defendant receives “depends on the crime he done.”
However, he demonstrated confusion about what might be possible sentences in his own case, estimating a prison term far longer than he could actually receive.
Regarding courtroom personnel, Mr. Doe was able to recognize some personnel and their roles.
For example, he was aware that his attorney would “defend [him]” and that her goal is to “get the court to say not guilty.”
Mr. Doe reported that the prosecutor’s job is to “get you found guilty.”
Despite recognizing their roles, he failed to give any other indication that he recognized the adversarial nature of legal proceedings.
Rather, he simply and repeatedly stated, “they all talk to the judge” when asked any more specific questions about how they might proceed.
Mr. Doe described the judge’s job as to “give a sentence,” but he expressed confusion about the judge’s neutral role, and implied that the judge would assume guilt before proceedings began.
Efforts to correct Mr. Doe’s factual misunderstandings were sometimes unsuccessful, because he became irritable and apparently defensive, offering statements like “I just wanna get this done with.”
Mr. Doe had difficulty explaining that evidence is used at trial, but was able to respond to more concrete questions in a way that indicated he understood one or more of the alleged victims may be in court to describe the alleged offense.
He expressed a limited understanding of plea bargaining (“they just make a deal”), and focused on the benefit of not going to trial and “getting it done with.”
However, when asked about a hypothetical plea bargain, Mr. Doe appeared to base his answer on his general distress around the criminal justice system, rather than reasoning about precise sentence lengths and outcomes.
Ability to Assist Counsel
Based on our interview alone, Mr. Doe appeared to have the basic motivation necessary to assist counsel, at least theoretically.
For example, he was able to identify his attorney by name, conveyed that he trusted his attorney, and noted that he was willing to work with his attorney.
However, collateral interviews
[SIZE=36]Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities [SIZE=27.98]Introduction / OverviewThis manual provides guidance for restoring competency in adult defendants through outpatient services, emphasizing the importance of tailored interventions based on individual assessments and needs.
[SIZE=27.98]Section 1: Restoration Training PresentationsThis section includes educational presentations designed to inform defendants about the legal process, their rights, and the nature of their charges, aiming to improve understanding and cooperation.
[SIZE=27.98]Section 2: Small Group Work & Case StudiesEngagement in small group activities and analysis of case studies to enhance comprehension of legal concepts, improve communication skills, and foster peer support during restoration.
[SIZE=27.98]Section 3: Orientation for CSB/BHA Restoration CounselorsGuidelines and training for counselors working with defendants, focusing on effective communication strategies, assessment techniques, and individualized treatment planning.
[SIZE=27.98]Sample Case Summaries and Evaluations Sample Competency Evaluation #1Evaluation of a defendant with mild intellectual disability and associated legal understanding deficits.
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Demographic: 59-year-old male
Charge(s): 5 counts of simple assault
Background: Resided with family; family responsible for rent, groceries, bills; married; no significant medical history except possible head injury from being thrown from a horse in his twenties; developmental history unknown but classified as “trainable mentally retarded” in special education; dropped out of school in 9th grade; inconsistent, unsuccessful employment history.
Mental Health History: No history of receiving mental health services; no substance abuse history.
Interview: Cooperative, brief answers; difficulty with abstraction; acknowledged sad mood but denied symptoms of mood or psychotic disorder; presentation consistent with mild intellectual disability; became irritable, expressed frustration, repeatedly stated desire to “get this done with.”
Competence-Related Interview: Brief, concrete responses; simple description of charges; could not understand the seriousness of charges; did not grasp purpose of court appearances; required direct questioning; did not retain legal information after education; lacked understanding of courtroom roles and adversarial process; impaired reasoning when considering hypothetical plea deal; reports irritability and cutting meetings short when discussing unpleasant outcomes.
Conclusions Regarding Competence: Marginal factual understanding; did not grasp legal concepts; irritability and frustration impair rational decision-making; difficulty retaining new information; not competent to stand trial; outpatient restoration recommended, addressing factual knowledge and distress about legal charges, including possible depression symptoms.
Evaluation of trial competence for Jay Smith, a 23-year-old male charged with Trespassing, Disorderly Conduct, and Simple Assault.
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Evaluation Date: April 29, 2014
Court: Anytown Circuit Court, VA
Summary: Met with Mr. Smith for approximately three hours; explained evaluation purpose; obtained informed consent; used multiple sources including clinical interview, social, school, psychiatric, and court records.
Background: Born January 1, 1991; oldest child; parents separated; developmental milestones met; mild delays in speech and motor skills as a toddler; placed in custody of paternal grandmother due to parental neglect; history of unstable living arrangements; close relationships with siblings and grandparents.
Medical History: Unremarkable except childhood hospitalization after automobile accident; no long-term consequences noted.
Educational and Employment History: Attended special education preschool; mediocre middle school performance; failed classes in high school; withdrew at age 17; obtained GED three years later; worked in auto repair and informal jobs.
Substance Use: Light social drinking; regular marijuana use since age 15; tested positive for cannabis at arrest; no other drug use reported.
Legal History: Prior legal issues not detailed here.
This report is shortened for training purposes and omits detailed source lists and some specifics for confidentiality.
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
criminal history includes only charges for possession of marijuana (twice in adolescence and once as an adult). Records do not indicate that Mr. Smith has ever previously been incarcerated or participated in lengthy legal proceedings.
Mental Health History
Mr. Smith’s family history is notable for three close family members with psychiatric illness. Mr. Smith’s biological father has a lengthy history of long-term psychiatric hospitalizations and reportedly carries a diagnosis of schizophrenia. Mr. Smith’s biological mother has reportedly carried diagnoses of bipolar disorder, schizophrenia, and personality disorders. Finally, Mr. Smith’s youngest brother was hospitalized at the Commonwealth Center for Children and Adolescents on two occasions, both reportedly resulting from severe depression and possible psychotic symptoms.
Mr. Smith received testing for psychiatric symptoms as early as age 14, during a regular re-evaluation for Special Education eligibility. At that point, school staff assigned only a diagnosis of Attention-Deficit/Hyperactivity Disorder and Adjustment Disorder with Disturbance of Mood and Conduct.
At age 16 Mr. Smith began receiving services through his local Community Service Board, he reported. Although records were not available at the time of this writing, Mr. Smith reported that he received a diagnosis of Bipolar Disorder at age 17 and began trials of various antidepressant and mood-stabilizing medications.
However, he reported that he received services at the CSB less frequently upon reaching adulthood, and that he had obtained no services for over one year (again, formal records from the CSB were not available at the time of this writing).
According to our collateral interview with Mr. Smith’s grandmother, Mr. Smith has demonstrated significant mood variability (i.e., periods of apparent depression and periods of restlessness, minimal sleep, and excessive energy) since late adolescence.
However, he demonstrated what appeared (to her) to be increasing symptoms for approximately six months preceding his arrest. Specifically, she described Mr. Smith as demonstrating dramatic mood swings, staying up all night, frequently crying, exhibiting a depressed mood, and discussing suicide.
Furthermore, she reported that he developed an intense preoccupation with the Bible and literature from Jehovah’s Witnesses, though he had not expressed religious beliefs of any sort in the past.
She stated that Mr. Smith’s apparent symptoms worsened over the following months, and that he tended to “lecture” incoherently about the Bible, reincarnation, and what she described as unusual ideas with quasi-religious themes.
Records from Big Region Regional Jail and Mr. Smith’s attorney show that Mr. Smith was initially boisterous and energetic upon incarceration, speaking rapidly and continuously, primarily on religious topics.
Likewise, records maintained by defense counsel documenting their early meetings with Mr. Smith memorialize numerous statements and behaviors that appear consistent with psychiatric illness. For example, Mr. Smith reportedly instructed counsel “to call Jesus for real on the phone” so that Jesus “could strike down all this persecution and say-so.”
He also reportedly told counsel -- when they mentioned the possibility of hospitalization -- that he “will not subject [him]self to the government’s devils and blasphemers pretending to be doctors.”
According to jail records, however, Mr. Smith’s behavior became noticeably calmer in late February of this year, after the jail’s contracted psychiatrist prescribed mood-stabilizing and anti-psychotic medications.
Similarly, defense counsel acknowledged that his more outlandish statements have decreased, and he appears more calm and cooperative. Nevertheless, they emphasized that they have ongoing concerns about his competence, given his tendency to drift into monologues (primarily around religious themes) when speaking with them.
INTERVIEW AND CLINICAL STATUS
Mental Status and Behavioral Observations
Mr. Smith presented with an appearance that was slightly unkempt and malodorous (though apparently less so than in prior weeks, according to the jail staff). His affect, or emotional tone, varied considerably over the course of interviews.
Although the emotions that he expressed generally matched the content of his statements, they were somewhat more intense than emotions typically exhibited by defendants in similar conversations. He also interjected occasional laughter at statements that were not particularly humorous.
Despite jail staff reporting behaviors that appear typical of significant mania (i.e., sleeplessness, loud and boisterous “sermons,” pacing), Mr. Smith flatly denied experiencing mania or unusual energy.
He also eventually acknowledged some periods of depression in the past (prior to incarceration), including thoughts of suicide, but dismissed these with “that was another man; I was someone else then.”
Mr. Smith emphatically claimed that he had no current inclination toward suicide, but also “got no fear of death.”
In addition to denying depression, Mr. Smith also denied all other psychiatric symptoms about which we queried. Specifically, he did not exhibit any gross signs of hallucinations, such as responding to stimuli that were not present.
He also explicitly denied seeing or hearing stimuli that others do not see or hear.
Despite denying most symptoms of psychosis, many of his statements seemed frankly delusional. For example, he lamented that his fellow inmates were “like fools stuck in the current dimension with no mind to the superior dimensions.”
Although some of his ideas shared similarities with certain subsets of Christianity, he also incorporated some ideas from Eastern religion (i.e., repeated discussions of reincarnation or repeating a life because of errors in a past life), as well as some ideas that appeared unrelated to any organized religion.
Thus, his overall pattern of expressed beliefs appeared idiosyncratic, and was not attributable to any specific, shared religious belief system.
When queried about anxiety, he flatly denied any worry, even about pending legal proceedings (“I never worry about man’s word, only God’s,” he emphasized).
Interpersonally, Mr. Smith tended to be lively, engaging, and superficially friendly, but he often answered our questions with questions of his own and attempted to redirect conversation to idiosyncratic religious or philosophical matters.
This often came across as dismissing questions about legal matters and sometimes was explicitly dismissive (e.g., “I got no concerns about man’s courts; God’s gonna put them in their place, and me in my rightful place.”).
Regarding his style of speech, Mr. Smith often made circumstantial, meandering statements. For example, when asked about his understanding of the competence evaluation process, he stated, “I am ready for court, you got nothing more to ask me. Let’s just send me in there and God can vindicate me with a power.”
EVALUATION OF ADJUDICATIVE COMPETENCE
Factual and Rational Understanding of Legal ProceedingsOverall, Mr. Smith demonstrated only marginal legal knowledge and frequently strayed into philosophical and religious objections when asked about specific court personnel, procedures, and legal principles.
He often seemed uninterested when we attempted to provide education on these topics, dismissing the value or importance of the legal process.
Most of these dismissals involved his preference to discuss religious matters (and convey that court proceedings were relatively less important).
However, his dismissal of evaluation questions occasionally seemed to obscure a genuine lack of knowledge. For example, when queried about court personnel, Mr. Smith provided a rudimentary description of the judge’s role (“he’s like the boss, pretending he’s in charge of anything”), but initially confused the role of defense counsel and the Commonwealth’s Attorney.
When queried again, he became mildly frustrated and emphasized, “Look, no attorney defends me, only God defends me. None of these people matter that much to me.”
Although he could at times acknowledge, at least theoretically, that court proceedings are adversarial, he more often described both opposing sides as similarly inept (“Neither of them make much a difference in the end,” he summarized).
In some instances, Mr. Smith’s mischaracterizations of legal proceedings could be attributed to a belief system that simply devalued legal proceedings in favor of religious themes.
But at other times, he simply seemed to lack knowledge about some basic elements of legal proceedings. For example, he repeatedly failed to recognize that a trial was an effort to adjudicate guilt for a particular alleged offense; instead, he repeatedly characterized a trial as a broader effort to determine whether someone “is a good person or not.” Ability to Assist Counsel
Although Mr. Smith recognized that the general role of defense counsel is to represent the defendant, he tended to be dismissive of his own counsel.
He lamented that counsel “treats [him] like a child,” asking “all these court questions” and dismissing his own efforts to “seek vindication and restoration.”
The frustration and cynicism Mr. Smith expressed regarding defense counsel was entirely consistent with the report that defense counsel offered when we queried them about interactions with Mr. Smith.
For example, counsel reported that he often refused to discuss his case and instead perseverated on his religious beliefs or an idea that he was inappropriately persecuted.
CONCLUSIONS
Regarding psychiatric status, although there is limited information regarding Mr. Smith’s psychiatric condition as an adult in the community, the available evidence suggests that he manifested some symptoms of significant psychiatric illness during the period preceding his arrest and incarceration.
Specifically, collateral accounts indicate what appear to be symptoms of mania (a highly energized, elevated, and restless mood) as well as symptoms of psychosis, including delusions (fixed, false beliefs not based in reality) and bizarre behaviors.
These symptoms appeared to persist through his initial incarceration, though they have apparently decreased since he was medicated approximately six weeks ago.
Since then, his mood and behavior have appeared less highly energized, but he has continued to make unusual statements and emphasize idiosyncratic religious and philosophical beliefs.
This pattern and combination of symptoms could be attributable to any one of a few psychiatric conditions (e.g., bipolar disorder, schizoaffective disorder) that involve psychosis and alterations in mood.
Fortunately, assigning a precise diagnosis is not necessary to draw firm conclusions regarding the more circumscribed issue of his current ability to understand his legal proceedings and assist defense counsel.
Regarding competence to stand trial, Mr. Smith showed only a weak grasp of basic legal proceedings, and he often minimized his factual deficits by dismissing questions about legal matters and returning to lengthy discussions of his idiosyncratic beliefs.
Likewise, he was overtly dismissive of his own legal status as a criminal defendant and instead emphasized various beliefs, such as the belief that “God will vindicate [him] with a forcefulness.”
Similarly, Mr. Smith has consistently failed to demonstrate the capacity to work with his attorneys in his own defense.
He did not identify counsel as an ally in an adversarial legal process. Rather, he has appeared consistently annoyed with counsel and declined his attorney’s efforts to discuss the case in favor of his own efforts to discuss idiosyncratic religious matters.
Finally, his approach to mounting a defense is irrational. He is quick to dismiss the gravity of his situation and the standard steps in legal proceedings, based on his stated desire to “let
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
God vindicate [him] for properly spreading good words.” Given these data, it is our opinion that:
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1. Mr. Smith does not presently demonstrate the capacity to adequately understand the legal proceedings against him in a rational and factual manner.
2. Mr. Smith does not presently demonstrate the capacity to rationally collaborate with defense counsel or otherwise assist in his defense.
When opining that a defendant is not competent to stand trial, Virginia code also requires an opinion regarding prospects for remediation and appropriate location for remediation. In my view, Mr. Smith is a reasonable candidate for outpatient (i.e., jail-based) restoration efforts. Indeed, members of jail medical staff have already begun administering medication, and this appears to have resulted in some decrease in symptoms.
Ideally, any restoration efforts will involve collaboration with the staff administering medication and psycho-educational efforts to address the deficits in Mr. Smith’s factual understanding of legal proceedings. Although predictions regarding competence restoration are necessarily speculative, the majority of incompetent defendants are indeed restored to competence. I see no reason at present to conclude Mr. Smith could not regain the necessary capacities to stand trial.
Sincerely,
Sally James, Ph.D.
Forensic Psychologist
Anytown Clinic
CC: Ms. Dee Fender, Esq.
Office of the Public Defender Anytown, VA Mr. Luke Emallup, Esq. Office of the Commonwealth’s Attorney Anytown, VAREPORT SUMMARY SAMPLE CASE #2
Demographic:
23 year old male
Charge(s):
Trespassing, disorderly conduct, simple assault
Background:
Developmentally and medically typical except for mild speech and motor impairments warranting early intervention services. Automobile accident resulted in hospitalization in childhood, but no apparent lasting negative effects from that accident. Removed from parents’ custody at age two due to neglect. Placed with grandmother—stable home environment until mid-adolescence, when household destabilized and he rotated through various DSS placements and extended family members’ homes. Received special education services for speech, attention, and behavior problems. Mediocre academic performance. IQ was in the normal range. Dropped out of high school at age 17, completed GED—score in the average range. Brief informal employment as an adult.
Mental Health History:
Immediate family notable for three members with major mood and psychotic psychiatric illnesses. Mother, father, sister all with multiple hospitalizations. Regular marijuana user since adolescence. No evidence of other drug use or problematic alcohol abuse. Defendant diagnosed with ADHD and Adjustment Disorder with Disturbance of Mood and Conduct at age 14. Diagnosed with Bipolar Disorder at age 17, and began pharmacologic treatment. No services from CSB in the year prior to offense. Mood lability starting in late adolescence. Family members describe onset of apparent mania symptoms in six months prior to offense. Also in this six-month period, developed preoccupation with unconventional religious themes. Defense attorney and jail staff report rapid and incessant speech when first incarcerated. Statements reflecting grandiose religious/persecutory delusions. Behavior dramatically decreased later after prescription of mood-stabilizing and antipsychotic meds. Still focused on religious themes when consulting with attorney.
Interview: Mental Status.
Unkempt, malodorous. Affect varied considerably over course of interviews. Emotions were unusually intense. Some inappropriate laughter. Denied mania and all other psychiatric symptoms. Made frankly delusional statements. Lively and friendly, but dismissive. Circumstantial speech.
Competence-Related Interview.
Marginal factual legal knowledge, drifted into circumstantial statements related to religious preoccupations. Could acknowledge some legal concepts superficially, but tended to lose distinctions when describing legal circumstances within framework of delusional beliefs. Dismissive attitude towards his counsel.
Conclusions Regarding Competence:
Marginal factual understanding, and knowledge was occasionally distorted by delusional beliefs. Apparently experiencing mood and psychosis symptoms with onset at least six months prior to offense. Ability to work with attorney and process new information impaired by preoccupation with delusional beliefs, which also cause him to fail to appreciate seriousness of legal situation. Therefore, not competent to stand trial. Reasonable candidate for outpatient restoration, because recent medication appears to have alleviated symptoms somewhat already. Restoration should include both psychoeducational efforts and medication.
Sample Competency Evaluation #3
The Honorable Judge Bill Bench Anytown Circuit Court 321 Courtside Ave. Anytown, VA
April 29, 2014
RE: Commonwealth of Virginia v. William White
Dear Judge:
Pursuant to your order dated March 1, 2014, we have completed an evaluation of Mr. William White’s competence to stand trial.
Mr. White is a nineteen-year-old man who was charged with Felony Breaking and Entering, arising from an alleged incident on January 17, 2013. Mr. White, who has been released on bond, was evaluated at our Anytown Community Clinic on March 22, 2014.
At the beginning of the evaluation, Mr. White was informed about the nature, scope, and purpose of the evaluation, including the relevant limits of confidentially and privilege. He was also informed that a copy of the ensuing report would be sent to the Court, defense counsel, and the Commonwealth’s Attorney. Mr. White indicated that he understood the purpose and limits of confidentiality associated with the evaluation and agreed to participate.
SOURCES OF INFORMATION
In conducting the evaluation, we completed a 3-hour interview with Mr. White, as well as a 1-hour collateral interview with his mother, Pearl White, and a 45-minute interview with his father, Mr. William White, Sr. We also relied on the following sources of information:
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Social Service Records
School Records
Mental Health Records
Court Records
BACKGROUND INFORMATION AND RELEVANT HISTORY
Social/Developmental History
Mr. White’s mother, Ms. White, described her pregnancy with Mr. White as “normal” but stated that he was delayed in meeting typical developmental milestones such as walking and speaking. She indicated that he did not have any significant medical concerns or accidents during his childhood. Collateral information indicated that Mr. White was raised in an unstable family marked by parental discord, financial difficulties, and frequent relocation due to eviction. According to records, Ms. White has previously reported that the family moved multiple times and occasionally resided in hotel rooms. There is also a pattern of family involvement in the criminal justice system, and some reports of substance abuse within the home.
Regarding Mr. White’s behavior, a Sociocultural Report authored by Mary Moore, M.Ed., when Mr. White was age 16, described Mr. White as “impulsive and aggressive.” The caseworker noted that he “rarely recognizes and avoids harmful and dangerous situations” and described him as “very caring…curious…and impulsive.”
Observations made by Mr. Edwards, Esq., Mr. White’s Guardian ad litem during his adolescent years, characterized Mr. White as an impulsive child who tended to avoid difficult discussions or mundane tasks. Mr. Edwards also noted, “His responses to questions befitted a child five to six years younger…when he did answer, questions were most prefaced with an ‘I don’t care’ attitude.”
Educational History
Ms. White noted that Mr. White was enrolled in a Head Start program at age three. School records indicated that Mr. White was first evaluated in Anytown County School Systems, also at age three, because he exhibited developmental delays in cognition, socialization, and perceptual skills. He also exhibited articulation errors that required services from a speech-language therapist. When he was around age six, school staff determined that Mr. White remained eligible for Special Education as a student with significant learning disabilities. He transferred, around age seven, to Anytown County Schools where he continued to receive special education services. Records indicated that Mr. White was last evaluated at age 16. Test results over the years (i.e., in elementary, middle, and high school) indicated evenly developed cognitive abilities in the well-below-average range. Specifically, his Full-Scale IQ scores have ranged from 78 to 85 over the years.
Records described consistently below-average achievement in reading, writing, and mathematics. However, these scores are very low; only 7% to 16% of the population obtains scores within or below this range. These scores are not sufficiently low to warrant a diagnosis of Mild Intellectual Disability (formerly called “mental retardation”).
Per records from Anytown County Schools, in addition to academic deficits, Mr. White has a history of social and behavioral difficulties. For example, according to his high school teacher’s responses to a structured behavior rating form, Mr. White demonstrated significant problems with externalizing behavior (i.e., not accepting responsibility for his actions and instead blaming others) and inattention. The teacher perceived his Adaptive Skills to be below average. In contrast, his mother’s report on the same structured rating form placed Mr. White’s functioning and adaptive skills within normal limits for his age.
Over the years, school records document teachers describing Mr. White as “rough edged,” argumentative, impulsive, and “needing tremendous structure.” Teachers explained that although he has typically had friends in his classrooms, he has a difficult time when he does not get his way. Reports by teachers at Anytown Middle School highlighted that Mr. White sometimes behaved appropriately in the special education setting; however, his behavior deteriorated in regular education classes. High school records revealed that he had been suspended for defiance toward teachers and fighting peers on several occasions. Ultimately, Mr. White left school at age 17 (amid a variety of academic and disciplinary problems) without graduating.
Psychiatric History
Mr. White reported that he has never participated in individual or family counseling, received treatment in a psychiatric hospital, or received psychiatric medication. Ms. White described her son as having “mood swings” and explained that he becomes upset when limits are set and “he can’t get his way.” She added, “He is not sad, but mad at everybody. He’s like that since when he was a teenager.”
According to Ms. White, teachers have corroborated this report and stated, “He always looks angry.” As previously mentioned, a psychological report conducted by Mr. Smith at age 16 revealed significant concerns regarding hyperactivity, conduct problems, learning difficulties, and low intellectual ability. There were no other indications of psychiatric symptoms or treatment in the available records.
CLINICAL ASSESSMENT
Mental Status Examination and Behavioral Observations
Mr. White presented as a slender young man who appeared younger than his chronological age of nineteen. His appearance was slightly disheveled. His eye contact was poor and he remained silent throughout most of the consent process. Mr. White was oriented to person, place, and date. None of his statements suggested disorganized thinking or formal thought disorder. He failed to answer some of the simple questions that clinicians often ask in order to gauge concentration and memory. However, his failure to answer often appeared more attributable to a lack of motivation to answer,
[SIZE=36]Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities [SIZE=27.98]Introduction / OverviewThis manual provides guidance for restoring competency in adult outpatients within community services boards and behavioral health authorities. It covers assessment, treatment, and educational strategies to ensure individuals understand legal processes and can participate effectively in their defense.
[SIZE=27.98]Section 1: Restoration Training PresentationsThis section includes structured presentations designed to educate individuals about the legal system, courtroom roles, and trial procedures. The goal is to improve understanding and facilitate meaningful participation in legal proceedings.
[SIZE=27.98]Section 2: Small Group Work & Case StudiesInteractive activities and case studies are employed to reinforce learning, assess comprehension, and develop decision-making skills. These exercises are tailored to individual needs and cognitive abilities.
[SIZE=27.98]Section 3: Orientation for CSB/BHA Restoration CounselorsThis section provides training for counselors on how to effectively deliver competency restoration services, including assessment techniques, educational methods, and documentation practices.
[SIZE=27.98]Case Example: William WhiteWilliam White is a 19-year-old male facing a charge of Felony Breaking and Entering in Anytown Circuit Court.
Assessment of Legal Understanding and Appreciation
When assessing competence, four domains are considered: 1) understanding of the legal process, 2) appreciation of the legal process as it applies to his case, 3) capacity to communicate with counsel, and 4) decisional capacity.
Regarding his understanding and appreciation, Mr. White did not demonstrate adequate awareness of the purpose of his legal proceedings. He believed the trial was an effort to gauge his "good behavior" rather than to determine guilt or innocence of a specific offense (i.e., Breaking and Entering). His knowledge of legal roles and procedures was minimal and resistant to remediation.
Interview Observations
During the interview, Mr. White appeared minimally cooperative, often responding with "I don’t know" and requiring prompts. He sometimes knew more than he initially indicated, as shown by his ability to identify correct answers after prompts or recall information spontaneously.
His coping style involved becoming quiet, uncommunicative, and often defiant when faced with challenging information. He tended to deny worry or vulnerability, adopting a tough, unconcerned demeanor, described by a former Guardian ad litem as an “I don’t care attitude.” Over time, with patience, he became somewhat more communicative.
Understanding of Court Roles and Procedures
Initially, Mr. White failed to distinguish roles of courtroom personnel, describing them vaguely or inaccurately. With further questioning, he could define some roles, such as:
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The Commonwealth’s Attorney as “to get you locked up.”
Defense counsel as “to help me.”
The judge as a neutral arbiter who “has say-so over both of them” and “listens to the stories.”
He recognized the judge’s neutrality but did not understand that proceedings aim to determine guilt or innocence. Instead, he viewed them as assessing whether his behavior was generally appropriate, believing the judge should decide his guilt “if she’s done her research” before trial.
When asked how guilt is determined, he responded with vague explanations involving “your background” or “your history,” and thought the judge might decide based on his employment or behavior outside court. He also believed that a judge might find him guilty if she heard negative gossip, indicating a misunderstanding of evidence-based decision-making.
Education on Trial Process
After explanation, Mr. White could articulate a basic understanding that opposing sides “argue” and that a judge “listens to both sides” before rendering a verdict. However, his responses were often parroting my language, lacking elaboration or independent reasoning. He failed to recognize that pleading not guilty would lead to a trial, sometimes suggesting the judge might be convinced of his innocence simply because he pled not guilty.
Legal Decision-Making and Defense Counsel
He demonstrated immature perspectives, dismissing his legal circumstances as “not serious” and expressing bravado about confronting witnesses. When questioned about expressing anger or aggression in court, he dismissed concerns about legal repercussions.
Regarding his defense attorney, Mr. White provided simplistic explanations, such as “He talks to them... it’s a bunch of talking,” and showed little interest in understanding legal strategies. When asked about plea bargaining, he waved it off, saying, “Let the lawyer handle it.” He also believed his attorney “might could tell the judge” anything he disclosed, indicating a lack of understanding of attorney-client privilege.
[SIZE=27.98] ConclusionWilliam White is a 19-year-old male facing charges in the juvenile justice system. His assessment indicates significant deficits in understanding the legal process, appreciation of his case, and decision-making capacity.
He does not appreciate the purpose of the trial, viewing it as a measure of his behavior rather than a determination of guilt. His legal knowledge is minimal, and he resists efforts to remediate these gaps, likely due to low intellectual functioning, embarrassment, and oppositional personality traits.
His coping style involves withdrawal and defiance, which complicates engagement. With patience and continued education, some improvement in understanding may be possible, but his immature and oppositional traits suggest ongoing challenges.
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
Introduction / Overview
adequate time and resources to interact productively with this defendant. Mr. White described a simplistic understanding of the role of defense counsel, and he exhibited wariness about disclosing information to his attorney. He exhibited a disengaged approach, with poor investment, interest, or appreciation of the need to develop a legal strategy with the assistance of counsel. His oppositional stance and limited grasp of important factual information, particularly the concept of attorney-client privilege, would substantially impair his ability to work with his attorney and assist in his defense.
Overall, Mr. White shows substantial deficits in his legal factual knowledge and his ability to apply his limited knowledge to his present circumstances, and to collaborate with his attorney in his defense. Additionally, he has a personality and coping style that inhibits his ability to benefit from educational efforts, requiring more intensive intervention. His capacity to make informed decisions currently appears inadequate due to his below-average intellectual ability and poor motivation to attend to new information.
Should the Court find Mr. White incompetent to stand trial, restoration services are available from the Virginia Department of Behavioral Health and Developmental Services (DBHDS). Virginia policy encourages outpatient competence restoration (i.e., restoration services provided by the Community Services Boards, delivered to the defendant’s location in jail or community) in circumstances when inpatient hospitalization is not necessary.
In Mr. White’s case, inpatient hospitalization does not appear necessary, as his deficits are primarily intellectual and we did not see any indications of a major psychiatric illness. Thus, he appears to be an ideal candidate for outpatient (rather than inpatient, hospital-based) restoration. Given Mr. White’s below-average intellectual ability, restoration content should be delivered in simplified, brief, repeated interventions, with regular checking for understanding.
Counselors should be aware that his personality style may make educational efforts more challenging, but not impossible. Restoration efforts may need to initially focus on information aimed at increasing Mr. White’s motivation to learn legal information, consider his rights, and collaborate with his. Please do not hesitate to contact me should you have any questions, or if I can be of further assistance.
Susie Small, Ph.D.
Anytown Clinic
Cc: Fred Freeman, Esq. Counsel for Defense
Gregory Guiltman, Esq. Assistant Commonwealth’s Attorney
REPORT SUMMARY SAMPLE CASE #3
Demographic:
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19 year old male
Charge(s):
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Felony breaking and entering
Background:
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Developmentally delayed in reaching motor and language milestones.
No major medical problems.
Unstable home life marked by family conflict and poverty.
Impulsive and aggressive as a child. Also described as caring and curious.
Tended to avoid challenging or boring tasks.
Guardian ad litem described him as immature and having “I don’t care” attitude.
Received early intervention and special education services for learning disabilities.
Borderline intellectual functioning with tested IQ ranging from 78-85.
Below average academic achievement.
Behavior problems in school reported by teachers.
Oppositional and defiant at times.
Dropped out at age 17.
Mental Health History:
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No formal psychiatric treatment.
Mother says he has had “mood swings” and becomes upset when “he can’t get his way.”
Angry as a child and adolescent.
Psych eval conducted when he was 16 years old described concerns related to hyperactivity, conduct, learning problems, low intellectual ability.
Interview:
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Mental Status: Slightly disheveled. Eye contact poor. Very little speech at outset of interview. No signs or reports of significant psychiatric problems.
Failed some items related to concentration and memory, but difficulty appeared more related to motivation than ability.
Frequently stated “I don’t know.”
Easily frustrated by mildly challenging tasks.
Emotional expression varied from flat, to indifferent, to annoyed.
Minimally cooperative for first part of evaluation, improved cooperativeness and attitude during latter half.
Often required several prompts/probes to provide sufficiently detailed responses to questions.
Came across as immature with low intellectual ability.
Competence-Related Interview:
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Frequently answered “I don’t know.”
Had some superficial factual legal knowledge, lacked appreciation of overarching framework and purpose of legal proceedings.
Very rudimentary understanding of court personnel roles and responsibilities.
Evaluator had difficulty remediating gaps in defendant’s knowledge due to his apparent low motivation and ability to process new information.
Simplistic understanding of defense counsel role, overly deferential to his attorney with respect to legal decision-making.
Did not grasp attorney-client privilege, even after attempts made to explain.
Conclusions Regarding Competence:
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Marginal factual understanding, ability to remediate misunderstandings and gaps in knowledge was impeded by low intellectual ability, poor motivation, defensive coping style.
Legal understanding is superficial; does not appreciate overall meaning of proceedings as an adjudication of his guilt with respect to specific offenses.
Ability to work with attorney and process new information appeared impaired by low IQ and attitude toward proceedings.
Tended to deny worry and adopt toughened demeanor, possibly as coping strategy.
Therefore, not CST.
Good candidate for outpatient, because low intellectual ability (not major psychiatric illness) is cause of incompetence.
Restoration efforts should be slowly paced, delivered in brief simple interventions.
Report is crucial and may be somewhat slow to develop.
Initial restoration efforts may need to focus on information aimed at increasing his motivation to learn legal information, consider his rights, and collaborate with counsel.
Sample Restoration Case Plan Format
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Presenting Issue/Problem :
Goal #1 :
Objective #1:
Intervention #1:
Intervention #2:
Intervention #3:
Objective #2:
Intervention #1:
Intervention #2:
Intervention #3:
Goal #2 :
Objective #1:
Intervention #1:
Intervention #2:
Intervention #3:
Objective #2:
Intervention #1:
Intervention #2:
Intervention #3:
Section 3: Orientation for CSB/BHA Restoration Counselors
Current Legal & Professional Criteria for Competency
[Pg]87[/Pg] Practical Tips
[Pg]87[/Pg] Steps in the Outpatient Restoration Process
[Pg]89[/Pg] Getting Started - Working with the Defendant
[Pg]90[/Pg] Pre-Test for Competency
[Pg]92[/Pg] Confidentiality
[Pg]93[/Pg]ORIENTATION FOR CSB/BHA RESTORATION COUNSELORS
CURRENT LEGAL AND PROFESSIONAL CRITERIA FOR COMPETENCY
Virginia Code § 19.2-169.1 states that a competency evaluation shall be performed when “… the defendant lacks substantial capacity to understand the proceedings against him or to assist his attorney in his own defense.”
To further explain the above legal standard, the professional standards for competency have been summarized below:
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Defendant’s understanding of the seriousness of the charges and likely consequences
Defendant’s ability to participate in the trial and ability to understand the court proceedings
Defendant’s ability to assist his attorney
Defendant’s ability to maintain the dignity of the courtroom
PRACTICAL TIPS FOR RESTORATION COUNSELORS
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The defendant who has been found incompetent to stand trial and is in need of restoration services on an outpatient basis is probably an individual with limited cognitive abilities or an individual whose mental illness may be interfering with their normal thought processes. The CSB/BHA staff are already trained and experienced in working with people with mental illness or mental retardation.
Restoration services include educational information and training and/or clinical intervention including medications. The clinical skills are the same that are used with other CSB/BHA clients. The primary difference is that restoration services include legal information that is to be taught and assessed.
Before restoration services are initiated by the CSB/BHA, make sure that you have a copy of the current restoration court order and that it is written for the provision of restoration services pursuant to §19.2-169.2. Note the date of the Court order and remember that the court order is valid for six (6) months from the date that the defendant is “admitted to the treating facility”. See Virginia Code § 19.2-169.3A & B for reference. Note that there are forty-five (45) day limits placed on restoration orders for certain misdemeanant charges - see § 19.2-169.3C for specific charges.
Before restoration services are initiated by the CSB/BHA, obtain a copy of the competency to stand trial evaluation for the defendant. Make sure that the restoration counselor assigned to work with the defendant has a copy of the competency evaluation. It will assist your staff in a number of ways, including providing some background information about the defendant, information about the charges and possibly the incident that led to those charges, and most importantly, it should provide a description of the defendant’s areas of impairment in their competency abilities. In the competency evaluation, look for the specific deficit(s) that preclude this defendant from being competent, e.g., psychosis, delusional disorder, mental retardation, or organic brain impairment.
The restoration counselor may want to contact the competency evaluator directly to review and/or clarify the areas of deficiencies in the defendant’s competency abilities.
If not provided with the competency evaluation or restoration court order, it may be helpful to obtain copies of the charges/arrest warrant(s), the police report and witness/victim statements from the Court.
The defendant ordered for restoration services will be in jail or out on bond, you will likely have to contact the attorneys to determine the defendant’s location. If the defendant is in jail (and cannot be transported to the CSB/BHA office), inquire about the jail’s requirements for reserving a professional visitation room (sometimes called a contact visitation room) with a table.
STEPS IN THE OUTPATIENT RESTORATION TO COMPETENCY PROCESS
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1. Receipt of order from court.
2. Request/obtain copy of competency to stand trial evaluation, warrants and criminal complaint if not provided with the order. (via the defense attorney, prosecutor, or clerk)
3. If needed, contact the evaluator to clarify deficits that need to be addressed during restoration.
4. Provide services as described in DBHDS Adult Outpatient Restoration Services Manual. May also refer to psychiatric services and/or education services, or any type of services that will serve to restore competency.
5. One month prior to the expiration of the restoration order or when you think the client is restored or unrestorable, contact an evaluator (per Code this must be a psychiatrist or licensed clinical psychologist with forensic training) to arrange a new restoration “outcome” evaluation. No new order is required as evaluation is part of the process of restoration. CSB should obtain consent from the client or their surrogate decision maker to exchange information with the evaluator. CSB contracts with the provider for the evaluation. The CSB will be reimbursed by DBHDS and CSB will pay the evaluator.
6. Provide evaluator with information regarding the case such as original evaluation, warrants and criminal complaints (unless it is the same evaluator as who originally evaluated them). Also provide evaluator with updated information regarding the progress of the restoration process (e.g., restoration and other relevant notes/assessments).
7. If you feel the
Sample Restoration Order #1
[SIZE=27.98]Pg. 95Sample Restoration Order #2
[SIZE=27.98]Pg. 97 [SIZE=27.98]Section 5: Providing Restoration Services to the DefendantExplaining the Purposes of Restoration
You are here because you have been accused of breaking the law.
You have already been arrested and have an attorney.
You are waiting to go back to court with your attorney who will help to defend you.
Soon after you were arrested, you may remember going before the judge.
At that time, it was recommended that you be evaluated to determine whether you understood the charges against you and what could happen to you if you are convicted of these charges.
The results of the evaluation showed that you needed help in learning more about the court process in order to help your attorney.
We will spend our time trying to teach you things that you will need to know to help your attorney in court.
EXPLAINING LEGAL RIGHTS
Even though you have been arrested, you still have many rights.
The United States Constitution grants these rights to you.
Violations of your Constitutional rights can be appealed up to the U.S. Supreme Court.
It is important to know your rights so that you can protect yourself when necessary.
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You have the right to remain silent when you are arrested and afterwards. This means that you do not have to answer questions or explain anything unless you have your attorney present.
You have the right to an attorney. If you cannot afford one, the Court will appoint an attorney for you. Work with your attorney and don’t make their job harder by trying to handle your legal affairs on your own.
You have the right to face your accuser. You should know who has accused you of the crime and the accuser will be at the trial. You have the right to ask your accuser questions through your attorney.
You have the right to be present at your trial. You cannot be tried unless you are in the courtroom. If you cannot behave appropriately in the courtroom, the Judge may order that you be restrained.
You have the right to a public trial. Anyone can come to your trial, including the press. This right is to protect you from the court doing anything unfair to you behind closed doors.
You have the right to a jury trial. This means that 12 people must be selected who do not know you or anything about you and should decide about your charges fairly.
You have the right to a speedy trial. When you were referred for restoration services, your trial was put on hold. Your defense attorney knows the rules about speedy trials.
You have the right to know why you were arrested.
You have the right to understand the possible pleas.
You have the right to know what sentence you could be given if you are convicted.
It is important to know your rights and to ask questions if you are unsure about your rights.
Tell me what some of your rights are.
EXPLAINING CHARGES, PENALTIES, AND EVIDENCE
NOTE: The restoration counselor should pay close attention to paranoid thinking that interferes with the defendant’s ability to effectively communicate with their attorney.
You have been charged with a crime because a law enforcement officer reported that you broke a law.
It is important that you understand the charges against you.
You will hear about your charges many times.
The Judge will tell you the formal name of your charges in Court and will read the brief legal description of your charges.
You need to know 1) the formal name of your charges, 2) the brief legal description of your charges, and 3) what they say you did that caused you to receive these charges.
Even though you may not agree with the charges, you need to know what they are and the seriousness of your charges.
You need to be able to describe your charge to your attorney in a clear, coherent manner.
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Felony - This is a crime that is considered serious and can result in a long prison sentence and/or a large fine, e.g., more than $1000 fine and more than 1 year in prison.
Misdemeanor - This is a crime that is not as serious as a felony and can result in a shorter jail sentence, smaller fine, or another less serious consequence, e.g., up to a $1000 fine and/or up to a year in jail.
Judges have guidelines for penalties (length of jail/prison time, fines, etc.) when you are found guilty of the charges. Although the Judge does not have to stay within these guidelines, he/she usually does.
Your attorney can tell you what the penalty guidelines are for your charges.
It is also important that you understand how much evidence there is against you.
You may make a different decision about whether you will plead guilty or not guilty depending on the evidence against you.
Some of the evidence comes from the Criminal Complaint, which gives a brief description from a police officer or other witness.
Also, ask your attorney to review the police report and any witness statements with you if they are available.
In summary, do you know the following? 1. What is the
[SIZE=36]Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities [SIZE=27.98]Introduction / OverviewThis manual provides guidance on competency restoration procedures and related legal processes for adults involved with Community Services Boards (CSBs) and Behavioral Health Authorities (BHAs). It covers essential topics such as plea options, criminal penalties, courtroom personnel, and the legal rights of defendants.
[SIZE=27.98]Section 1: Restoration Training PresentationsDetails about training sessions, presentation materials, and educational content aimed at preparing individuals for competency restoration and understanding legal processes are included in this section.
[SIZE=27.98]Section 2: Small Group Work & Case StudiesThis section involves interactive case studies and small group activities designed to reinforce understanding of legal concepts, plea negotiations, and courtroom procedures.
[SIZE=27.98]Section 3: Orientation for CSB/BHA Restoration CounselorsGuidance for counselors on how to support clients through the legal process, including explaining charges, plea options, penalties, and courtroom roles.
[SIZE=27.98]Explaining Pleas and Plea Bargains PLEAS: A plea is the answer you (and your lawyer) give to the charges made against you. There are four different ways to plead: guilty, not guilty, no contest, or not guilty by reason of insanity.-
Not Guilty: A plea of not guilty means you say that you did not commit the crime. When you plead not guilty, you go to trial and have evidence presented against you and for you. You retain all your legal rights.
Guilty: A plea of guilty means that you admit to doing the crime. You will have the conviction on your record if you plead guilty. You give up certain rights such as the right to a trial and the right to confront witnesses in court.
No Contest: A plea of no contest (Nolo Contendere) means you say there is evidence you did the crime, but you are not admitting you did it. In other words, you are not fighting the charge, and you will accept whatever sentence the court gives you and not ask for a trial. You give up some rights to get a speedy decision and a lighter sentence, which you will know about and agree to ahead of time. The outcome for you is similar to a plea bargain except you have a no contest plea instead of a guilty plea on your record.
Not Guilty by Reason of Insanity: A plea of Not Guilty by Reason of Insanity means you admit you did the crime, but you are asking that you not be put in jail and not be held criminally responsible because you have mental retardation or were mentally ill at the time. You are telling the court that at the time of the crime, your mental illness or mental retardation caused you to act in a way that you didn’t understand was wrong. This plea cannot be forced upon you. You and your attorney must decide together if this is how you want to defend yourself. In admitting you did the crime, you must admit you were mentally ill or have mental retardation. A psychiatrist or psychologist will examine you and report to the court about your mental state and the crime.
If the Judge or jury believes that, due to your mental illness or mental retardation, you did not know that your behavior was wrong, you could be found not guilty by reason of insanity. If you are found not guilty by reason of insanity, you will be sent to a state psychiatric hospital for an indeterminate period. If the Judge or jury believes you understood that your behavior was wrong, you will be found guilty of the charge(s).
[SIZE=27.98]Plea BargainA plea bargain is when your lawyer, the Commonwealth’s Attorney (prosecutor), and the Judge allow you to plead guilty to a less serious charge. The Judge and Commonwealth’s Attorney avoid the time and expense of a trial. In exchange, you will usually get a lighter sentence. You must agree to a plea bargain, and the Judge must approve it.
People usually take a plea bargain because they believe the Commonwealth’s Attorney has enough evidence to convict them (be found guilty) in court. You may accept a plea bargain because:
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1. You might get a lighter sentence;
2. Some charges may be dropped; or,
3. It reduces uncertainty about what will happen.
If you take a plea bargain, you give up your rights to a trial and to appeal the conviction. You return to court to hear the Judge sentence you (e.g., jail time, fines, probation, etc.).
[SIZE=27.98]Questions for Pleas and Plea Bargains (Correct answer has an asterisk)-
1. When you plead guilty, you give up your right to a trial. True* False
2. Pleading No Contest means you are going to fight the charges. True False*
3. List the four pleas you can make to a charge in court.
a. Guilty
b. Not guilty
c. No contest
d. Not guilty by reason of insanity
4. Which plea will guarantee me I will not serve any time?
a. Guilty
b. Not guilty
c. No Contest
d. Not Guilty by Reason of Insanity
e. None of the above*
5. Which pleas will result in a trial?
a. Guilty
b. Not guilty
c. No Contest
d. Not guilty by reason of insanity
e. 2 and 4*
6. If you accept a plea bargain, who has to agree to the deal?
a. Judge
b. Commonwealth’s Attorney (prosecutor)
c. Your attorney
d. You (defendant)
e. All of the above*
7. What might you gain by accepting a plea bargain?
a. All charges are dropped
b. A shorter sentence
c. Less serious charges
d. Number 2 and 3*
8. What right do you not give up in a plea bargain?
a. Right to a trial
b. Right to an attorney*
c. Right to appeal the conviction
d. Right to confront your accusers
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Jail or Prison: You could be locked up in a jail or prison. Whether you serve your sentence in jail or in prison depends on the seriousness of the crime (e.g., felony or misdemeanor), the length of your sentence, and your criminal history. If you are found guilty of a misdemeanor, a less serious crime, it can result in jail time ranging from one day to twelve months. If you are found guilty of a felony, a more serious crime, it can result in a prison sentence ranging from one year to life.
Suspended sentence: A suspended sentence is a jail sentence that the Judge gives you, but instead of actually spending time in jail, you can serve that time on probation. If you successfully complete probation, your charge will be dismissed. However, if you do not complete probation successfully, you will be required to serve any remaining time in jail. For example, if you get a six-month suspended sentence for assault, you will have to serve six months in jail if you do not follow all the rules of probation.
Probation: This means you don’t have to go to jail, but you must live by some rules decided by the Judge. You must meet regularly (usually weekly or monthly) with a probation officer who will ensure you follow the rules. Typical probation rules include:
• No drug or alcohol use
• Comply with mental health and/or substance abuse treatment
• Take all medicine prescribed by your doctor
• Live in a certain place or with certain people
You may remain on probation for the entire period you would otherwise have served in jail.
Treatment: Mental health and/or substance abuse treatment may be ordered by the Judge as part of your sentence. You may be required to participate in counseling and possibly take medication if found guilty. Treatment could occur in jail, prison, or as part of probation when you return home. Treatment is usually part of probation rules. You give up some privacy rights because your therapist must inform the probation officer and/or Judge about your treatment attendance and progress.
If found Not Guilty by Reason of Insanity: You will be sent to a state psychiatric hospital for treatment. You do not go home. Staff will treat your mental illness or mental retardation. You cannot leave until the Judge deems you safe. The treatment duration can last from several months to many years. You may remain under court-ordered supervised treatment even after leaving the hospital, called conditional release. The Judge determines the length of stay in the hospital and on conditional release.
It is very important to understand all the pleas and their possible outcomes. They are listed below:
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If you plead Not Guilty: You go to trial and exercise all your legal rights. Possible outcomes include:
Found not guilty – you are sent home
Found guilty – conviction on your record and sentencing to:
Jail (for a misdemeanor, 1 day to 12 months)
Prison (for a felony, 1 year to life)
Probation – for all or part of the sentence in jail or prison
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Sentenced to Jail (1 day to 12 months)
Sentenced to Prison (1 year to life)
Given Probation – for all or part of the sentence
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If guilty, sentenced to:
Jail (as above)
Prison (as above)
Probation (as above)
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1. If you plead not guilty, which of the following might happen in court?
a. You are found not guilty
b. You are found guilty and sentenced to jail
c. You are found guilty and placed on probation
d. All of the above*
2. If you are found Not Guilty by Reason of Insanity, it means:
a. You knew what you were doing
b. The judge lets you go home
c. You have mental illness or mental retardation and did not know that your behavior was wrong*
3. If you plead Not Guilty by Reason of Insanity, which of the following outcomes are possible?
a. Found guilty and go to jail
b. Found not guilty by reason of insanity and sent to a hospital
c. Found not guilty and sent home
d. Found not guilty by reason of insanity and sent home
e. 1 and 2*
4. What charge could result in the longest sentence?
a. Misdemeanor
b. Felony*
5. What are the possible penalties if you are found guilty of your charge?
a. You would serve a six-month sentence in prison. True False*
6. What might the judge do if you stop going to therapy when therapy is part of your probation?
a. Put me in jail*
This manual provides guidance for adult outpatient competency restoration programs, outlining procedures, roles, and responsibilities within community services boards and behavioral health authorities.
[SIZE=27.98]Section 1: Restoration Training PresentationsDetails regarding training modules, presentation formats, and educational content aimed at restoring competency are included here.
[SIZE=27.98]Section 2: Small Group Work & Case StudiesThis section covers interactive activities, case study analyses, and small group exercises designed to reinforce learning and practical application.
[SIZE=27.98]Section 3: Orientation for CSB/BHA Restoration CounselorsGuidelines and orientation materials for counselors working within community services boards and behavioral health authorities to effectively support competency restoration efforts.
[SIZE=27.98]Legal Proceedings and Courtroom RolesThe following section explains the courtroom procedures, roles of personnel, and the defendant’s responsibilities during a criminal trial.
Courtroom Personnel and Their Roles-
Prosecutor (Commonwealth’s Attorney): The prosecutor is against you. They work with law enforcement to present evidence to convict you of the crime.
Jury: A group of twelve impartial community members who listen to the case and decide guilt or innocence. Their decision must be unanimous. They may also recommend punishment if you are found guilty.
Witness: Provides sworn testimony related to the crime. They are subpoenaed, sworn to tell the truth, and answer questions posed by attorneys. They may support either the prosecution or defense.
Bailiff (Court Security): Ensures order in the courtroom, introduces the judge, maintains quiet, and transports defendants from jail to court.
Court Clerk and Court Stenographer: Assist with swearing in witnesses and recording court proceedings.
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Who is the defendant?
What is the job of the Judge?
What is the job of the jury?
What is the job of a witness?
How is the role of the Commonwealth’s Attorney different from the Defense Attorney?
The defendant should be able to (1) explain where each courtroom personnel sits and (2) describe their roles. The defendant’s cooperation and understanding are crucial for a fair trial.
[SIZE=27.98]Assisting Your Defense AttorneyYour defense attorney is responsible for defending you against charges. Knowing how to assist your attorney can improve your defense strategy.
What Your Defense Attorney DoesYour attorney is trained to help you legally and represents you in court. They spend years in college, law school, and pass the bar exam to practice law.
A court-appointed attorney, often called a Public Defender, is assigned if you cannot afford one. Your attorney is on your side whether you are innocent or guilty.
Your attorney explains possible outcomes, answers questions, and provides legal advice based on their knowledge and experience.
What is Legal Advice?Legal advice involves sharing the attorney’s knowledge of law and case strategies. It helps you understand your options and the best course of action, including how to plead or testify.
Your Attorney’s Responsibilities-
Protect your rights by ensuring all proceedings are legal and fair.
Plan an effective defense, including cross-examining witnesses, calling witnesses, and negotiating plea bargains.
If found guilty, seek the lightest sentence possible through negotiations or advocacy.
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Character Witness: Describes your personality and character.
Expert Witness: Provides specialized knowledge or opinions relevant to your case.
Material/Fact Witness: Testifies about facts, such as your whereabouts during the crime.
Cooperate with your attorney and tell the truth. Your statements are confidential and cannot be used against you. Your honesty helps your attorney build the best defense.
Remember to inform your attorney of all relevant details, including events leading to your arrest and witnesses.
Questions for Assisting Your Defense Attorney-
Who is your defense attorney?
What do you think of your defense attorney?
What is the job of your defense attorney?
Why is a criminal trial called an adversarial proceeding?
Does a defendant have to testify?
How does the defendant help their attorney?
The criminal trial follows a specific order of proceedings:
ArraignmentA court appearance where you hear the charges and enter a plea of guilty or not guilty. If you refuse, the court enters a not guilty plea and sets the case for trial.
Pre-trial HearingsYour attorney may file motions, such as requesting a mental health evaluation. You decide whether to accept a plea bargain or go to trial, with your attorney’s guidance.
Trial by JuryEntitled if charged with a crime that could result in jail or prison. You can opt for a bench trial where the Judge hears the case instead of a jury.
Jury SelectionJurors are chosen from a panel, questioned, and approved by the Judge. Both attorneys can question and excuse jurors as needed.
Opening StatementsThe prosecution (Commonwealth’s Attorney) must prove guilt beyond a reasonable doubt and makes the first statement. The defense then presents its opening statement.
Presentation of EvidenceThe prosecution calls witnesses and introduces physical evidence. Witnesses testify under oath, answering questions from both sides. Cross-examination follows direct testimony.
Your attorney then presents your evidence and calls witnesses, who are also cross-examined. You are not required to testify.
Closing Arguments and InstructionsAfter all evidence, the prosecution makes a closing argument, followed by the defense. The prosecution may have a rebuttal. The Judge then provides instructions to the jury.
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
gives the jury instruction on the law as it relates to your case. Verdict: The jury reaches a verdict (decision) about whether you are guilty or not guilty. The verdict must be unanimous among all jurors. The jury also may make a recommendation about punishment. The Judge decides the final verdict.
Sentence: If you are found guilty, the Judge will decide your sentence. Your sentence could include jail or prison time, a suspended sentence, probation, etc. Probation allows you to leave jail or prison but requires you to report to a probation officer and follow the rules of probation.
Appeal: You have the right to request an appeal of your verdict or sentence, but your request must be made soon after your conviction.
Questions for Proceedings of a Trial:
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1. What does testimony mean?
2. Who gives testimony?
3. What does cross-examination mean?
4. What does verdict mean?
5. Who decides the verdict?
APPROPRIATE COURTROOM BEHAVIOR
When you go to court, the way you look and act is important and could affect the impression you give the Judge and the jury. You will help your attorney defend you by dressing in clean, neat clothing.
You can help your attorney defend you by behaving respectfully in court. Some of the ways you show respect for the court are:
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When the Judge enters the courtroom, the bailiff will announce that the Judge is about to enter and will ask everyone to rise. You, along with everyone else in the room, will stand up and remain standing until the Judge sits down and tells you to sit down.
You must never speak out unless the Judge asks you to speak. You should stand or sit when your attorney tells you.
If you are confused, have a question, or don’t understand what’s going on, whisper your question to your attorney or write a note and quietly give it to your attorney.
You may not chew gum.
You should only speak if you are asked a question. If you are asked a question, answer ONLY the questions asked of you. Do not try to add any other information. If you want to say something, you should tell your attorney and let your attorney talk for you.
You must not speak too loudly, yell, get angry or curse in the courtroom. If you do, you may be held in contempt of court and taken out of the room. The Judge can also impose a sentence (i.e., fine you or give you more time in jail).
If you become upset and feel you can’t remain quiet, you should tell your attorney that you need a break.
You should listen and pay careful attention to what is being said so you understand what is happening and can help your attorney. If you don’t understand something, you should ask your attorney to explain it.
If one of the witnesses says something about you that is not true, you should let your attorney know.
Questions for Appropriate Courtroom Behavior:
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1. Is it important for the defendant to dress nicely?
2. Can the defendant speak directly to the judge during the trial?
3. How are people in the courtroom supposed to behave?
4. What do you do if you become upset in the courtroom?
5. What do you do when a witness tells a lie about you?
COURTROOM DIAGRAM
Section 6: When is Restoration Over & What’s Next?
Assessing Restoration Services Completion : Restoration Counselor Pg. 115
Next Steps for the Restoration Coordinator Pg. 116
Next Steps for CSB/ BHA Executive Director/Designee Pg. 116
Post-Test for Competency Pg. 118
WHEN IS RESTORATION OVER & NEXT STEPS
RESTORATION COUNSELOR
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Give a post-test to the defendant. See the post-test at the end of this chapter. This post-test should be administered with the understanding that it includes the required elements for competency. The required elements for competency are summarized below:
Defendant’s understanding of the seriousness of the charges and likely consequences
Defendant’s ability to participate in the trial and ability to understand the court proceedings
Defendant’s ability to assist his attorney
Defendant’s ability to maintain the dignity of the courtroom
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Review initial competency evaluation and any follow-up competency evaluations (if appropriate) for statements regarding defendant’s previous inabilities or problem areas
Assess whether defendant has made any progress in those areas
Assess whether defendant might make any additional progress in those areas
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Do you believe the defendant’s symptoms will improve with further treatment or are they at their optimal level of functioning?
Is there evidence of a learning curve or has the defendant reached their learning plateau?
Are the clinical problems contributing to the defendant’s incompetence such that they are not likely to improve (e.g., mental retardation) or possibly worsen over time (e.g., dementia)?
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The defendant is competent. Tell your supervisor as soon as this determination is made.
The defendant is likely to remain incompetent for the foreseeable future. Tell your supervisor as soon as this determination is made.
The defendant is incompetent but restorable to competency in the foreseeable future. Tell your supervisor one (1) month prior to the expiration of the restoration court order.
If the defendant is charged with certain targeted misdemeanor offenses and is under a 45-day restoration order, tell your supervisor about the short time frame. The possible outcomes remain the same as above - competent, incompetent for the foreseeable future or incompetent but restorable in the foreseeable future.
NOTE: Do not repeat any statements of the defendant about the time period of the offense.
RESTORATION COORDINATOR
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Notify the CSB/BHA Executive Director (or designee) of the restoration counselor’s recommendations at the appropriate time in order to obtain a follow-up competency evaluation (often called a restoration outcome evaluation) in a timely manner.
The appropriate time could be at any time after the initiation of restoration services if the defendant appears competent or incompetent for the foreseeable future. If the defendant is incompetent but restorable in the foreseeable future, the CSB/BHA Executive Director (or designee) should be notified at least one (1) month in advance of the expiration of the current restoration court order.
The CSB/BHA Executive Director (or designee) should be notified upon initiation of restoration services for the defendant with targeted misdemeanor charges under a 45-day restoration order.
CSB/BHA EXECUTIVE DIRECTOR OR DESIGNEE
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The CSB/BHA Executive Director (or designee) should arrange for follow-up competency evaluation (often called a restoration outcome evaluation) to be performed by a forensically trained evaluator for all restoration court orders and outcomes. See #4 on the previous page and #5 above.
According to § 19.2-169.1D, the evaluator’s report should address (1) the defendant’s capacity to understand the proceedings against him; (2) the defendant’s ability to assist his attorney; and (3) the defendant’s need for treatment in the event he is found incompetent. The CSB/BHA Executive Director (or designee) may consider contacting the original competency evaluator to perform this follow-up competency evaluation.
The CSB/BHA Executive Director (or designee) is responsible for reporting back to the court within the appropriate time frame. The report to the court should be addressed to the judge and copied to the attorneys of record. The report should include a cover letter stating the competency evaluation findings (with a copy of the competency evaluation attached) and the CSB/BHA recommendations. A summary of the findings and recommendations are listed below:
The defendant is competent. Continued restoration services are not necessary. (See § 19.2-169.2B for reference)
The defendant is incompetent but restorable in the foreseeable future; continued restoration services and other mental health treatment are recommended. (See § 19.2-169.3B for reference)
The defendant is likely to remain incompetent for the foreseeable future. The CSB/BHA should review the recommendations detailed in § 19.2-169.3A. Some of these Code recommendations, however, are more hospital-based in nature, e.g., civil commitment and certification. Because restoration services were ordered in the community, the court is probably interested in community-based treatment recommendations that would include risk reduction strategies.
For the defendant with targeted misdemeanor charges and a 45-day restoration order, the findings can be any of those listed above. The CSB/BHA should review the recommendations detailed in § 19.2-169.3C. Some of these Code recommendations, however, are more hospital-based in nature, e.g., release, civil commitment and certification. Because restoration services were ordered in the community, the court is probably interested in community-based treatment recommendations that would include risk reduction strategies.
An exception to the points above occurs in the cases of defendants who are opined to be unrestorable on sexually violent charges, as defined in § 37.2-900. The Code of Virginia § 19.2-169.3 (E) provides that such individuals “shall be reviewed for commitment pursuant to Chapter 9 (§ 37.2-900 et seq.) of Title 37.2.” The court will order that the defendant be held in the custody of the Department of Behavioral Health and Developmental Services “for secure confinement and treatment.”
POST-TEST
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Assess the defendant’s understanding of the seriousness of the charges and likely consequences, including pleas and plea bargains. Can the defendant sufficiently explain the following?
Formal name of charge(s)
Ability to describe the events surrounding the incident(s) that led to his/her arrest and being charged with the offense.
Type of charge(s) involved - felony and/or misdemeanor
If convicted, what are the likely consequences (e.g., jail or prison sentence, probation, etc.)?
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Role of the participants in the trial:
What is the role of the judge? (Defendant should be able to explain that the judge makes decisions in courtroom, should be fair/neutral and decides guilt or innocence if it’s a bench trial)
What is the role of the defense attorney? (Defendant should be able to explain that the defense attorney is “on the side” of the defendant and tries to get him/her off or the least possible sentence)
What is the role of the Commonwealth’s attorney? (Defendant should be able to explain that the Commonwealth’s attorney is “against” the defendant and will try to get him/her convicted)
What is the role of jury? (Defendant should be able to explain that the jury decides whether the defendant is guilty or not guilty)
What is a witness? (Defendant should be able to explain that a witness is someone who tells the court what they know)
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The defendant should be able to explain available pleas
The defendant should be able to describe direct testimony and cross-examination
The defendant should be able to describe possible penalties for a guilty verdict
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Can the defendant tell a complete and accurate story about the incident and the charges to their attorney?
Can the defendant
Explain when an attorney would be doing a “good” job? (Defendant should be able to explain that the attorney would listen to the defendant, explain things to the defendant, and/or relay that this attorney defended an acquaintance and “got them off”).
Can the defendant describe how “strong” the case is against the defendant? (Defendant should be able to describe the evidence that is available and if that makes it a “strong” or “weak” case).
Can the defendant describe how the attorney and the defendant would decide to take a plea bargain? (The defendant should be able to explain the concept of “the stronger the case, the more attractive a plea bargain should be”).
Can the defendant describe an effective working relationship with his attorney?
Is there any evidence of paranoid delusions or other clinical symptoms that may interfere with the defendant’s ability to assist their attorney?
[SIZE=27.98]Assessing Courtroom Behavior and UnderstandingAssess the defendant’s ability for appropriate behavior in the courtroom. Can the defendant sufficiently and accurately describe the following?
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How are you supposed to dress in the courtroom? (Defendant should be able to explain that clothing should be neat and that the defendant should be clean).
How are you supposed to behave in the courtroom? (Defendant should be able to explain that they should be quiet unless spoken to by the judge or on the witness stand and remain in their seat).
What do you do when a witness is on the stand and says something that is not true? (Defendant should be able to explain that they should write a note to their attorney or quietly whisper to the attorney).
What do you do when you do not understand what is going on in the courtroom? (Defendant should be able to explain that they should write a note to their attorney or quietly whisper to the attorney).
What will happen if you “act out” in the courtroom? (Defendant should be able to explain that they will “get in trouble” and could be held in contempt, get extra jail time, be put in restraints, etc.).
When is it ok to talk in the courtroom? (Defendant should be able to explain that they should be quiet unless spoken to by the judge or called to the witness stand).
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Sample Letter 1: Defendant is Competent Pg. 121
The Honorable __________________ __________________ Court _______________________________ ________________ , VA __________
Re: ___________________ ______ Case #: ______________________
Dear Judge ___________:
The above captioned defendant has been receiving treatment to restore his competency to stand trial pursuant to your order, dated _______. Enclosed you will find an evaluation of competency to stand trial in accordance with requirements of Section 19.2-169.2 of the Code of Virginia, as amended. The evaluator, ________________, has opined that the defendant is now competent to stand trial. Based upon our work with the defendant, we agree with this finding. I hope that this information is sufficient for the court to proceed with a hearing. Should you have any questions or concerns in this matter, please feel free to contact me at (phone number). Sincerely, ________, Executive Director (or designee) ________ CSB/BHA
ATTACHMENT (Outcome Competency Evaluation)
cc: ______, Commonwealth’s Attorney ______, Defense Attorney
Sample Letter 2: Defendant is found incompetent to stand trial at the present time, but restorable to competency in the foreseeable future Pg. 122
The Honorable __________________ __________________ Court _______________________________ ________________, VA _____________
Re: _________________________ Case #: _________________ _____
Dear Judge ___________:
The above captioned defendant has been receiving treatment to restore his competency to stand trial pursuant to your §19.2-169.2 order, dated _______. Enclosed you will find an evaluation of competency to stand trial in accordance with requirements of §19.2-169.2, as amended. The evaluator, ________________, has opined that the defendant remains incompetent to stand trial at this time, but may be restorable in the near future. We agree with this finding and recommend that outpatient restoration services be continued. A model order for (continued) treatment of an incompetent defendant is enclosed for your convenience. I hope that this information is sufficient for the court to proceed with a hearing. Should you have any questions or concerns in this matter, please feel free to contact me at (phone number). Respectfully, ________, Executive Director (or designee) ________ CSB/BHA
ATTACHMENTS (2) Outcome Competency Evaluation Model court order for restoration services, §19.2-169.2
cc: ______, Commonwealth’s Attorney ______, Defense Attorney
Sample Letter 3: Defendant is incompetent to stand trial for the foreseeable future (Unrestorable) Pg. 123
(Date)
The Honorable __________________ __________________ Court _______________________________ ________________ , VA __________
Re: ____________________________ Case #: _________________________
Dear Judge __________________:
The above captioned defendant has been receiving treatment to restore his competency to stand trial pursuant to your § 19.2-169.2 order, dated _______. Mr./Ms. _________________ continues to not understand the nature and consequences of the proceedings against him/her and continues to be unable to assist his attorney in his/her own defense. In our opinion, he/she remains incompetent to stand trial and will remain incompetent for the foreseeable future. Enclosed you will find an evaluation of competency to stand trial in accordance with requirements of §19.2-169.2, as amended. The evaluator, ________________, has opined that (insert evaluator’s opinion). Our recommendation is that Mr./Ms. __________ does not appear to meet the criteria for commitment pursuant to §§ 37.2-814, 37.2-900 or 37.2-806. Should the defendant be released, community services are available (clarify what is available) to the defendant. I hope that this information is sufficient for the court to proceed with a hearing. Should you have any questions or concerns in this matter, please feel free to contact me at (phone number). Sincerely, ________, Executive Director (or designee) ________ CSB/BHA
ATTACHMENT (Outcome Competency Evaluation)
cc: _____________, Commonwealth’s Attorney ______________, Defense Attorney
Sample Letter 4: Defendant is incompetent to stand trial for the foreseeable future (Unrestorable) and had been charged with a sexually violent offense(s) as defined in § 37.2-900 Pg. 124
(Date)
The Honorable __________________ __________________ Court _______________________________ ________________, VA __________
Re: ____________________________ Case #: _________________________
Dear Judge __________________:
The above captioned defendant has been receiving treatment to restore his competency to stand trial pursuant to your §19.2-169.2 order, dated _______. Mr./Ms. _________________ continues to not understand the nature and consequences of the proceedings against him/her and continues to be unable to assist his attorney in his/her own defense. In our opinion, he/she remains incompetent to stand trial and will remain incompetent for the foreseeable future. Enclosed you will find an evaluation of competency to stand trial in accordance with requirements of §19.2-169.2, as amended. The evaluator, ________________, has opined that (insert evaluator’s opinion). Our recommendation is that Mr./Ms. __________ does not appear to meet the criteria for commitment pursuant to §§ 37.2-814, 37.2-900 or 37.2-806. Should the defendant be released, community services are available (clarify what is available) to the defendant. I hope that this information is sufficient for the court to proceed with a hearing. It is our understanding Mr./Ms. ___________ has been charged with a sexually violent offense, as defined in § 37.2-900. §19.2-169.3 states that he shall be screened pursuant to the procedures set forth in §§ 37.2-903 and 37.2-904. Should you have any questions or concerns in this matter, please feel free to contact me at (phone number). Sincerely, ________, Executive Director (or designee) ________ CSB/BHA
ATTACHMENT (Outcome Competency Evaluation)
cc: _____________, Commonwealth’s Attorney ______________, Defense Attorney
Sample Letter 5: Too psychiatrically unstable for outpatient restoration services; restoration not initiated, therefore no outcome evaluation is required. Pg. 125
(Date)
The Honorable __________________ __________________ Court _______________________________ ________________, VA __________
Re: _________________________ Case #: ______________________
Dear Judge ___________:
In a court order dated _______, you ordered Mr./Ms. ___________ to receive treatment in an attempt to restore his/her competency to stand trial pursuant to Virginia Code § 19.2-169.2. Upon receipt of the court order, I conducted an initial assessment of Mr./Ms. ______________. During the course of my initial assessment, it became clear Mr./Ms. _____________ is currently too psychiatrically impaired to receive outpatient competency restoration services. This paragraph should describe the specific conditions that made them psychiatrically unsuitable for outpatient restoration. Some examples are: Mr./Ms. _____________ is evidencing significant symptoms of psychosis to include _____________, ___________, and ________________. Mr./Ms. ________________ refused to be evaluated by __________________ CSB’s psychiatrist for a medication consultation. Mr./Ms. ___________________ indicated he/she would not voluntarily consent to taking prescribed medications. As a result of his/her current mental status and his/her unwillingness to receive psychiatric services, it is my professional opinion Mr./Ms. ________________ is not an appropriate candidate for outpatient competency restoration services. My recommendation is that the Court amend the current court order and order Mr./Ms. __________ to receive competency restoration services on an inpatient basis at a DBHDS hospital. If you have any questions, please call me at (phone number). Sincerely, ________, Executive Director (or designee) ________ CSB/BHA
ATTACHMENT: Model order for restoration pursuant to § 19.2-169.2
cc: _____________ , Commonwealth’s Attorney ______________, Defense Attorney
Sample Letter 6: Initially able to participate in outpatient restoration but mental status deteriorated & is no longer appropriate for outpatient restoration. Because outpatient restoration was started, an outcome competency evaluation is required. Pg. 126
(Date)
The Honorable __________________ __________________ Court _______________________________ ________________, VA __________
Re: _________________________ Case #: ______________________
Dear Judge ___________:
In a court order dated _______, you ordered Mr./Ms. ___________ to receive treatment in an attempt to restore his/her competency to stand trial pursuant to Virginia Code § 19.2-169.2. Upon receipt of the court order, I conducted an initial assessment of Mr./Ms. ______________ and began providing restoration services. Over time, Mr./Ms. ________’s mental status began to deteriorate. This paragraph should describe the specific conditions that led to your recommendation. For example: Mr./Ms. _____________
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
bega n evidencing significant symptoms of psychosis to include _____________, ___________, and ________________. Mr./ Ms. ________________ refused to be evaluated by __________________ CSB’s psychiatrist for a medication consultation (or: Despite agreeing to receive psychiatric services, Mr./ Ms. ________’s condition did not improve). As a result of his/her current mental status and our inability to fully stabilize his/her condition on an outpatient basis, it is my professional opinion Mr./Ms. ______________ __ is no longer an appropriate candidate for outpatient competency restoration services. Dr. __________ provided an outcome evaluation and agrees with this recommendation for inpatient restoration. Please see their evaluation attached. I recommend the Court amend the current court order and order Mr./ Ms. __________ to receive competency restoration services on an inpatient basis at a DBHDS hospital. If you have any questions, please call me at (phone number). Sincerely, ________, Executive Director (or designee) ________ CSB/BHA ATTACHMENT (Outcome Competency Evaluation) cc: _____________, Commonwealth’s Attorney ______________, Defense Attorney
127 SAMPLE LETTER # 7 - Unable to Find Defendant or Defendant Refuses to Cooperate, therefore unable to Initiate Restoration Services
date The Honorable __________________ __________________ Court ______________________________ ______________, VA ___________
Re: _________________________ Case #: ______________________
Dear Judge ___________:
In a court order dated _______, you ordered Mr./Ms. ___________ to receive treatment in an attempt to restore his/her competency to stand trial pursuant to Virginia Code § 19.2 -169.2.
Upon receipt of the court order, I attempted to communicate with Mr./Ms. _______ at the address/phone number provided. I have ( sent letter/left phone message ) but Mr./Ms. ___________ has not responded ( or has refused to cooperate, if that is the issue ).
I have spoken with Mr./Ms. _________’s attorney to enlist his/her help to locate ( or engage, if the issue is defendant cooperation ) Mr./Ms. ________ to no avail.
At this point in time, I am unable to initiate competency restoration services with Mr./Ms. _________.
If the court is able to address Mr./Ms. _________’s non-compliance with the court’s order, the _____ CSB/BHA would be willing to reinitiate restoration efforts should we receive further instruction from the court.
At this point in time, we are unable to proceed. If you have any questions, please feel free to contact me at (phone number).
Sincerely, ________, Executive Director (or designee) ________ CSB/BHA
cc: _____________, Attorney for the Commonwealth _____________, Attorney for the Defense
128 SAMPLE LETTER #8 - Initially able to participate in 0-P restoration but too symptomatic for outcome evaluation - URIST.
date The Honorable __________________ __________________ Court ______________________________ ______________, VA
Re: ____________ _____________ Case #: ______________________
Dear Judge ___________:
In a court order dated _______, you ordered Mr./ Ms. ___________ to receive treatment in an attempt to restore his/her competency to stand trial pursuant to Virginia Code § 19.2 -169.2.
Upon receipt of the court order, I conducted an initial assessment of Mr./ Ms. ______________ and began providing restoration services. Mr./ Ms. _________________ continues to not understand the nature and consequences of the proceedings against him/her and continues to be unable to assist his/her attorney in his/her own defense.
In our opinion, he/she remains incompetent to stand trial and will remain incompetent for the foreseeable future.
However, as a result of Mr./ Ms. _____________’s significant symptoms of psychosis to include _____________, ___________, and ________________, she has been unable to complete the outcome competency evaluation despite repeated attempts to schedule.
As a result of his/her current mental status and our inability to obtain an outcome competency evaluation, we have concluded restoration services.
Our recommendation is that Mr./ Ms. __________ does not appear to meet the criteria for commitment pursuant to §§ 37.2 -814, 37.2 - 900 or 37.2 -806.
Should the defendant be released, community services are available (clarify what is available) to the defendant.
I hope that this information is sufficient for the court to proceed with a hearing. Should you have any questions or concerns in this matter, please feel free to contact me at (phone number).
Sincerely, ________, Executive Director (or designee) ________ CSB/BHA
ATTACHMENT (Outcome Competency Evaluation)
cc: _____________, Commonwealth’s Attorney _____________, Defense Attorney
Section 8: Relevant Virginia Code Sections
Raising the Question of Competency to Stand Trial & Initial Evaluation Pg. 129 Disposition When Defendant is Found Incompetent Pg. 131 Disposition of an Unrestorable Incompetent Defendant Pg. 132 Certification to Training Centers for Unrestorable Defendants Pg. 134 Involuntary Commitment for Unrestorable Defendants Pg. 136 Relevant Code Definitions Pg. 138 Disposition of Unrestorable Defendants with Sexually Violent Offenses ____ Pg. 139 Registration of Defendants with Sexually Violent Offenses Pg. 141 Charges Considered Sexually Violent Offenses Pg. 142129 RELEVANT CODE SECTIONS
Code of Virginia Title 19.2. Criminal Procedure Chapter 11. Proceedings on Question of Insanity § 19.2-169.1. Raising question of competency to stand trial or plead; evaluation and determination of competency
A. Raising competency issue; appointment of evaluators. If, at any time after the attorney for the defendant has been retained or appointed and before the end of trial, the court finds, upon hearing evidence or representations of counsel for the defendant or the attorney for the Commonwealth, that there is probable cause to believe that the defendant, whether a juvenile transferred pursuant to § 16.1-269.1 or adult, lacks substantial capacity to understand the proceedings against him or to assist his attorney in his own defense, the court shall order that a competency evaluation be performed by at least one psychiatrist or clinical psychologist who (i) has performed forensic evaluations; (ii) has successfully completed forensic evaluation training recognized by the Commissioner of Behavioral Health and Developmental Services; (iii) has demonstrated to the Commissioner competence to perform forensic evaluations; and (iv) is included on a list of approved evaluators maintained by the Commissioner.
B. Location of evaluation. The evaluation shall be performed on an outpatient basis at a mental health facility or in jail unless the court specifically finds that outpatient evaluation services are unavailable or unless the results of outpatient evaluation indicate that hospitalization of the defendant for evaluation on competency is necessary. If the court finds that hospitalization is necessary, the court, under authority of this subsection, may order the defendant sent to a hospital designated by the Commissioner of Behavioral Health and Developmental Services as appropriate for evaluations of persons under criminal charge. The defendant shall be hospitalized for such time as the director of the hospital deems necessary to perform an adequate evaluation of the defendant's competency, but not to exceed 30 days from the date of admission to the hospital.
C. Provision of information to evaluators. The court shall require the attorney for the Commonwealth to provide to the evaluators appointed under subsection A any information relevant to the evaluation, including, but not limited to (i) a copy of the warrant or indictment; (ii) the names and addresses of the attorney for the Commonwealth, the attorney for the defendant, and the judge ordering the evaluation; (iii) information about the alleged crime; and (iv) a summary of the reasons for the evaluation request. The court shall require the attorney for the defendant to provide any available psychiatric records and other information that is deemed relevant. The court shall require that information be provided to the evaluator within 96 hours of the issuance of the court order pursuant to this section.
D. The competency report. Upon completion of the evaluation, the evaluators shall promptly submit a report in writing to the court and the attorneys of record concerning (i) the defendant's capacity to understand the proceedings against him; (ii) his ability to assist his attorney; and (iii) his need for treatment in the event he is found incompetent but restorable, or incompetent for the foreseeable future. If a need for restoration treatment is identified pursuant to clause (iii), the report shall state whether inpatient or outpatient treatment is recommended. No statements of the defendant relating to the time period of the alleged offense shall be included in the report. The evaluator shall also send a redacted copy of the report removing references to the defendant's name, date of birth, case number, and court of jurisdiction to the Commissioner of Behavioral Health and Developmental Services for the purpose of peer review to establish and maintain the list of approved evaluators described in subsection A.
E. The competency determination. After receiving the report described in subsection D, the court shall promptly determine whether the defendant is competent to stand trial. A hearing on the defendant's competency is not required unless one is requested by the attorney for the Commonwealth or the attorney for the defendant, or unless the court has reasonable cause to believe the defendant will be hospitalized under § 19.2-169.2 . If a hearing is held, the party alleging that the defendant is incompetent shall bear the burden of proving by a preponderance of the evidence the defendant's incompetency. The defendant shall have the right to notice of the hearing, the right to counsel at the hearing and the right to personally participate in and introduce evidence at the hearing. The fact that the defendant claims to be unable to remember the time period surrounding the alleged offense shall not, by itself, bar a finding of competency if the defendant otherwise understands the charges against him and can assist in his defense. Nor shall the fact that the defendant is under the influence of medication bar a finding of competency if the defendant is able to understand the charges against him and assist in his defense while medicated.
130 Code of Virginia Title 19.2. Criminal Procedure Chapter 11. Proceedings on Question of Insanity § 19.2-169.2. Disposition when defendant found incompetent
A. Upon finding pursuant to subsection E of § 19.2-169.1 that the defendant, including a juvenile transferred pursuant to § 16.1-269.1 , is incompetent, the court shall order that the defendant receive treatment to restore his competency on an outpatient basis or, if the court specifically finds that the defendant requires inpatient hospital treatment, at a hospital designated by the Commissioner of Behavioral Health and Developmental Services as appropriate for treatment of persons under criminal charge. Any psychiatric records and other information that have been deemed relevant and submitted by the attorney for the defendant pursuant to subsection C of § 19.2-169.1 and any reports submitted pursuant to subsection D of § 19.2-169.1 shall be made available to the director of the community services board or behavioral health authority or his designee or to the director of the treating inpatient facility or his designee within 96 hours of the issuance of the court order requiring treatment to restore the defendant's competency. If the 96- hour period expires on a Saturday, Sunday, or other legal holiday, the 96 hours
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
This manual provides guidance on the procedures and legal considerations involved in competency restoration for adults within community-based settings. It covers various aspects including treatment orders, court procedures, and certification processes for individuals with intellectual disabilities or mental health issues.
Introduction / Overview
This section introduces the legal framework and the importance of proper procedures in restoring competency and certifying individuals for admission to training centers or other facilities. It emphasizes the roles of courts, community services boards, behavioral health authorities, and other involved entities.
Section 1: Restoration Training Presentations
Details regarding training presentations for staff and stakeholders involved in competency restoration are outlined here. These presentations aim to ensure understanding of legal procedures, treatment protocols, and coordination among agencies.
Section 2: Small Group Work & Case Studies
This section includes case studies and small group activities designed to enhance practical understanding of the legal and clinical processes involved in competency restoration and certification. Participants analyze real or hypothetical cases to apply learned principles.
Section 3: Orientation for CSB/BHA Restoration Counselors
Orientation materials for community services board (CSB) and behavioral health authority (BHA) counselors focus on their roles in assessment, treatment planning, court communication, and legal compliance.
Legal Procedures and Treatment Orders
The following outlines the legal procedures related to competency restoration and treatment orders, including extensions, court reporting, and disposition of defendants.
Extended Treatment Orders
The treatment period shall be extended to the next day that is not a Saturday, Sunday, or legal holiday.
Reporting and Court Rulings
If, at any time after the defendant is ordered to undergo treatment under subsection A, the director of the community services board or behavioral health authority, or their designee, believes the defendant's competency is restored, they shall immediately send a report to the court as prescribed in subsection D of § 19.2-169.1.
The court shall then make a ruling on the defendant's competency according to the procedures specified in subsection E of § 19.2-169.1.
Certification and Recordkeeping
The clerk of court shall certify and forward promptly to the Central Criminal Records Exchange, on a form provided by the Exchange, a copy of an order for treatment issued pursuant to subsection A.
Code References and Legal Citations
The legal citations include references to the Virginia Code, such as Title 19.2 and Title 37.2, detailing procedures for competency, treatment, and certification.
Section 19.2-169.3: Disposition of the Unrestorably Incompetent Defendant; Capital Murder Charge; Sexually Violent Offense Charge
This section describes procedures when a defendant is deemed likely to remain incompetent for the foreseeable future, including reporting requirements, court dispositions, and special considerations for sexually violent offenses.
Key Points:
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Report Submission: The director of the community services board or inpatient facility shall send a report indicating whether the defendant should be released, committed, or certified, especially if deemed unrestorably incompetent.
Court Decisions: The court shall determine the defendant's competency and order appropriate disposition, including continued treatment or release, based on the report.
Sexually Violent Offenders: If charged with a sexually violent offense, the defendant shall be screened according to §§ 37.2-903 and 37.2-904.
Long-term Incompetency: The court may order continued treatment for up to six months at a time, with hearings at each interval, if the defendant remains incompetent but restorable.
Charges and Dismissals: If a defendant remains incompetent after 45 days for certain misdemeanor charges, the court may dismiss charges or order other dispositions.
Court Proceedings and Custody: The court shall order the defendant held in custody until review or trial, and gather relevant information from law enforcement and treatment providers.
Capital Murder Cases: Charges shall not be dismissed if the defendant is charged with capital murder; continued treatment may be ordered.
Restoration and Re-charging: The attorney for the Commonwealth may bring charges once the defendant is restored to competency.
Section 37.2-806: Judicial Certification of Eligibility for Admission of Persons with Intellectual Disability
This section details the process for certifying eligibility for admission to training centers for individuals with intellectual disabilities who cannot request admission themselves.
Procedural Steps:
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Initiation: A parent, guardian, or responsible person may initiate a proceeding if the individual cannot request admission.
Pre-admission Screening: Prior to proceeding, a report recommending admission from the community services board or behavioral health authority must be obtained, along with approval from the proposed training center.
Petition Filing: A petition alleging intellectual disability and need for training or habilitation is filed in a district court or with a special justice.
Service of Process and Representation: Copies of the petition are personally served on the individual, their attorney, and guardian or conservator. An attorney is appointed to represent the individual.
Hearing and Evaluation: The individual has opportunity to prepare defenses, obtain evaluations, and summon witnesses. The judge or special justice shall summon qualified professionals to assess the individual.
Certification: The professional shall certify whether the individual has intellectual disability, is eligible for less restrictive services, and needs training or habilitation.
The process emphasizes careful evaluation, legal protections, and the rights of individuals with intellectual disabilities during certification proceedings.
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
---Introduction / Overview
This manual provides guidance on the procedures and legal frameworks surrounding competency restoration and civil commitments related to mental health and sexually violent predators in Virginia. It includes detailed descriptions of the processes for involuntary admission, voluntary treatment, and the assessment and commitment of sexually violent predators. ---
Section 1: Restoration Training Presentations
Details about training presentations are not included in the provided excerpt. Please refer to the full manual for specific session content and objectives. ---
Section 2: Small Group Work & Case Studies
This section is not detailed in the provided text. For case studies and group work guidelines, consult the complete manual. ---
Section 3: Orientation for CSB/BHA Restoration Counselors
This section offers an overview of legal procedures, assessment protocols, and rights of individuals undergoing involuntary commitment or civil commitment processes in Virginia. ---
Legal Framework for Admission and Commitment
The following sections describe the legal procedures, including certification, hearings, and assessments related to involuntary and civil commitments. ---
Legal Procedures for Certification and Admission
The process involves assessments by physicians, psychologists, or designated officials, and requires compliance with statutory requirements.
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F. If the judge or special justice, having observed the person and having obtained the necessary positive certification and other relevant evidence, specifically finds that:
• (i) the person is not capable of requesting his own admission,
• (ii) the training center has approved the proposed admission pursuant to subsection B,
• (iii) there is no less restrictive alternative to training center admission, consistent with the best interests of the person who is the subject of the proceeding,
• (iv) the person has intellectual disability and is in need of training or habilitation in a training center,
then the judge or special justice shall by written order certify that the person is eligible for admission to a training center.
G. Certification of eligibility for admission hereunder shall not be construed as a judicial commitment for involuntary admission of the person but shall authorize the parent or guardian or other responsible person to admit the person to a training center and shall authorize the training center to accept the person.
Code of Virginia References
This legal framework is codified in Virginia law, specifically Title 37.2, Chapter 8, § 37.2-814, which details the procedures for commitment hearings for involuntary admission. ---
Commitment Hearing for Involuntary Admission (§ 37.2-814)
The hearing shall be held after a sufficient period to complete examinations, prepare reports, and initiate treatment, but within 72 hours of the temporary detention order. If the 72-hour period falls on a weekend or holiday, detention may continue until the next business day.
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A. The hearing shall be held within the specified timeframe, with considerations for weekends and holidays.
B. The judge shall inform the person of their right to voluntary admission and advise that voluntary admission prohibits possession of firearms pursuant to § 18.2-308.1:3. The judge shall assess if the person is willing and capable of voluntary admission, which may be for a minimum of 72 hours, with a 48-hour notice required before discharge.
C. If the person is incapable or unwilling to accept voluntary treatment, the judge shall inform them of their right to a commitment hearing and counsel. The judge shall appoint an attorney if needed.
D. A written explanation of the involuntary admission process and protections shall be provided and explained by an attorney before the hearing.
E. The attorney shall interview the client, review reports, and actively represent the client’s wishes during proceedings.
F. The petitioner shall be given notice of the hearing and may retain counsel, testify, and present evidence. The person sought for involuntary admission shall not be released solely due to petitioner’s absence or failure to testify.
Civil Commitment of Sexually Violent Predators
This section outlines the definitions, assessments, and legal procedures for civil commitment of sexually violent predators in Virginia.
Definitions (§ 37.2-900)
"Commissioner" means the Commissioner of Behavioral Health and Developmental Services.
"Defendant" refers to any person charged with a sexually violent offense deemed unrestorably incompetent pursuant to § 19.2-169.3 and referred for commitment review.
"Department" is the Department of Behavioral Health and Developmental Services.
"Director" is the Director of the Department of Corrections.
"Mental abnormality" or "personality disorder" refers to a congenital or acquired condition affecting emotional or volitional capacity, making the person likely to commit sexually violent offenses and a menace to others.
"Respondent" is the person subject of a petition filed under this chapter.
"Sexually violent offense" includes various felonies under specified statutes, including former and current laws, involving sexual violence or related crimes.
"Sexually violent predator" is a person convicted or charged with a sexually violent offense, deemed unrestorably incompetent, and likely to engage in sexually violent acts due to a mental abnormality or personality disorder. ---
Assessment of Sexually Violent Predators (§ 37.2-904)
Within 180 days of receiving a name from the Director, the CRC shall:
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a. Complete an assessment of the prisoner or defendant for possible commitment.
b. Forward a written recommendation to the Attorney General.
The assessment includes a mental health examination by a licensed psychiatrist or clinical psychologist, not a member of the CRC, skilled in sex offender diagnosis and treatment. The examiner determines if the individual is a sexually violent predator and forwards results and supporting documents to the CRC. The assessment may be based on actuarial or clinical evaluations, review of institutional history, criminal background, and other relevant factors. ---
Recommendation Process (§ 37.2-904)
Following review, the CRC shall recommend whether the individual:
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i. Should be committed as a sexually violent predator; or
ii. Should not be committed but placed in a conditional release program.
Further procedures and criteria for commitment are detailed in the full legal statutes. --- [END OF DOCUMENT]
Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities
Introduction / Overview
This manual provides guidance and resources for competency restoration services provided by CSBs and BHAs. It includes training presentations, small group work, case studies, and orientation materials to support professionals involved in the restoration process.
Section 1: Restoration Training Presentations
This section covers the core training modules designed to equip staff with the necessary skills and knowledge for competency restoration.
Section 2: Small Group Work & Case Studies
Practical exercises and case studies are included to enhance understanding and application of restoration principles in real-world scenarios.
Section 3: Orientation for CSB/BHA Restoration Counselors
Orientation materials are provided to familiarize counselors with procedures, tools, and resources essential for effective restoration services.
Charges that are Considered Sexually Violent Offenses
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18-54 Rape, 1950 Code
18.1-44 Rape, 1950 Code
18.2-31 (5) Capital Murder with sexual assault
18.2-61 Rape
18.2-67.1 Forcible Sodomy
18.2-67.2 Object Sexual Penetration
18.2-48 (ii) Abduction with sexual intent
18.2-48 (iii) Abduction of a child <16 with intent for concubinage or prostitution
18.2-63 Carnal Knowledge of child 13 to 15
18.2-64.1 Carnal Knowledge of minor in care by caregiver
18.2-67.3 Aggravated Sexual Battery
18.2-31 (1) Capital Murder in commission of abduction with intent to defile
18.2-32 1st or 2nd degree murder when present with intent to rape, forcible sodomy or inanimate or animate object sexual penetration
With conspiracy or attempt to commit or attempt any of the above offenses
Forcible sexual offense committed prior to July 1, 1981 that constitutes forcible sodomy, object sexual penetration or aggravated sexual battery
Section 9: Tools and Resources Summary and Supplements
During the training, participants will see demonstrations of various tools and resources used in restoration services. Below is a summary of these tools:
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1. Competency Restoration Training Powerpoints - In English, with informal and formal Spanish translations. Links available at:
Using DJ & Alicia Interactive Video with Adults (CD-ROM)
DJ & Alicia is a 24-chapter interactive computer program, developed by ILPPP and UVA, copyrighted to UVA. It is intended for use with adults in Virginia by CSBs and DBHDS staff only. The program tracks the process of two characters: Alicia, a 13-year-old tried as a juvenile, and DJ, a 15-year-old tried as an adult. The content is tailored to their respective legal statuses.
The program includes interactive videos and flashcards, with exercises following each chapter to assess understanding of legal concepts. It requires no reading, making it suitable for non-readers. Counselors can skip or repeat chapters to tailor restoration to individual needs.
[SIZE=36]Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities [SIZE=27.98]Introduction / OverviewNoted, however, that the program is not a “plug and play” program in that for optimal use the restoration counselor should routinely stop the video and engage the defendant in discussion about what just transpired on the tape.
The program was developed to assess both factual and rational understanding of court related issues.
As with any test/program, the defendant’s results on DJ & Alicia are simply one piece of data to consider when determining whether a particular defendant has regained capacity to proceed to trial.
Simply “passing” the DJ & Alicia sub-tests or final review does not necessarily mean a particular defendant is competent to stand trial.
Prior to using the DJ & Alicia interactive computer program, it is highly recommended that the restoration counselor review the video in its entirety (we recommend reviewing it multiple times) so as to become familiar with the concepts covered in each chapter.
With regard to its applicability to adults, the DJ & Alicia interactive video is likely most appropriate for the following types of defendants:
-
Those with or suspected of having intellectual disabilities
Those defendants with severe learning disabilities
Young defendants (those 18-22)
Immature defendants (as the material is presented in cartoon format)
Non-readers
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Load the DVD into the DVD drive of your computer. If the DVD does not automatically begin playing, follow these steps:
Hit the “Start” key
Select “Computer” or “My Computer”
Double click on “DVD” drive.
Double click on “PC Manual Install Files”
Double click on “DJ & Alicia.exe”
Enter a “dummy” counselor ID number 194
Enter either a “dummy” student ID or assign a student ID (assigning student ID will facilitate your starting back where you left off during previous session).
After you have entered the student ID, click on “Add Student”
Next click on “Continue”
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DJ’s lawyer discusses transfer
DJ in detention reviews transfer
Juvenile Courtroom personnel (AKA Alicia’s court preview)
Juvenile court review of evidence & witnesses
Juvenile court review of closing arguments & verdict
DJ Transfer hearing
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Definitions for Outpatient Restoration Services Pg. 195
Outpatient Restoration Services Flow Chart Pg. 198
Outpatient Restoration Payment Guidelines Pg. 199
Adult Outpatient Competency Restoration Services Report Pg. 201
Definitions for Adult Outpatient Restoration Services SERVICE FUNCTIONS
There are three service functions listed on the DBHDS Adult Competency Restoration Services Report. They are assessment, case management, and restoration.
The definitions are listed below.
I. ASSESSMENT
Assessment is not only a separate category, it is also a REQUIRED part of the adult restoration process.
Assessment should be completed for every court order that is received by the CSB for O-P services and then recorded on the DBHDS Adult Competency Restoration Services Report.
This initial phase of the restoration process called assessment refers to the work of the CSB Outpatient Restoration Coordinator or Counselor.
This is a required function and must be provided by the CSB for all Outpatient Restoration court orders.
The allowable reporting activities in this category include the following:
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Collection of the necessary collateral materials (restoration order, competency evaluation, jail medical info),
Review of medical/treatment collateral materials and preparation for initial interview(s),
Initial interview(s) with the defendant and/or jail medical staff and/or other collateral contacts,
Travel time to assess the defendant and return to the office,
Coordination of psychiatric services or psychological testing when indicated.
**Before the CSB designee makes a recommendation to the court that inpatient services are actually necessary for the restoration of the defendant, they should take the time to carefully evaluate the defendant, possibly meeting with them on several occasions. However, this should not be done at the expense of the defendant who clearly needs inpatient services upon the initial CSB visit. These visits should be conducted as soon as possible to ensure a timely response to the order.
**This required assessment function is not the same as the function of the competency evaluator. The time spent by the evaluator is not included under assessment on the Adult Competency Restoration Services Report.
**The only reasons that the CSB should NOT proceed from assessment into restoration are:**
-
The defendant clearly needs inpatient restoration services, is actively psychotic, won’t take medications, etc.,
The defendant refuses to meet with the restoration counselor after several attempts to engage in the process,
The defendant is unavailable—doesn’t show for several appointments and refuses to meet if in jail after several attempts to engage,
The defendant can’t be located, either the jail location or the community address,
The defendant moves; no forwarding address in the community,
The defendant is transferred to a jail outside of the CSB jurisdiction.
If any of these problems persist, the CSB O-P Coordinator must write to the judge (with copies to the Defense Attorney & Commonwealth Attorney) and explain the problem(s) related to the delivery of services pursuant to the § 19.2-169.2 court order.
Example letters were provided at the training.
**When the CSB receives a 2nd (or more) O-P restoration order for the same defendant, there may not be a need to have additional assessment time on the 2nd (or additional) DBHDS Adult Competency Restoration Services Report.
**The only time an outcome evaluation is not required is when the CSB recommends inpatient restoration services at the time of the assessment phase, prior to the initiation of restoration services.
The CSB should complete and submit the DBHDS Adult Competency Restoration Services Report when the court changes the O-P restoration order to an inpatient restoration order.
II. RESTORATION
The allowable reporting activities in this category include the following:
-
Delivery of psycho-educational restoration services to improve the factual and rational understanding of court issues and related documentation (not to exceed 10-15 minutes per hour of restoration service),
Provision of pre- and post-tests,
Arrangements for the provision of restoration at the jail, at the CSB, in the defendant’s home, etc.,
Travel time to provide restoration services to the defendant and return to the office,
Psychiatric services and/or brief therapy when indicated,
Supervision time can be included as appropriate to the complexity of the case.
**Any time restoration services are initiated after assessment, even if the CSB finds that outpatient restoration is not feasible after all, an outcome evaluation is still required to obtain and submit with the letter to the court explaining the circumstances of the case and the CSB recommendation.
**When the CSB does complete restoration, or at the expiration of the court order (whichever comes first), an outcome evaluation is required to obtain and submit with the letter to the court explaining the outcome of restoration with the CSB recommendation.
III. CASE MANAGEMENT
The allowable reporting activities in this category include the following:
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Arrangement of the outcome evaluation,
Correspondence to the presiding judge, the assigned Commonwealth Attorney, and the defense attorney,
Completing release of information forms, etc.,
Reviewing relevant documents,
Coordination of all services required for the restoration to competency order, including collaborating with jail staff (if detained) and/or treatment providers and other collateral contacts.
There are times when the court will call DBHDS and ask which CSB should be ordered to provide the outpatient restoration because they don’t have the CSB information or because of jurisdictional questions.
In any situation, the court of jurisdiction will not change but the CSB normally associated with the court may change.
If asked by the court for the appropriate CSB, we will recommend a CSB based on accessibility to/location of the defendant.
If a CSB should get an O-P restoration order for a defendant residing outside of their jurisdiction or incarcerated in another jurisdiction, that CSB still has a court order to provide O-P restoration until and/or if the court changes the O-P restoration order to another CSB.
The time spent responding to the original court order, determining the location of the defendant, and communicating back to the Court can all be recorded as assessment and/or case management time spent on the DBHDS Adult Competency Restoration Services Report and submitted to DBHDS for payment with the letter to the court explaining the situation and the CSB recommendation.
[SIZE=27.98]Important Rules to Remember-
Assessment time should be recorded for every restoration case.
Outcome evaluations are required once restoration services have ended or a court order expires (whichever comes first).
A separate report is required for every court order (even if further restoration attempts are needed to bring the defendant to competency).
* See Definitions document, updated 2/1/16.
**There are other reasons for the CSB to find that the defendant is not appropriate for Out-Patient Restoration services during the assessment phase, including the following:
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Defendant refuses to meet with the CSB restoration staff after several attempts by staff to engage the defendant in the process. This can apply to the defendant on bond or in jail.
Defendant is “unavailable”—doesn’t show for several appointments.
Defendant can’t be located or no forwarding address can be obtained if moved.
Defendant moves outside CSB catchment area, either on bond or while incarcerated.
Appears to be appropriate for O-P restoration & restoration is initiated and/or attempted.
Appears to be inappropriate for O-P restoration due to clinical need for inpatient services, restoration, or other reasons.
Restoration & Case Management*
CSB writes letter to court with their recommendation. An outcome evaluation is attached to the court letter.
CSB writes letter to court explaining why...
[SIZE=36]Adult Outpatient Competency Restoration Manual for Community Services Boards & Behavioral Health Authorities [SIZE=27.98]Introduction / Overviewinpatient restoration is indicated. No outcome evaluation is needed Assessment* Court Order for Out-Patient Restoration to the CSB 199 ADULT COMPETENCY RESTORATION PAYMENT GUIDELINES
[SIZE=27.98]Section 1: Restoration Training Presentations1. DBHDS will pay the CSB under the following two circumstances:
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a) The CSB is directly ordered by the Court to provide services to restore an adult’s competency to stand trial pursuant to §19.2-169.2 or
b) The CSB receives a referral from a DBHDS hospital to assess the outpatient restoration appropriateness for an adult ordered to the state hospital for inpatient restoration services pursuant to §19.2-169.2.
2. DBHDS will only pay for those services not covered by the other payment source(s). CSBs should only report those services to DBHDS for which they were not paid from another payment source.
3. DBHDS will pay $50/hour for the following services:
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a) Assessment Services - Please note that this service function is required in all situations.
b) Restoration Services
c) Case Management Services
4. Please refer to the document Definitions for Adult Out-Patient Restoration (Revised 2/1/16) for a summary of allowable functions under the above services.
5. DBHDS will reimburse the CSB up to $400 for an outcome evaluation completed by a licensed clinical psychologist or psychiatrist who has the requisite forensic training and experience prescribed by the Code of Virginia, only if the outcome evaluation is not reimbursed from another source. The CSB should indicate the amount paid to the evaluator when submitting for reimbursement from DBHDS.
An outcome evaluation is required after the conclusion of restoration services or the expiration of the court order (whichever comes first). Cases requiring multiple outcome evaluations per episode (a rare occurrence) will be decided on a case-by-case basis and payment must be approved in advance if requesting DBHDS payment for multiple evaluations.
6. DBHDS will pay the CSB regardless of the actual outcome of restoration services.
7. To receive payment, the CSB must provide the following documentation to DBHDS:
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a) A copy of the court order designating the CSB to provide competency restoration services or a copy of the referral from the state hospital (the CSB should date stamp the order upon receipt),
b) A copy of the outcome evaluation when restoration was attempted or completed,
c) A completed Adult Competency Restoration Services Report (Revised 2/1/16), and
d) A copy of the letter sent to the court explaining the disposition of the restoration order.
8. DBHDS will not pay the CSB if:
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a. Assessment time is not included on Adult Competency Restoration Services Report,
b. An outcome evaluation is not included for restoration services that were attempted or completed, or
c. An Adult Competency Restoration Services Report is received for services that were completed more than 2 months earlier.
9. The Adult Competency Restoration Services Report should be submitted when CSB services are completed, mailed to Sarah Shrum at DBHDS, Office of Forensic Services, P.O. Box 1797, Richmond, VA 23218-1797 or faxed to 804-786-9621.
10. Payment will be processed upon receipt of the required information and included in CSB’s next warrant with a notification email sent to the Executive Director and O-P Restoration Coordinator.
[SIZE=27.98]Section 2: Small Group Work & Case StudiesNo specific content provided in the raw text for this section.
[SIZE=27.98]Section 3: Orientation for CSB/BHA Restoration CounselorsNo specific content provided in the raw text for this section.
[SIZE=27.98]Section 11: Glossary & Helpful Contacts [SIZE=27.98] Glossary of Legal Terminology Pg. 203 [SIZE=27.98] DBHDS Facility & Central Office Staff Pg. 210 [SIZE=27.98]GLOSSARY & HELPFUL CONTACTSDBHDS Facility & Department Staff
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FACILITY | FORENSIC STAFF/CONTACT | PHONE/FAX/EMAIL
Catawba Hospital | P.O. Box 200 Catawba, VA 24070 | 5525 Catawba Hospital Dr. Catawba, VA 24070-0200 | Walton Mitchell, MSW, Hospital Director | Phone: (540) 375-4201 | Fax: (540) 375-4394 | Email: walton.mitchell@dbhds.virginia.gov
| Sherry Weaver, Executive Assistant/Forensic Secretary (FIMS user) | Phone: (540) 375-4259 | Fax: (540) 375-4394 | Email: sherry.weaver@dbhds.virginia.gov
Central State Hospital | P.O. Box 4030 Petersburg, VA 23803-0030 | 23617 West Washington St. Petersburg, VA 23803-0030 | Kristie Hansen, Psy.D., Chief Forensic Coordinator | Phone: (804) 524-7054 | Fax: (804) 524-7069 | Email: Kristie.Hansen@dbhds.virginia.gov
| Martin N. Bauer, Ph.D., Forensic Coordinator | Phone: (804) 518-3678 | Fax: (804) 524-7069/7567 | Email: martin.bauer@dbhds.virginia.gov
| Tonie Williams, Administrative Program Specialist III (FIMS user) | Phone: (804) 524-7117 | Fax: (804) 524-7069 | Email: tonie.williams@dbhds.virginia.gov
| Jamillah Harris, Chief Forensics Admissions Coordinator | Phone: (804) 518-3754 | Fax: (804) 524-7440 | Email: jamillah.harris@dbhds.virginia.gov
| Jaalisa Darden, Assistant Forensic Admissions Officer | Phone: (804) 524-7941 | Fax: (804) 524-7440 | Email: jaalisa.darden@dbhds.virginia.gov
Commonwealth Center For Children & Adolescents | P.O. Box 4000 Staunton, VA 24402-4000 | 1355 Richmond Road Staunton, VA 24402 | Gary Pelton, Ph.D., Forensic Coordinator | Phone: (540) 332-2139 | Fax: (540) 332-2210 | Email: gary.pelton@dbhds.virginia.gov
| Diane Randolph, Administrative Support Specialist (FIMS user) | Phone: (540) 332-2119 | Fax: (540) 332-2209 | Email: diane.randolph@dbhds.virginia.gov
Eastern State Hospital | 4601 Ironbound Road Williamsburg, VA 23188 | Michael Kohn, Psy.D., Forensic Coordinator - NGRI | Phone: (757) 208-7609 | Fax: (757) 253-4703 | Beeper: (757) 881-0844 | Cell: (757) 323-3666 | Email: michael.kohn@dbhds.virginia.gov
| Ann VanSkiver, Psy.D., Assistant Forensic Coordinator | Phone: (757) 208-7990 | Fax: (757) 253-4703 | Email: ann.vanskiver@dbhds.virginia.gov
| Kristen Hudacek, Psy.D., Psychology Director and Forensic Coordinator - Pre-Trial | Phone: (757) 208-7697 | Cell: (757) 208-5465 | Fax: (757) 253-4703 | Email: Kristen.hudacek@dbhds.virginia.gov
| Roberta Ferrell-Holiday, Forensic Admissions Coordinator | Phone: (757) 208-7578, 7579 | Fax: (757) 253-4661 | Email: Roberta.Ferrell-Holiday@dbhds.virginia.gov
| Patty Thomas, Forensic Administrative Assistant (FIMS user) | Phone: (757) 208-7598 | Fax: (757) 253-4703 | Email: Patty.thomas@dbhds.virginia.gov
Northern Virginia Mental Health Institute | 3302 Gallows Road Falls Church, VA 22042 | Azure Baron, Psy.D., ABPP, Director of Psychology and Forensic Coordinator | Phone: (703) 645-4004 | Pager: (703) 719-8276 | Fax: (703) 645-4006 | Email: Azure.Baron@dbhds.virginia.gov
| Diane Corum, Forensic Administrative Assistant (FIMS user) | Phone: (703) 207-7157 | Fax: (703) 645-4006 | Email: diane.corum@dbhds.virginia.gov
Piedmont Geriatric Hospital | P.O. Box 427 Burkeville, VA 23922-0427 | 5001 E. Patrick Henry Hwy. Burkeville, VA 23922-0427 | Lindsey K. Slaughter, Psy.D., ABPP, Psychology Director and Forensic Coordinator | Phone: (434) 767-4424 | Fax: (434) 767-2381 | Email: lindsey.slaughter@dbhds.virginia.gov
| Kristen Wilborn, Administrative Assistant for Psychology Department (FIMS user) | Phone: (434) 767-4945 | Fax: (434) 767-2381 | Email: kristen.wilborn@dbhds.virginia.gov
Southern Virginia Mental Health Institute | 382 Taylor Drive Danville, VA 24541-4023 | Blanche Williams, Ph.D., Director of Psychology & Forensic Coordinator | Phone: (434) 773-4237 | Fax: (434) 791-5403 | Email: Blanche.williams@dbhds.virginia.gov
| Tosha Asumah, Psy.D., Assistant Forensic Coordinator | Phone: (434) 773-4319 | Fax: (434) 791-5403 | Email: tosha.asumah@dbhds.virginia.gov
| Dora Reynolds, Administrative & Office Specialist (FIMS user) | Phone: (434) 773-4290 | Fax: (434) 791-5403 | Email: dora.reynolds@dbhds.virginia.gov
Southwestern Virginia Mental Health Institute | 340 Bagley Circle Marion, VA 24354-3390 | Colin Barrom, Ph.D., Director of Psychology & Forensic Coordinator | Phone: (276) 783-0805 | Fax: (276) 783-1249 | Email: colin.barrom@dbhds.virginia.gov
| Connie Adams, Office Services Assistant (FIMS user) | Phone: (276) 783-0822 | Fax: (276) 783-1249 | Email: connie.adams@dbhds.virginia.gov
| Amanda Forster, Secretary Senior, Psychology Services, Community Services, Social Work (FIMS user) | Phone: (276) 783-1200 | Fax: (276) 783-1249 | Email: Amanda.forster@dbhds.virginia.gov
Western State Hospital | P.O. Box 2500 Staunton, VA 24402-2500 | 103 Valley Center Drive Staunton, VA 24402-2500 | Christy McFarland, Ph.D., Pre-Trial Forensic Coordinator | Phone: (540) 332-8074 | Fax: (540) 332-8145 | Email: Christy.mcfarland@dbhds.virginia.gov
| Brian Kiernan, Ph.D., NGRI Forensic Coordinator | Phone: (540) 332-8007 | Fax: (540) 332-8145 | Email: brian.kiernan@dbhds.virginia.gov
| Doris Kessler, Forensic Program Administrative Specialist (FIMS user) | Phone: (540) 332-8072 | Fax: (540) 332-8145 | Email: doris.kessler@dbhds.virginia.gov
| Margaret (Maggie) Weber, Forensic Admissions Coordinator | Phone: (540) 332-8556 | Fax: (540) 332-8614 | Email: Margaret.weber@dbhds.virginia.gov
Juvenile Competency Services
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P.O. Box 1797 Richmond, VA 23218
Jefferson Building 1220 Bank Street Richmond, VA 23219
Fax: (804) 786-0197
Ben Skowysz, LCSW, CSOTP Program Manager
Chantee Jiggetts, M.ED. Restoration Counselor
Susan Orr, M.Ed. Restoration Counselor
Gerry Walls, B.S. Restoration Counselor
Phone: (804) 840-0280
Email: ben.skowysz@dbhds.virginia.gov
Cell: 804-317-7859
chantee.jiggetts@dbhds.virginia.gov
Phone: (804) 221-0464
Email: susan.orr@dbhds.virginia.gov
Phone: (804) 221-0853
Email: gerry.walls@dbhds.virginia.gov
P.O. Box 1797 Richmond, VA 23218
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Jefferson Building 1220 Bank Street Richmond, VA 23219
Fax: (804) 786-9621
Michael Schaefer, Ph.D., ABPP, Assistant Commissioner of Forensic Services
Steven Dixon, Psy.D., Forensic Operations Manager
Richard Wright, M.S., Forensic Mental Health Consultant
Torres, Ph.D., ABPP Forensic Evaluation Oversight Manager
Jeffrey Aaron, Ph.D., Forensic Programs Consultant
Sarah Shrum, M.A. Diversion Coordinator/Forensic MH Consultant
Jana Braswell, M.S. Coordinator of the Center for Behavioral Health & Justice
Stephen Craver, Statewide CIT Assessment Center Coordinator
Diana Peña, Forensic Program Specialist (FIMS User)
[SIZE=27.98]Contact Information-
Phone: (804) 786-2615
Cell: (804) 363-9306
Fax: (804) 786-9621
Email: michael.schaefer@dbhds.virginia.gov
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Phone: (804) 786-8044
Cell: 804-763-9095
Fax: (804) 786-9621
Email: steven.dixon@dbhds.virginia.gov
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Phone: (804) 786-5399
Cell: (804) 840-2843
Fax: (804) 786-9621
Email: richard.wright@dbhds.virginia.gov
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Phone: 655-4431
Fax: (804) 786-9621
Email: angela.torres@dbhds.virginia.gov
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Phone: (804) 482-8800
Fax: (804) 786-9621
Cell: TBD
Email: jeff.aaron@dbhds.virginia.gov
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Phone: (804) 786-9084
Cell: (804) 814-3993
Fax: (804) 786-9621
Email: sarah.shrum@dbhds.virginia.gov
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Phone: (804) 786-1095
Cell: (804) 356-2859
Fax: (804) 786-9621
Email: jana.braswell@dbhds.virginia.gov
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Phone: (804) 371-0175
Cell: (804) 402-7930
Fax: (804) 786-9621
Email: stephen.craver@dbhds.virginia.gov
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Phone: (804) 774-4483
Fax: (804) 786-9621
Email: diana.pena@dbhds.virginia.gov
Details about the training presentations go here.
[SIZE=27.98]Section 2: Small Group Work & Case StudiesInformation regarding small group activities and case studies.
[SIZE=27.98]Section 3: Orientation for CSB/BHA Restoration CounselorsGuidance and orientation materials for restoration counselors in CSB/BHA settings.
Discharge Assistance Program Overview (5626_MH-CSB 02.pdf)
Discharge Assistance Program Administrative Manual
Effective April 1, 2018
Discharge Assistance Program Manual
Table of Contents
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1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
1. Background of the Discharge Assistance Program (DAP)
The Department of Behavioral Health and Developmental Services (Department) initiated the Discharge Assistance Program (DAP) in 1998.
The DAP supports the Department’s commitment to person-centered and recovery-based care and its vision of a system of services and supports driven by individuals receiving services that promotes self-determination, empowerment, recovery, resilience, health, and the highest level of participation by individuals receiving services in all aspects of community life, including work, school, family, and other meaningful relationships.
The DAP is supported with a pool of state mental health funds allocated to each DBHDS region (Region) to implement community capacity and/or individualized services and supports that enable adults receiving services in state hospitals to live in the community.
The DAP offers a flexible approach for responding to barriers to discharge from state hospitals once an individual has been determined to be clinically ready for discharge.
Community service boards and the behavioral health authority, hereafter referred to as CSBs, through the Regions, use the DAP to support community services and supports that enable individuals to transition from state hospitals to communities where they can recover in the least restrictive and most integrated settings possible.
Regional allocations of DAP state mental health funds are used for individuals at the state hospital whose needs cannot be addressed through the typical array of CSB services and community supports, or if they do not have the funding required to access those services.
Usually these individuals have had long lengths of stay in the hospital and have complex conditions or specialized needs that create barriers to discharge.
These barriers often include one or more of the following:
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• a forensic legal status;
• absence of guardians or authorized representatives;
• lack of affordable housing with sufficient and reliable services and supports that are necessary to enable independent living;
• challenging behaviors or conditions, including complex psychiatric symptoms or significant behaviors, that are difficult to manage and make it difficult to identify willing providers;
• complex medical and/or chronic health conditions;
2. Purpose of the DAP
This manual provides CSBs and their associated Regions with the guidelines for use of DAP.
The DAP has three purposes:
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A. to serve individuals already discharged from state hospitals who are presently receiving services through the DAP and transition them into non-DAP funded services and supports as soon as able;
B. to serve adults in state hospitals who have been determined to be clinically ready for discharge and for whom additional funding for services and supports is required to support their placement in the community through the development, funding, implementation, and utilization review of discharge assistance funds;
C. to fund start-up and/or support ongoing costs for community-based services and supports that enable individuals in state hospitals to be discharged to those services.
This manual describes a uniform mechanism for CSBs and Regions to manage, coordinate, and monitor services provided through the expenditure of DAP funds for IDAPPs and to review the effective utilization of DAP services and resources.
3. General Requirements
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A. The CSBs and state hospital in each region shall develop a memorandum of understanding (MOU) that outlines the region’s practices, processes, and timelines for ensuring compliance with the requirements in this manual. The MOU shall be consistent with the applicable regional provisions and procedures of the current Core Services Taxonomy. The fiscal agent CSB shall ensure the MOU is available for the Department’s review. A model MOU is contained in Appendix B of this manual.
B. CSBs, regional managers, and the Department shall comply in their implementation of the DAP with all applicable provisions of state and federal laws and regulations and the provisions and requirements of this manual, the current community services performance contract, the Discharge Protocols for Community Services Boards and State Hospitals, the current Human Rights and Licensing Regulations, and applicable State Board policies. Applicable provisions of the current Community Services Performance Contract (CSPC) include Exhibit C, attached to this manual as Appendix D, Appendix E: Regional Program Operating Principles and Appendix F: Regional Program Procedures that are in the most recent Core Services Taxonomy, available at http://www.dbhds.virginia.gov.
C. All participating CSBs, regional managers, state hospitals, and the Department shall encrypt transmissions of DAP-related information and data about individuals receiving DAP services, including all forms and reports containing protected health information (PHI) or protected individual information (PII), in a manner specified in the community services performance contract and pursuant to the applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and subsequent implementing regulations.
D. No exceptions or amendments to this manual shall be effective without being reviewed and approved by the Department, dated, and placed in this manual.
4. DAP Management Structure
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A. Regional Program Model: Participating CSBs shall select a regional program model from Appendix E of the current Core Services Taxonomy for the operation of the regional DAP and reflect this model in the MOU developed pursuant to section 3.a of this manual.
B. Regional Management Group (RMG): The participating CSBs and the state hospital serving the region shall establish a RMG. The executive director of each participating CSB and the director of the state hospital shall serve on or appoint one member to the RMG. The RMG shall establish and monitor the operation of a Regional Utilization Management and Consultation Team (RUMCT). The RMG shall:
• manage the DAP and coordinate the use of funding provided for the DAP, including reallocating state DAP funds among CSBs and working with the Department to reallocate state DAP funds among regions if necessary;
• assure the effective utilization of the services and resources provided through the DAP;
• assure that the guidelines outlined in the manual are consistently applied in the administration of DAP.
The RMG may authorize the employment of a regional manager and the necessary staff to administer the DAP with funds drawn from existing regional resources. The RMG shall identify the job description of all staff and identify which CSB will provide supervision of the regional manager and staff.
The establishment and operation of the RMG shall be described in the MOU implemented by the participating CSBs and the state hospital.
The RMG shall comply with the applicable provisions of the Regional Program Operating Principles and the Regional Program Procedures that are in the current Core Services Taxonomy.
In many instances, the responsibilities will be carried out by participating CSBs, the participating state hospital, or the regional manager.
C. Regional Utilization Management and Consultation Team (RUMCT): The RUMCT shall consist of representatives from participating CSBs in the region, participating state hospitals, and others as may be appointed by the RMG, such as the regional manager. The positions of the representatives who serve on this team shall be identified in the MOU.
Since DAP is only one component of the utilization management functions of the RUMCT, a subcommittee designated by the RUMCT may be given authority to perform the functions described in this section.
The RUMCT, through the regional manager and participating CSBs, shall ensure compliance with the documentation required for IDAPP submission and review.
The establishment and operation of the RUMCT shall be described in the MOU implemented by the participating CSBs and the state hospital.
The RUMCT shall comply with the applicable provisions of the Regional Program Operating Principles and the Regional Program Procedures that are in the current Core Services Taxonomy.
D. RUMCT Responsibilities: The responsibilities of the RUMCT will be carried out by designated representatives of the CSBs and the state hospital serving the region, designated subcommittees, and/or the regional manager. The RUMCT shall:
• review proposed IDAPPs to assure services correspond to the individuals’ needs and promote appropriate and effective services to assist with maintaining stability in the community.
• jointly conduct utilization reviews of all IDAPPs at least quarterly. Plans will be reviewed monthly or as needed to determine available funding if there are DAP approval requests for which insufficient funds exist.
• the utilization review by the RUMCT will ensure the:
a. continued appropriateness of services,
b. implementation of approved IDAPPS, including the review of events related to the individual such as re-hospitalization, incarceration, relocation, etc.
c. ensure accurate financial information is provided by their CSB to the regional managers for quarterly reports.
d. address reductions in service levels and/or discontinuation of DAP services resulting in available funds.
e. This utilization review process may result in revisions of IDAPPS, adjustment to and/or redistribution of DAP funds.
• review individuals who are clinically ready for discharge, especially individuals who have been on the state hospital Extraordinary Barriers to Discharge List (EBL), to identify or recommend the development of community services and funding appropriate to their clinical needs.
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
The RUMCT will ensure that the RMG is informed of the results of these reviews and subsequent related actions.
5. DAP Financial Management
A. Allocation and Re-allocation of State DAP FundsEffective in FY 2015, all mental health DAP funds were designated and distributed as regional funds. All DAP funds are designated as restricted funds. CSBs must track, account for, and report all of the actual expenditures supported by these funds separately in CARS and DAP reports. These restricted funds cannot be used for purposes other than DAP. This also applies to unspent prior year balances. B. Disbursement of State DAP Funds
The Department disburses regional DAP funds directly to the CSB acting as the DAP fiscal agent for the region, as part of the regular semi-monthly CSB payments. The fiscal agent CSB administers these funds and distributes the funds for payment of delivered services and/or as determined by the RMG and as described in the regional MOU. The CSB acting as the fiscal agent for the region shall receive payments of state funds from the Department for the DAP through its community services performance contract. The fiscal agent CSB for the region must ensure that previously approved IDAPPs continue to be funded first.
Due to the unpredictability of actual DAP expenditures for individual plans, it is expected that regions will maximize ultimate utilization of funds by over-allocating during the year and scrubbing existing plans to cover the needs. If a region is unable to identify funds sufficient to cover plans that were approved but above the region’s DAP allocation, DBHDS will assure that funding is provided to cover the DAP shortfall. C. Allowable Uses of State DAP Funds
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1. DAP funds allocated to regions and disbursed to participating CSBs shall be used for the discharge and community support of individuals for whom IDAPPs have been approved by the RUMCT or for DBHDS approved community infrastructure development or service expansion that directly and measurably facilitates state hospital discharges.
2. DAP funding may be expended for any approved combination of services that assures the needs of individuals with IDAPPs are met in the most integrated and least restrictive community settings.
3. Regions must use DAP funds only to support the costs of approved ongoing or one-time IDAPPs or DBHDS approved community infrastructure development or service expansion that directly and measurably facilitates state hospital discharges. Any other use of DAP funds is not allowed and funds used for other purposes are subject to recovery by the Department.
4. Regions shall prioritize the use of DAP funds for individuals who have the greatest tenure on the EBL. However, this requirement is subject to the availability of funds and the overall ability to facilitate discharge.
5. Regions may use DAP funds to pay for medications as part of an approved IDAPP only after other sources of support for medications have been exhausted. These sources include state MH Pharmacy-Medication Support funds allocated to CSBs, indigent care programs offered by most pharmaceutical manufacturers, and Medicaid. Medicare Part D, the prescription drug benefit, requires true out-of-pocket costs. DAP funds may not be used on behalf of a Part D beneficiary (e.g., assistance with copayments). DAP funds do not meet the federal definition of incurred out-of-pocket costs required by Part D.
6. Regions cannot use DAP funds to serve individuals receiving state-funded PACT, except for direct residential placement costs such as rent or housing subsidies or other non-PACT provided services.
7. Regions cannot use DAP funds for individuals already living in the community who were previously discharged or previously received DAP services but who no longer have an IDAPP authorized by the RUMCT.
8. Regions cannot use DAP funds to support CSB staff positions or other CSB programs or services that are unrelated to specific individual needs as reflected in ongoing IDAPPs. For example, this includes CSB state hospital liaison positions.
9. Regions cannot approve the use of DAP funds as direct income to any individual receiving DAP services. DAP funds are not individual entitlements and cannot be used to provide personal income to individuals receiving DAP services.
10. For individuals served under DAP who are not Medicaid eligible but are receiving State Plan or Clinic Option Services, the cost of those services is not to exceed the cost or frequency of those services.
D. Maximizing Other Funding and Revenue Sources
The region must use DAP funds as the funding source of last resort for all IDAPPs. The RMG, RUMCT, and the participating CSBs shall ensure that other funds such as Medicaid payments, other appropriate state general funds, fees paid by individuals receiving services, and other third-party funding sources are used to offset the costs of approved IDAPPs to the greatest extent possible so that state DAP funds can be used to discharge the greatest number of individuals from state hospitals.
The costs of an IDAPP must be adjusted to reflect other sources of funding or revenues that are identified and obtained. In cases where an application was made for benefits to be started/reinstated upon discharge from the hospitals, CSBs will monitor the status of the application monthly. CSBs will inform providers of expectations to back bill Medicaid whenever possible and return any DAP paybacks to the Region and will monitor compliance. This shall be documented in records maintained by the CSB and the regional manager and in reports submitted to the Department.
E. Unexpended State DAP Funds
Generally, the use of unspent DAP funds is governed by Appendix C of the CSB Administrative Requirements, incorporated by reference and agreement of the parties into the current community service performance contract and available on the Office of Support Services page of the Department’s website at http://www.dbhds.virginia.gov. All DAP funds are restricted. Any DAP funds that remain unspent at the end of the fiscal year in which they were disbursed by the Department shall remain restricted funds.
Consequently, those unspent DAP funds cannot be used for other purposes and shall be used by regions and participating CSBs to defray the costs of current IDAPPs before current fiscal year state DAP funds are used. Balances of unspent state DAP funds that are not used within the fiscal year in which they were allocated are subject to recovery by the Department through future payments to regional fiscal agent CSB.
During the fiscal year, unexpended DAP funds may accrue as a result of delays in discharges, re-hospitalization or incarceration of an individual receiving DAP services, reductions in services in approved IDAPPs, termination of an IDAPP, and/or changes in allocations among CSBs.
The RUMCT, with authorization from the RMG, may approve the use of any of its unexpended DAP funds only for the following priorities:
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1. for one-time IDAPPs to support the discharge of individuals in the state hospital;
2. for addressing the one-time needs of individuals with existing IDAPPs;
3. for transitional costs of individuals determined to be NGRI as part of the privileging process or for other individuals in state hospitals with documented clinical needs for transitional services and supports in order to be discharged. This may at times be an exception to the requirement that the individual be ‘ready for discharge’ as advancement through the NGRI privileging process requires trial passes;
4. for temporary funding to supplement an IDAPP while the CSB obtains benefits for an individual;
5. when needed, to cover the cost of obtaining a guardian for an individual in a state hospital. This process may begin prior to the individual becoming clinically ready for discharge in order to prevent the guardianship process from delaying discharge when the individual is clinically ready.
6. in specific cases and with the approval of the RUMCT, large one-time fund IDAPPs may be granted to individuals requiring ongoing supports when ongoing DAP dollars are not available at the time of discharge. In those cases, there is no time limitation on the one-time support. However, these individuals must be reported in CCS3 and be given a 910 Code designation.
7. for developing and/or expanding regional infrastructure to enable the discharge of individuals in state hospitals, such as residential resources or other community placements. When DAP funds are used to create community capacity, the specific use of the funds, the individuals discharged, and services provided as a result of the infrastructure will be reported annually along with the year-end IDAPP report to DBHDS.
If a region is not able to expend at least 90 percent of its total ongoing regional DAP allocation for active ongoing plans and obligate at least 95 percent of its total regional state DAP funding allocation by the end of the fiscal year, the Department will work with the RMG to transfer unspent or unobligated state DAP funds to other regions to reduce the EBL at other state hospitals unless the Department determines that there are extenuating circumstances which justify an exception.
6. Census Management
A. Discharge Readiness
Participating CSBs shall develop the discharge plan in consultation with the individual, guardian or authorized representative, and the state hospital treatment team. This plan describes the specific community mental health, developmental, substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services to the individual.
B. Clinically Ready for Discharge Monitoring
The participating CSBs through the RUMCT and regional manager shall monitor individuals who are clinically ready for discharge at the state hospital serving the region monthly to track individuals for whom they are the case management CSB and ensure the individuals are discharged as soon as possible.
C. Development of
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
Individualized Discharge Assistance Program Plans
1. The case management CSB, the individual being discharged, his/her guardian or authorized representative, and the state hospital treatment team shall determine the most appropriate services and placement in the community for the individual that are consistent with his or her choices to the greatest extent possible.
2. DAP services and supports must be documented on the IDAPP, and the IDAPP must be consistent with the individual’s preferences and choices to the greatest extent possible.
3. All individuals with ongoing IDAPPs must receive case management services or documented CSB monitoring. This shall be documented monthly in progress notes by the case management CSB and used to provide updates during regional DAP scrubbings.
4. The IDAPP shall be completed and endorsed by all relevant parties. The case management CSB must submit a brief narrative describing the individual needs and proposed plan, identified placement, projected discharge date, and an explanation of all revenues and costs with all new or renewing IDAPPs. The explanation of costs shall include a justification/explanation as to why DAP is a last-resort funding source, particularly for individuals who have Medicaid/Medicare, or will become eligible for these benefits upon discharge.
New IDAPPs must identify all the services the individual needs to successfully transition to the community, the providers who have agreed to provide the services, and a projected discharge date. The IDAPP must display all of the revenues by source and all of the projected expenses for the services in the IDAPP.
D. Monitoring of IDAPPs: The RUMCT or its designee shall review at least quarterly the implementation of all IDAPPs to ensure the effective and efficient utilization of the DAP funds. If the region does not have sufficient funds to approve new ongoing DAP requests, the review of existing plans shall occur monthly, or more often if needed. The RUMCT shall develop a process of communication to ensure that the RMG is informed of the utilization review activities.
If the case management CSB is not able to implement an approved IDAPP for the individual within 30 calendar days of his or her projected date of discharge, one of the following actions shall be taken within 30 calendar days following the projected date of discharge:
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The region shall identify and discharge another individual who is on the EBL or who has been determined to be clinically ready for discharge and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;
If the preceding action does not occur within 30 days, the funds identified for the IDAPP will revert to the RUMCT for an IDAPP to discharge an individual from another region on the EBL (according to prioritization process in C.4.) and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;
Should an individual who has been adjudicated Not Guilty by Reason of Insanity (NGRI) not be discharged within 30 days of the projected discharge date due to circumstances beyond the control of the individual, CSB and/or state hospital; the CSB shall send a memo to the RUMCT with an explanation of said circumstance. Examples of these circumstances could include, but are not limited to: IFPC and/or FRP revision requests, residential provider withdrawing acceptance for reasons not related to the individual’s behavior, the NGRI court’s delay in scheduling a conditional release hearing date, etc. The RUMCT shall make a decision to continue funding IDAPP based on the facts presented.
E. Rehospitalization: Upon occasion it may be necessary for DAP enrollees to receive inpatient psychiatric services or be incarcerated. Should this occur, the case management CSB will notify the RUMCT. The RUMCT then may select from the following options:
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If the RUMCT approves a written request from the CSB, it will stop current payments and resume payments upon the individual’s discharge, if that date is within an agreed-upon number of days not to exceed 90 days from the date of rehospitalization in a state hospital;
If the CSB submits a request to the RUMCT that states rehospitalization will exceed 30 days and ongoing funds will be needed to maintain the individual’s residence for an agreed-upon period not to exceed 90 days, the RUMCT may approve the provision of the necessary funds during that period only in the amount required to maintain the individual’s place of residence. The RMG shall redistribute any resulting unspent funds in accordance with the provisions in this manual;
The CSB returns the state DAP funds, less year-to-date expenditures, for the unimplemented IDAPP to the RUMCT for redistribution.
For all IDAPPs where the service provider is not the CSB, the CSB shall develop a purchase of service agreement, memorandum of agreement, or other instrument consistent with the CSBs’ purchasing policies and procedures. All such instruments shall be maintained by the affected CSBs and available to the Department upon request.
7. Transfers of Individuals Between CSBs or Regions
(These instructions apply unless the Department determines that there are extenuating circumstances which justify an exception)
A. In the case of individuals transferring between CSBs, the CSB in the chosen locality becomes the receiving case management CSB and works with the original case management CSB, the individual, and the state hospital to effect a smooth discharge and transition to the community.
The case management CSB of origin is responsible for the completion of the discharge plan, and shall collaborate with the receiving CSB. Effective July 1, 2018, DAP funds will be transferred from the originating/home CSB to the receiving CSB within 6 months of the individual’s transition.
B. The receiving region accepts the transfer of the IDAPP funds. The receiving CSB shall then be responsible for the reporting required by the performance contract. The affected CSBs and regions shall notify the respective regional managers and the Department of any changes in case management CSB designation and request the fund transfer no later than 30 days post-discharge or transfer.
C. If additional DAP funds other than those provided through the original IDAPP are required to support the individual in the new setting after transfer, the region holding the IDAPP funds for the individual shall provide the additional funding based on approval of a revised IDAPP.
D. If an individual receiving DAP services decides to move to another CSB’s service area within the region, the receiving CSB will assume Case Management CSB responsibilities and shall be responsible for the appropriate reporting in CARS and CCS 3.
E. If an individual approved for DAP funds elects to reside outside of their DBHDS region of origin, it is understood that the respective regions and CSBs shall work collaboratively in addressing the individual’s preferences and needs.
F. Individuals who have been adjudicated NGRI and are placed outside of their case management CSB service area or region may have specific conditions associated with their Conditional Release Plan related to their case management CSB or their area of residence. Under these conditions, the CSB may choose (or be required) not to reallocate funds and oversight to the new region, in which case the CSB and region of origin shall remain the case management CSB and region of record. The case management CSB is then responsible for all required reporting under the performance contract and conditional release plan.
Resolution process:
A. When disagreements related to transfer of DAP oversight occur, the regional utilization management teams shall make a reasonable effort to resolve the areas of disagreement. If they are unable to come to a resolution, then the regional managers shall notify their respective regional CSB Regional Chair of their disagreement with the transfer request.
B. The regional chairs shall make every attempt to resolve the issues that prevent agreement about transfer of the DAP.
C. If the disagreement remains unresolved, the regional managers shall within two weeks of the CSB chairs’ meeting, initiate a request in writing to the Director of Acute Care (or designee) for dispute resolution.
D. The Director of Acute Care (or designee) shall gather and review the information and consult with the relevant parties to come to a decision regarding the transfer of DAP oversight.
E. During the process outlined above, the individual’s placement and services shall not be delayed. The resolution process will simply address regional “ownership” of the DAP funds and case management CSB designation.
8. Reporting
A. Performance Contract Reporting Requirements:
Participating CSBs and regional managers shall comply with all of the requirements in Exhibit C of the community services performance contract, contained in this manual as Appendix D, including the following reporting requirements. The regional manager shall submit the quarterly summary of IDAPPs to the Department in a format reviewed by the Department in consultation with regional managers and designated members of VACSB.
Quarterly reports will document year-to-date information about ongoing and one-time IDAPPs, including data about each individual receiving DAP services, the amounts of DAP funds approved for each IDAPP, the total number of IDAPPs that have been implemented, and the total DAP funds obligated for these IDAPPs. The first and third quarter reports are due thirty (30) days following the end of the quarter. The second and fourth quarter reports are due forty-five (45) days after the end of the quarter.
It is the participating CSB’s responsibility to provide the regional manager with accurate information related to actual costs and other data to ensure the accuracy of reports. Reports on DAP funding that is used to increase community capacity will be due at the end of each fiscal year, or as otherwise required by DBHDS.
B. Community Consumer Submission 3 (CCS 3) Reporting:
The case management CSB is responsible for ensuring that the required information about the individual, his/her type of care (Consumer Designation Code for DAP), and the services received are entered in their information system and reported to the Department through the extraction by the CCS 3. CCS 3 submissions must satisfy the requirements in Exhibit I of the performance contract. These requirements apply to all IDAPPs implemented with DAP funds.
CSBs shall assign a 910 Consumer Designation Code only to individuals with ongoing IDAPPs, including those funded through extended use of one-time funds. Additional information about assigning, initiating, and ending consumer designation codes and about all other aspects of reporting data through the CCS is available in the current Community Discharge Assistance Program Administrative Manual 13 Consumer Submission 3 Extract Specifications, which is available at http://www.dbhds.virginia.gov/professionals-and-service-providers/office-of-support-services
C. Community Automated Reporting System (CARS) Reporting:
The case management CSB responsible for directly providing or purchasing the services in an individual’s IDAPP shall reflect, account for, and report the actual revenues and actual expenses associated with the services in the IDAPP through
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Reviews and Evaluation
Appendices
9. Reviews and Evaluation
A. Utilization Review
The participating CSBs and state hospital in each region shall develop and implement a utilization review process for all IDAPPs. At a minimum, this process (known as “scrubbing”) will include a review of the current IDAPPs, services being received, confirmation that the individual has applied for and/or is receiving all eligible benefits or entitlements (e.g., Medicaid, insurance, SSI/SSDI, or other sources), amounts of other income received, and confirmation of the residential placement during the quarter.
The RUMCT and/or designated subcommittee shall conduct quarterly utilization reviews of approved IDAPPs to ensure continued appropriateness of services, compliance with approved IDAPPs, and individual-related events such as re-hospitalizations, incarcerations, or terminations of services.
If the region does not have sufficient unallocated DAP funds to support approval requests for new plans, the RUMCT will review existing plans monthly, or more frequently as needed, to identify under or unused funds.
B. Department Review
The Department shall regularly monitor the performance of the regions’ management of the DAP as well as the CSBs’ implementation of IDDAPs. Pursuant to sections 6.f and 7.c in the CSPC, the Department may conduct ongoing utilization reviews and analyze information about individuals receiving services, the services they received, and financial information related to the DAP, such as re-hospitalizations, transitions to non-DAP supported services and supports, maximization of other revenue sources, expenditure patterns, use of resources, outcomes, and performance measures to ensure the continued effectiveness and efficiency of the DAP.
The Department shall include the financial and programmatic operations of the DAP as part of its regular CSB Review, which is conducted by multidisciplinary teams including Department fiscal and program staff.
CSBs are identified for review through standard risk management criteria.
C. Performance Measures
The Department has developed performance measures for the DAP to assess the effectiveness of the DAP. These measures use existing data sources to avoid imposing additional workload burdens on CSBs, state facilities, and regional managers.
The current set of measures is contained in Appendix E of this manual.
The RUMCT and RMG shall monitor the performance measures established by the Department through reports provided by the Department. The RMG and participating CSBs shall take action in a timely manner to address unsatisfactory performance on any measure.
Appendix A: Definitions
Case Management
Community Services Board (CSB) means the CSB that serves the area in which an adult resides. The case management CSB is responsible for case management, liaison with the state hospital when an individual is admitted, and discharge planning.
Reference in this manual to CSB means case management CSB, unless the context clearly indicates otherwise, and CSB includes the behavioral health authority established pursuant to § 37.2-601 of the Code of Virginia. CSB and BHA are defined in § 37.2-100 of the Code of Virginia.
Community Automated Reporting System (CARS)
means the Department software application that each CSB uses to report the types and capacities of services provided, costs for services provided, and revenues received by source and amount and expenses paid by program area (mental health, developmental, or substance abuse services) and for emergency and ancillary services.
CSBs submit CARS reports to the Department mid-year and at the end of the fiscal year.
Community Consumer Submission 3 (CCS 3)
means the Department software application that each CSB uses to report data on individuals receiving mental health, developmental, substance abuse, emergency, and ancillary services and the types and amounts of services they receive.
CSBs submit CCS 3 extracts to the Department monthly.
Clinical Readiness for Discharge
means the determination that an individual is clinically ready for discharge from a state hospital.
All state hospitals and CSBs make this determination consistently using the standard clinical readiness for discharge rating scales established by the Department. The rating scale is contained in Appendix C.
Discharge plan
means an individualized plan for post-hospital services that is developed by the CSB in consultation with the individual, guardian or authorized representative if one has been appointed or designated or if one is needed, and the state hospital treatment team.
This plan is required by § 37.2-505 or § 37.2-608 of the Code of Virginia, and it describes the specific community mental health, developmental, substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services and supports.
Extraordinary Barriers List (EBL)
means the list generated by the Department and state hospitals that identifies adults who have been determined to be clinically ready for discharge (rated Level 1), but who remain in the hospital for more than 14 days after that determination.
Individualized Discharge Assistance Program Plan (IDAPP)
means the plan developed by the case management CSB and reviewed and approved by the RUMCT that contains all of the services and supports an individual needs to be discharged from a state hospital and identifies the types and amounts of and all of the revenues and costs for those services.
On-going DAP Request
means an IDAPP for services and/or supports to be provided on an ongoing basis to the individual.
One-time DAP Request
means an IDAPP for services and/or supports to be provided to an individual on a time-limited basis. One-time DAP requests are not renewable.
Performance Contract
means the contract between the Department and a CSB that defines the responsibilities of and requirements on each party for delivery of services, reporting data about individuals receiving services and the services they receive, service quality, performance and outcome measures, and programmatic and fiscal accountability.
The contract is the primary accountability mechanism between the Department and CSBs.
DBHDS Region (Region)
means the grouping of CSBs and state hospital designated by the Department to address challenges, service needs, and collaborative planning and implementation of initiatives in a defined geographical area congruent with the state hospital’s service area.
Regional participants include representatives from the CSBs, state hospital, private psychiatric hospitals and other private providers, individuals receiving services, family members, advocates, and other stakeholders from within that region.
Regional Management Group (RMG)
means the group established in a DBHDS region by the participating CSBs and state hospital that oversees the management of regional programs and the use of regional resources, including state funds.
The RMG consists of the executive director of each CSB and the region’s state hospital director.
Regional Utilization Management and Consultation Team (RUMCT)
also referred to as Regional Utilization Management (RUM) in some documents, means the group that provides direct oversight and monitoring of the DAP, including development and approval of IDAPPs, DAP planning, funding decisions and the maximization of all revenue sources, utilization management, and the efficient discharge of individuals from state hospitals.
The RUMCT includes representatives of the participating CSBs and state hospital and involved private providers.
This team also is responsible for monitoring the use of other regional funds or programs, such as LIPOS or crisis stabilization.
While not members of the RUMCT, Department central office staff frequently participate in RUMCT meetings.
State Hospital
means a mental health hospital operated by the Department of Behavioral Health and Developmental Services.
For purpose of this manual, state hospital does not include the Hiram Davis Medical Center, the Commonwealth Center for Children and Adolescents, or the Virginia Center for Behavioral Rehabilitation.
Utilization Review
(also known as “scrubbing”) means the process in which the RUMCT reviews active IDAPPs and adjusts services, costs, and revenues to more accurately reflect the changing needs of supporting the individual in the community.
While individual needs change and IDAPP expenses may be more or less than the initial projection, these reviews often result in the identification of unneeded funds that may be used for IDAPPs to support discharges of other individuals from state hospitals.
Appendix B: Model Memorandum of Understanding
Planning Partnership Region (insert number) CSBs and (insert name) State Hospital Discharge Assistance Program Memorandum of Understanding for FY (insert year)
This Memorandum of Understanding (MOU) is made and entered into on (insert month, day, and year) by and between the community services boards, hereafter referred to as participating CSBs, and the state hospital, hereafter referred to as the participating State Hospital, listed below that are the parties to this MOU.
-
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating CSB
• insert name of participating State Hospital
I. Purpose
The parties listed above enter into this MOU for the purpose of implementing the regional Discharge Assistance Program, hereafter referred to as the DAP. The DAP has three purposes:
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• to serve individuals already discharged from state hospitals who are presently receiving services through the DAP and transition them into non-DAP funded services and supports;
• to serve adults in state hospitals who have been determined to be clinically ready for discharge and for whom additional funding for services and supports is required to support their placement in the community through the development, funding, implementation, and utilization review of discharge assistance funds.
• to fund start-up and/or support ongoing costs for community-based services and supports that enable individuals in state hospitals to be discharged to those services.
This MOU provides a uniform mechanism for the parties to manage, coordinate, and monitor services provided through the expenditure of DAP funds for IDAPPs and to review the effective utilization of DAP services and resources.
End of Document
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
---4. DAP Management Structure
The RMG shall manage the DAP and coordinate the use of funding provided for the DAP, including allocating state DAP funds among CSBs.
The RMG shall establish and monitor the operations of the Regional Utilization Management and Consultation Team (RUMCT) to manage all aspects of the DAP.
The RMG may authorize the employment of a regional manager and the necessary staff to administer the DAP with funds drawn from existing regional resources. The RMG shall identify the job description of all staff and identify which CSB will provide supervision of the regional manager and staff.
The RMG shall coordinate and monitor the effective utilization of the services and resources provided through the DAP using data and reports provided by the RUMCT and regional manager.
The RMG shall perform other duties identified in this MOU or assigned by the participating CSBs or participating State Hospital.
Although not members of the RMG, designated staff in the Central Office of the Department of Behavioral Health and Developmental Services (Department) shall have access to all documents including IDAPPs maintained or used by the RMG pursuant to applicable provisions of the current community services performance contract and may attend and participate in all meetings or other activities of the RMG. ---
B. Regional Utilization Management and Consultation Team (RUMCT)
The RMG shall establish a Regional Utilization Management and Consultation Team, hereafter referred to as the RUMCT, to manage all aspects of the DAP.
The RUMCT shall ensure compliance with the requirements outlined in the DAP Administrative Manual and IDAPP submission and review.
The RUMCT shall consist of representatives from participating CSBs in the region, the participating State Hospital, and others as may be appointed by the RMG, such as the regional manager.
The RUMCT shall be composed of:
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(insert name, title/position, and organization, e.g., name of CSB)
(insert name, title/position, and organization, e.g., name of CSB)
(insert name, title/position, and organization, e.g., name of CSB)
(insert name, title/position, and organization, e.g., name of CSB)
(insert name, title/position, and organization, e.g., name of CSB)
(insert name, title/position, and organization, e.g., name of CSB)
(insert name, title/position, and organization, e.g., name of CSB)
The RUMCT shall meet at least monthly or more frequently when necessary, for example, depending upon funding needs, census issues or the number of cases to be reviewed. Minutes shall be recorded at each meeting.
The RUMCT shall:
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review the proposal of the IDAPPs developed through the DAP to ensure that the services are the most appropriate, effective, and efficient services that meet the clinical needs of the individual receiving services.
jointly conduct utilization reviews (“scrubbing”) of all IDAPPs quarterly, or if indicated, more frequently to ensure the:
continued appropriateness of services,
implementation of approved IDAPPs, including the review of events related to the individual such as re-hospitalization, incarceration, relocation, etc.,
ensure accurate financial information is provided by their CSB to the regional managers for quarterly reports,
address reductions in service levels and/or discontinuation of DAP services resulting in available funds.
The regional manager, in collaboration with the participating CSBs, shall maintain a current database on all individuals receiving DAP-funded services. This database shall include electronic copies of all ongoing or one-time IDAPPs. All IDAPPs shall be submitted using the Department approved form.
The regional manager shall maintain automated back-up data transferable by encryption on all regional DAP activities.
Although not members of the RUMCT, designated staff in the Central Office of the Department shall have access to all documents including IDAPPs maintained or used by the RUMCT pursuant to applicable provisions of the current community services performance and may attend and participate in all meetings or other activities of the RUMCT. ---
III. DAP Financial Management
A. Allocation and Re-allocation of State DAP Funds
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The Department allocates all mental health DAP funds on a regional basis among the DBHDS Regions. DAP funds previously designated as local DAP funds and allocated to individual CSBs are now included in the regional state DAP funds.
Additionally, all DAP funds are designated as restricted funds. CSBs must track, account for, and report all of the actual expenditures supported by these funds separately in CARS and DAP reports. These restricted funds cannot be used for purposes other than DAP.
B. Disbursement of State DAP Funds
The Department disburses regional DAP funds directly to the CSB acting as the fiscal agent for the region, as part of the regular semi-monthly CSB payments.
The fiscal agent CSB administers these funds and distributes the funds for payment of delivered services and/or as determined by the RMG and as described in the regional MOU.
The CSB acting as the fiscal agent for the region shall receive payments of state funds from the Department for the DAP through its community services performance contract.
The fiscal agent CSB for the region must provide CSBs with sufficient funding to ensure the previously approved IDAPPs continue to be funded.
C. Allowable Uses of State DAP Funds
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DAP funds allocated to regions and disbursed to participating CSBs shall be used exclusively for the following purposes:
to serve individuals already discharged from state hospitals who are presently receiving services through the DAP and transition them, when possible, into non-DAP funded services and supports;
to serve adults in state hospitals who have been determined to be clinically ready for discharge and for whom additional funding for services and supports is required to support their placement in the community through the utilization of discharge assistance funds.
to fund start-up and/or support ongoing costs for community-based services and supports that enable individuals in state hospitals to be discharged to those services.
D. Maximizing Other Funding and Revenue Sources
The region and participating CSBs must use DAP funds as the last resort funding source for all IDAPPs.
The RMG, RUMCT, and the participating CSBs shall ensure that other funds such as Medicaid payments, other appropriate state general funds, fees paid by individuals receiving services, and other third-party funding sources are used to offset the costs of approved IDAPPs to the greatest extent possible so that state DAP funds can be used to discharge the greatest number of individuals from state hospitals.
The costs of an IDAPP must be adjusted to reflect other sources of funding or revenues that are identified and obtained. This shall be documented in records maintained by the CSB and the regional manager and in reports submitted to the Department.
E. Unexpended State DAP Funds
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Generally, the use of unspent DAP funds is governed by Appendix C of the CSB Administrative Requirements. However, all DAP funds are restricted, and any DAP funds that remain unspent at the end of the fiscal year in which they were disbursed by the Department shall remain restricted funds.
Consequently, those unspent balances above 10% of the annual allocation of state DAP funds that are not used within the fiscal year in which they were allocated are subject to recovery by the Department through payments to the Department by the region holding the balances, reductions in current disbursements to the region holding the balances, or reductions in other funding.
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
---4. DAP Service Management
IV. Census Management
A. Discharge Planning:Participating CSBs shall develop the discharge plan in consultation with the individual, guardian or authorized representative, and the state hospital treatment team. This plan describes the specific community mental health, developmental, or substance abuse, employment, health, educational, housing, recreation, transportation, legal, and advocacy services and supports needed by the individual following an episode of hospitalization and identifies the providers that have agreed to provide these services to the individual. B. Extraordinary Barriers to Discharge List (EBL) Monitoring and Reporting:
The participating CSBs through the RUMCT and regional manager shall monitor the EBL and the Discharge Ready list at the state hospital serving the region monthly to track individuals for whom they are the case management CSBs to ensure the individuals are discharged as soon as possible. C. Development of Individualized Discharge Assistance Program Plans (IDAPP):
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1. The case management CSB, the individual being discharged, his/her guardian or authorized representative, and the state hospital treatment team shall determine the most appropriate services and placement in the community for the individual that are consistent with his or her choices to the greatest extent possible.
2. DAP services and supports must be documented on the IDAPP, and the IDAPP must be consistent with the individual’s preferences and choices to the greatest extent possible.
3. All individuals with ongoing IDAPPs must receive case management services or documented CSB monitoring. This shall be documented monthly in progress notes by the case management CSB and used to provide updates during DAP “scrubbing”.
4. The IDAPP shall be completed and endorsed by all relevant parties. The case management CSB must submit a brief narrative describing the individual needs and proposed plan, identified placement, projected discharge date, and an explanation of all revenues and costs with all new or renewing IDAPPs. New IDAPPs must identify all the services the individual needs to successfully transition to the community, the providers who have agreed to provide the services, and a projected discharge date. The IDAPP must display all of the revenues by source and all of the projected expenses for the services in the IDAPP.
5. When DAP funds are used to create or expand community infrastructure, the planned use, costs, services/supports, and number of individuals to be served must be submitted to DBHDS for prior approval. The regional manager shall then submit an accounting of expenditures, units/types of service provided, and individuals served at the end of each fiscal year.
6. Monitoring of IDAPPs: The RUMCT or its designee shall review at least quarterly and more frequently when there is a shortage of regional DAP funds, the implementation of all IDAPPs to ensure the effective and efficient utilization of the DAP funds. The RUMCT shall develop a process of communication to ensure that the RMG is informed of the utilization review activities. If the case management CSB is not able to implement an approved IDAPP for the individual within 30 calendar days of his or her projected date of discharge, one of the following actions shall be taken within 30 calendar days following the projected date of discharge:
a. The region shall identify and discharge another individual who is on the EBL or who has been determined to be clinically ready for discharge and for whom DAP funding is appropriate for addressing the barriers to that individual’s discharge;
b. If the preceding action does not occur within 30 days, the funds identified for the IDAPP will revert to the RUMCT for an IDAPP to discharge another individual according to the DAP prioritization process;
c. Should an individual who has been adjudicated Not Guilty by Reason of Insanity (NGRI) not be discharged within 30 days of the projected discharge date due to circumstances beyond the control of the individual, CSB and/or state hospital; the CSB shall send a memo to the RUMCT with an explanation of said circumstance. Examples include: IFPC and/or FRP revision requests, residential provider withdrawing acceptance for reasons not related to the individual’s behavior, the NGRI court’s delay in scheduling a conditional release hearing date, etc. The RUMCT shall decide whether to continue funding the IDAPP based on the facts presented.
D. Rehospitalization:
Upon occasion, it may be necessary for DAP enrollees to receive inpatient psychiatric services or be incarcerated. Should this occur, the case management CSB will notify the RUMCT. The RUMCT then may select from the following options: 1. If the RUMCT approves a written request from the CSB, it will stop current payments and resume payments upon the individual’s discharge, if that date is within an agreed-upon number of days not to exceed 90 days from the date of re-hospitalization in a state hospital; 2. If the CSB submits a request to the RUMCT that states re-hospitalization will exceed 30 days and ongoing funds will be needed to maintain the individual’s residence for an agreed period not to exceed 90 days, the RUMCT may approve the necessary funds during that period in the amount required to maintain the individual’s place of residence and other critical services such as guardianship. The RMG shall redistribute any resulting unspent funds in accordance with this manual; 3. The CSB returns the state DAP funds, less year-to-date expenditures, for the unimplemented IDAPP to the RUMCT for redistribution.
The cost of supporting a substitute individual shall not exceed the amount requested in the originally approved IDAPP unless funding is available and approved by the RUMCT. If the cost of services is less than originally requested, unexpended funds will be available to the RUMCT for redistribution in accordance with this manual.
For all IDAPPs where the service provider is not the CSB of origin, that CSB shall develop a purchase of service agreement, memorandum of agreement, or other instrument consistent with the CSBs’ purchasing policies and procedures. All such instruments shall be maintained by the affected CSBs and available to the Department upon request. ---
5. Transfers of Individuals Between CSBs or Regions
If the individual, or with the consent of a guardian or an authorized representative, chooses to reside in a different locality after discharge from the state hospital, the CSB in the chosen locality becomes the receiving case management CSB and works with the original case management CSB, the individual, and the state hospital to effect a smooth discharge and transition to the community.
The case management CSB of origin is responsible for the completion of the discharge plan and is expected to collaborate with the receiving CSB. If an individual receiving DAP services decides to move to another CSB’s service area within the region, the receiving CSB will assume case management responsibilities and shall be responsible for the appropriate reporting in CARS and CCS.
If an individual approved for DAP funds elects to reside outside of the DBHDS region of origin, it is understood that the respective regions and CSBs shall work collaboratively in addressing the individual’s preferences and needs. The following are examples of how this process applies:
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The receiving region accepts the transfer of the IDAPP funds and assumes case management CSB responsibilities. Effective July 1, 2018, the transfer of DAP funds shall occur within six months of the individual being placed in the receiving region.
The receiving CSB shall then be responsible for the reporting required of the performance contract.
The affected CSBs and regions shall notify the respective regional managers and the Department of any changes in case management CSB designation and request the fund transfer no later than 30 days post-discharge or transfer.
This transfer of DAP funds shall apply unless the Department determines that there are extenuating circumstances which justify an exception.
If additional DAP funds other than those provided through the original IDAPP are required to support the individual in the new setting after transfer, the region holding the IDAPP funds for the individual shall provide the additional funding based on approval of a revised IDAPP.
In all cases of an individual residing outside of their original region, DAP funds shall be transferred to the region in which the individual resides within six months of discharge from the hospital.
Individuals who have been adjudicated NGRI and are placed outside of their case management CSB service area or region may have specific conditions associated with their Conditional Release Plan related to their case management CSB or their area of residence. Under these conditions, the CSB may choose (or be required) not to reallocate funds and oversight to the new region, in which case the CSB and region of origin shall remain the case management CSB and region of record.
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
---VI. Reporting
Modify this section and insert applicable details in this section of the reporting operations of the regional program model selected by the RMG.
A. Performance Contract Requirements:
Participating CSBs and the regional manager shall comply with all of the requirements in Exhibit C of the community services performance contract, including the following reporting requirements.
The regional manager shall submit the quarterly summary of IDAPPs to the Department in a format developed by the Department in consultation with regional managers and designated members of VACSB.
Quarterly reports will document year-to-date information about ongoing and one-time IDAPPs, including data about each individual receiving DAP services and the amounts of DAP funds approved for each IDAPP (if requested), the total number of IDAPPs that have been implemented, and the total DAP funds obligated for these IDAPPs.
The first and third quarter reports are due thirty (30) days following the end of the quarter. The second and fourth quarter reports are due forty-five (45) days after the end of the quarter.
It is the participating CSBs’ responsibility to provide the regional manager with accurate information related to actual costs and other revenue to ensure the accuracy of reports.
B. Community Consumer Submission 3 (CCS 3) Reporting:
The case management CSB is responsible for ensuring that the required information about the individual, his/her type of care (Consumer Designation Code for DAP), and the services received are entered in their information system and reported to the Department through the extraction by the CCS 3.
CCS 3 submissions must satisfy the requirements in Exhibit I of the performance contract.
These requirements apply to all IDAPPs implemented with DAP funds.
CSBs shall assign a 910 Consumer Designation Code only to individuals with ongoing IDAPPs, including ongoing plans that are supported through extended use of one-time funds.
Additional information about assigning, initiating, and ending consumer designation codes and about all other aspects of reporting data through the CCS is available in the current Community Consumer Submission 3 Extraction Specifications, which is available at .
C. Community Automated Reporting System (CARS) Reporting:
The case management CSB responsible for directly providing or purchasing the services in an individual’s IDAPP shall reflect, account for, and report the actual revenues and actual expenses associated with the services in the IDAPP through the mid-year and end of the fiscal year CARS reports.
Reports must satisfy the requirements in Exhibit I of the performance contract.
These requirements apply to all IDAPPs implemented with DAP funds. ---
VII. Review and Evaluation
A. Utilization Review:
The participating CSBs and the state hospital in each region shall develop and implement a utilization review process for all IDAPPs and DAP-supported programs.
At a minimum, this process (known as “scrubbing”) will include a review of the current IDAPP, services being received or provided, confirmation that the individual has applied for and/or is receiving all eligible benefits or entitlements (e.g., Medicaid, insurance, SSI/SSDI, or other sources), amounts of other income received, and confirmation of the residential placement during the quarter.
The RUMCT and/or designated subcommittee shall conduct quarterly utilization reviews of approved IDAPPs to ensure continued appropriateness of services, compliance with Discharge Assistance Program Administrative Manual, and individual-related events such as re-hospitalizations, incarcerations, or terminations of services.
If the region does not have sufficient funds to approve new ongoing DAP requests, the review of existing plans shall occur monthly, or more often if needed.
B. Department Reviews:
The Department shall regularly monitor the performance of the regions’ management of the DAP as well as the CSBs’ implementation of IDAPPs.
Pursuant to sections 6.f and 7.c in the Community Services Performance Contract, the Department may conduct ongoing utilization reviews and analyze information about individuals receiving services, the services they received, and financial information related to the DAP, such as re-hospitalizations, transitions to non-DAP supported services and supports, maximization of other revenue sources, expenditure patterns, use of resources, outcomes, and performance measures to ensure the continued effectiveness and efficiency of the DAP.
The Department shall include the financial and programmatic operations of the DAP as part of its regular CSB Review, which is conducted by multidisciplinary teams including Department fiscal and program staff.
C. Performance Measures:
The RUMCT and RMG shall monitor the performance measures established by the Department in the DAP Manual by receiving reports at least quarterly from the regional manager on the DAP’s achievement of the measures.
The RMG and participating CSBs shall take actions in a timely manner to address unsatisfactory performance on any measure. ---
VIII. Term of the MOU
This MOU shall be in effect for one year beginning on July 1, (enter year) and ending on June 30, (enter year).
This MOU shall automatically renew for four additional 12-month periods unless terminated in writing as provided below. ---
IX. Termination of the MOU
Each of the parties is authorized to terminate this MOU if it determines that another party has violated a material term of the MOU.
Each of the parties may terminate its obligations under this MOU by giving each of the other parties 60 days’ written notice.
If one or more of the parties gives notice of its desire to terminate the MOU, the parties shall confer to determine whether the DAP may continue in effect without the participation of the terminating party or parties.
If the DAP is terminated or the Department reduces state funding for the DAP, participating CSBs shall not be required to continue to provide services that are the subject of this MOU.
In the event funding is terminated or reduced, continued access to community services for individuals currently receiving DAP services shall be governed by the existing community services performance contract, CSB policies, and other procedures for the provision of services. ---
X. General Terms and Conditions
A. Compliance:
The parties and the regional manager agree they shall comply in their implementation of the DAP with all applicable provisions of state and federal law and regulations, the provisions and requirements of the DAP Manual, the current community services performance contract, the Discharge Protocols for Community Services Boards and State Hospitals, the current Human Rights and Licensing Regulations, and applicable State Board policies.
Applicable provisions of the current community services performance contract include Exhibit C and Appendix E: Regional Program Operating Principles and Appendix F: Regional Program Procedures that are in current Core Services Taxonomy.
If there are any conflicts or inconsistencies between any provisions of this MOU and the current community services performance contract, applicable provisions of the contract shall control.
However, this MOU may modify applicable provisions in Appendix F of Core Services Taxonomy to reflect the unique nature of the DAP.
B. Authority and Amendments:
Nothing in this MOU shall be construed as authority for any of the parties to make commitments that will bind the other parties beyond the scope of this MOU.
Furthermore, the parties shall not assign, sublet, or subcontract any work related to this MOU or any interest it may have herein without the prior written consent of the other parties.
No alteration, amendment, or modification in the provisions of this MOU shall be effective unless put in writing, signed by the parties, and attached hereto.
Nothing in this MOU is intended to, nor does it create, any claim or right on behalf of any individual to any services or benefits from any of the parties.
C. Privacy of Personal and Health Information:
For purposes of this section, parties include the regional manager. A. Confidentiality:
The parties to this MOU agree to maintain all protected health information (PHI) and personally identifiable information (PII) learned about individuals receiving services confidential and agree to disclose that information only in accordance with applicable state and federal law and regulations, including the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Virginia Health Records Privacy Act, the Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers of Mental Health, Developmental, and Substance Abuse Services, and each party’s own privacy policies and practices. B. Disclosures and Responsibilities:
Even though each party may not provide services directly to each of the individuals receiving services through DAP and this MOU, the parties may disclose PHI, PII, or other confidential information about individuals to one another under 45 C.F.R. § 164.512(k)(6)(ii) and applicable provisions in the current community services performance contract in order to perform their responsibilities under this MOU, including coordination of the services and functions provided under this MOU and improving the administration and management of the services provided to the individuals receiving services hereunder.
In carrying out their responsibilities under this MOU, the parties may use and disclose PHI, PII, or other confidential information to one another to perform the functions, activities, or services specified in this MOU on behalf of one another, including utilization review, financial and service management and coordination, collaboration and sharing of information relative to discharge planning and clinical case consultation.
In so doing, the parties and the regional manager agree to:
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not use or further disclose PHI, PII, or other confidential information other than as permitted or required by the terms of this MOU or as required by law;
use appropriate safeguards to prevent use or disclosure of PHI, PII, or other confidential information other than as permitted by this MOU;
report to the other parties any use or disclosure of PHI, PII, or other confidential information not provided for by this MOU of which they become aware;
impose the same requirements and restrictions contained in this MOU on their subcontractors and agents to whom they provide PHI, PII, or other confidential information received from, or created or received by, the other parties to perform any services, activities or functions on behalf of the other parties;
provide access to PHI, PII, or other confidential information contained in a designated record set to the other parties, in the time and manner designated by the other parties, or, at the request of the other parties, to an individual in order to meet the requirements of 45 CFR 164.524 or applicable provisions in the current community services performance contract;
make available PHI, PII, or other confidential information in its records to the other parties for amendment and incorporate any amendments to PHI, PII, or other confidential information in its records at the request of the other parties;
document and provide to the other parties information relating to disclosures of PHI, PII, or other confidential information as required for the other parties to respond to a request by an individual for an accounting of disclosures of PHI, PII, or other confidential information in accordance with 45 CFR 164.528;
make their internal records available to the other parties for review and amendment as needed, and to respond to requests for disclosures or amendments in accordance with applicable law and regulations.
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
---Section 3. General Requirements
practices, books, and records relating to use and disclosure of PHI, PII, or other confidential information received from or created or received by the other parties, available to the Secretary of the U.S. Department of Health and Human Services for the purposes of determining compliance with 45 CFR Parts 160 and 164, subparts A and E applicable provisions in the current community services performance;
9. implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI, PII, or other confidential information that they create, receive, maintain, or transmit on behalf of the other parties as required by the HIPAA Security Rule, 45 C.F.R. Parts 160, 162, and 164 applicable provisions in the current community services performance contract;
10. ensure that any agent, including a subcontractor, to whom they provide electronic PHI, PII, or other confidential information agrees to implement reasonable and appropriate safeguards to protect it;
11. report to the other parties any security incident of which they become aware; and
12. at termination of this MOU, if feasible, return or destroy all PHI, PII, or other confidential information received from or created or received by the parties on behalf of the other parties that the parties still maintain in any form and retain no copies of such information or, if such return or destruction is not feasible, extend the protections of this MOU to the information and limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible.
D. Use and Disclosure of Confidential Information
Each of the parties may use and disclose PHI, PII, or other confidential information received from the other parties, if necessary, to carry out its legal responsibilities and for the proper management and administration of its business.
Each of the parties may disclose PHI, PII, or other confidential information for such purposes if the disclosure is required by law, or if the party obtains reasonable assurances from the person to whom the PHI, PII, or other confidential information is disclosed that it will be held confidentially, that it will be used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and that the person will notify the party of any instances of which it is aware in which the confidentiality of the information has been breached.
E. Data Transmission and Security
All parties shall encrypt transmissions of DAP-related information and data about individuals receiving DAP services, including all forms and reports containing PHI, PII, or other confidential information, in a manner specified in the community services performance contract and pursuant to the applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and subsequent implementing regulations.
Discharge Assistance Program Administrative Manual - Signature Section
IN WITNESS WHEREOF, the parties have caused this agreement to be duly executed, intending to be bound thereby.
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Appendix C: Clinical Readiness for Discharge Rating Scale
Treatment teams shall rate the clinical readiness for discharge of all individuals receiving services in state hospitals at least monthly using the following scale.
1. Clinically Ready for Discharge:
The individual meets any of the following criteria.
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has met treatment goals and does not need inpatient psychiatric treatment
NGRI with up to 48-hour privilege level
NGRI under a temporary custody order and at least one forensic evaluator has recommended conditional or unconditional release and there is a pending court date
NGRI on revocation status and the treatment team and CSB recommend conditional or unconditional release and there is a pending court hearing
2. Almost Clinically Ready for Discharge:
The individual meets any of the following criteria.
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needs additional inpatient care to fully address clinical issues and/or there is concern about adjustment difficulties
can take community trial visits to assess readiness for discharge; may have the civil privilege level to go on overnight temporary visits
resistant to discharge and refuses to engage in discharge process
NGRI with unescorted community visits privilege
3. Not Clinically Ready for Discharge:
The individual meets any of the following criteria.
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participates in treatment (engaged, adherent with medications, groups, etc.) but unable to function independent of 24-hour supervision in an inpatient psychiatric setting
not yet able to take independent passes or trial passes to a supervised placement but may have unescorted grounds privileges if available at the hospital
NGRI and does not have unescorted community visits privilege
4. Significant Clinical Instability Limiting Privileges and Engagement in Treatment:
The individual meets any of the following criteria.
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not psychiatrically stable
requires constant 24-hour supervision in an inpatient psychiatric setting
presents significant risk and/or behavioral management issues
acutely psychotic
Notes: Discharge planning begins on admission and should be active throughout the individual’s hospitalization independent of his or her clinical readiness for discharge rating. An individual may be clinically ready for discharge before the rating is formally completed. ---
Appendix D: Community Services Performance Contract
Exhibit C: Discharge Assistance Program Requirements
The Department and the CSB agree to implement the following requirements for management and utilization of all current regional state DAP funds to enhance monitoring of and financial accountability for DAP funding, decrease the number of individuals on state hospital extraordinary barriers to discharge lists (EBLs), and return the greatest number of individuals from state hospitals to their communities.
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The Department shall work with the VACSB, representative CSBs, and regional managers to develop clear and consistent criteria for identification of individuals who would benefit from use of DAP to support their discharge and acceptable uses of regional state DAP funds and standard terminology that all CSBs and regions shall use for collecting and reporting data about individuals, services, revenues, expenditures, and costs.
The CSB shall comply with the current Discharge Assistance Program Manual issued by the Department, which by agreement of the parties is hereby incorporated into and made a part of this contract by reference. If there are conflicts or inconsistencies between the Manual and this contract, applicable provisions of the contract shall control.
All regional state DAP funds allocated within the region shall be managed by the regional management group (RMG) and the regional utilization management and consultation team (RUMCT) on which the CSB participates in accordance with Appendices E and F of the current Core Services Taxonomy.
The CSB, through the RMG and RUMCT on which it participates, shall ensure that other funds such as Medicaid payments are used to offset the costs of approved IDAPPs to the greatest extent possible so that regional state DAP funds can be used to implement additional DAP services and supports to reduce EBLs.
On behalf of the CSBs in the region, the regional manager funded by the Department and employed by a participating CSB shall submit mid-year and end-of-the-fiscal-year reports to the Department in a format developed by the Department in consultation with regional managers that separately displays the total actual year-to-date expenditures of regional state DAP funds for ongoing IDAPPs and for one-time IDAPPs and the amounts of obligated but unspent regional state DAP funds.
If CSBs in the region cannot expend at least 90 percent and obligate at least 95 percent of the total annual regional state DAP fund allocations on a regional basis by the end of the fiscal year, the Department may work with the RMG and participating CSBs to transfer regional state DAP funds to other regions to reduce EBLs to the greatest extent possible, unless the Department determines that there are extenuating circumstances which justify an exception.
On behalf of the CSBs in a region, the regional manager shall continue submitting the quarterly summary of IDAPPs to the Department in a format developed by the Department in consultation with regional managers that displays year-to-date information about ongoing and one-time IDAPPs, including data about each individual receiving DAP services, the amounts of regional state DAP funds approved for each IDAPP, the total number of IDAPPs that have been implemented, and the projected total net regional state DAP funds obligated for these IDAPPs.
The Department, pursuant to sections 6.f and 7.g of this contract, may conduct utilization reviews of the CSB or region at any time to confirm the effective utilization of regional state DAP funds and the implementation of all approved ongoing and one-time IDAPPs.
Appendix E: DAP Performance Measures Data
Performance Measures Data Sources for Measures
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1. Utilization of State Hospital Bed Days by Individuals Before and After Enrollment in DAP
State Hospital Bed Days Used by DAP-Enrolled Individuals Over Equal Time Periods Pre- and Post-DAP Enrollment
CCS 3 Type of Care and Service Records
AVATAR
2. Readmission to a State Hospital within 30 and 180 Days After Enrollment in DAP
Percent of 30 and 180 Day State Hospital Readmissions by Individuals Enrolled in DAP ÷ Percent of 30 and 180 Day State Hospital Readmissions by All Adults During the Reporting Period
CCS 3 Type of Care and Service Records
AVATAR
3. Admission to a State Hospital After Release From a DAP Episode of Care
Individuals Admitted to a State Hospital Within 60 Days of Release From a DAP Episode of Care ÷ Total Number of Individuals Released From DAP During the Reporting Period
CCS 3 Type of Care and Service Records
AVATAR
4. Individuals Discharged to DAP From a State Hospital Extraordinary Barrier List (EBL)
State Hospital EBL Individuals Discharged to DAP ÷ All Individuals Newly Enrolled in DAP During the Reporting Period
CCS 3 Type of Care and Service Records
AVATAR
5. Utilization of State DAP Funds
Total State DAP Funds Expended ÷ Total State DAP Funds Allocated During the Reporting Period for Each Region
Quarterly DAP Reports
CARS
6. Housing Stability (deferred)
Number of Individuals in DAP with No More Than One Housing Move ÷ Total Number of
Discharge Assistance Program Administrative Manual
Table of Contents
1. Background of the Discharge Assistance Program (DAP)
2. Purpose of the DAP
3. General Requirements
4. DAP Management Structure
5. DAP Financial Management
6. DAP Service Management
7. Transfers of Individuals Among CSBs and Regions
8. Reporting
9. Review and Evaluation
Appendices
---Appendix F: Notes and Sources for DAP Performance Measures
1. Data for all measures can be displayed statewide, by region, and by individual CSB.
2. Number of individuals receiving DAP services is derived from the CCS 3 Type of Care (910 Code) and Service (receipt of valid mental health services) Records.
3. Number of individuals completing a DAP episode of care (released from the DAP) is derived from the CCS 3 Type of Care (910 Code and type of care through date).
4. Number of individuals admitted to a state hospital is derived from AVATAR.
5. Number of state hospital beds is derived from AVATAR.
6. Number of individuals enrolled in Medicaid: CCS 3 Consumer Record (insurance type and Medicaid number) and quarterly DAP reports.
7. Number of individuals for whom Medicaid payments have been received is derived from quarterly DAP reports.
8. Amount of state DAP funds allocated is derived from CARS reports.
9. Amount of state DAP funds expended is derived from Quarterly DAP Reports.
10. Changes in residence are derived from the CCS 3 Consumer Record (Data Element 88).
Guidelines for Managing NGRI Individuals (1989_FOR 01.pdf)
i
[SIZE=21.96pt]INTRODUCTIONIndividuals who have been found Not Guilty by Reason of Insanity (herein referred to as insanity acquittees, acquittees, or NGRIs) by Virginia criminal courts require attention for clinical and legal needs as a result of their connection to both the mental health and criminal justice systems.
This manual outlines the basic expectations regarding the management of individuals found Not Guilty by Reason of Insanity.
This information should assist administrators, clinicians, court personnel, treatment team members in state operated mental health facilities, and staff of Community Services Boards /Behavioral Health Authorities in evaluating, treating, and managing individuals found Not Guilty by Reason of Insanity in a manner that is consistent with legal mandates and professional standards.
This set of guidelines is based on Chapter 11.1 of Title 19.2 of the Code of Virginia, specifically Sections 19.2-167 through 19.2-182 which describe proceedings on the question of insanity, Sections 19.2-182.2 through 19.2-182.16 which describe the legal process for Virginia's disposition of individuals acquitted by reason of insanity, and Virginia Code Section 19.2-174.1 which describes the information required prior to admission to a mental health facility.
The Code of Virginia may be accessed at https://law.lis.virginia.gov/vacode.
This document revises and replaces previous versions of the NGRI Manual: Guidelines for the Management of Individuals Found Not Guilty by Reason of Insanity, which was originally disseminated in 1997 and updated in 2003.
Any questions regarding these guidelines should be referred to the Office of Forensic Services at the Department of Behavioral Health & Developmental Services.
Christine Schein, LCSW Deputy Director for Forensic Services Virginia Department of Behavioral Health & Developmental Services
ii TABLE OF CONTENTS Chapter 1: The Insanity Defense in Virginia-
I. The Insanity Defense is One of Several Mental Health Law Questions ........................................1
II. Use of the Insanity Defense .................................................................................................1
III. Tests for Insanity ..................................................................................................................2
IV. Expert Evaluations for Indigent Defendants ........................................................................3
V. Presentation of the Insanity Defense ....................................................................................3
VI. Use of Insanity Defense in Juvenile Courts .........................................................................4
VII. Disposition of Insanity Acquittees: What Happens after a Finding of Insanity? ................4
VIII. Highlights of Virginia's Code-Mandated Disposition of Acquittees ...................................4
IX. Multiple Courts of Jurisdiction ...........................................................................................10
• Chart 1.1: Disposition of Insanity Acquittees under §§ 19.2-182.2 through 19.2-182.16 .....................................................................................................11
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I. Placement ...........................................................................................................................13
II. Assignment of Community Services Board Case Manager ...............................................17
III. Temporary Custody Evaluation .........................................................................................17
IV. One or Both Evaluators Recommend Conditional Release or Release without Conditions ..........................................................................................................................19
V. Hearing and Disposition .....................................................................................................20
• Table 2.1: Evaluation during Temporary Custody .....................................................21
• Table 2.2: Criteria for Commitment for Inpatient Hospitalization .............................22
• Table 2.3: Criteria for Conditional Release ................................................................23
• Table 2.4: Criteria for Release without Conditions ....................................................24
• Form: Model Order for Temporary Custody ...............................................................25
• Form: Model Order for Extension of Temporary Custody .........................................27
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I. Placement Decisions Following Commitment ...................................................................28
II. Forensic Coordinator Responsibilities ...............................................................................28
III. Transfers from a Civil Unit back to Maximum Security Unit at Central State Hospital ...29
IV. Continuation of Confinement Hearings for Felony Acquittees .........................................29
V. Acquittee Petitions for Release ..........................................................................................32
VI. Release Without Conditions from the Custody of the Commissioner ................................33
VII. Escape from Custody of the Commissioner ......................................................................33
• Table 3.1: Required Court Hearings for Felony Acquittees after Commitment to the Commissioner for Inpatient Hospitalization ........................................36
• Table 3.2: Procedures for Annual Continuation of Confinement Evaluations ...........37
• Table 3.3: Procedures for Commissioner Petitions for Conditional or Unconditional Release ...............................................................................38
• Table 3.4: Procedures for Acquittee Petitions for Release Evaluations .....................39
• Form: Cover Letter for Annual Report to the Court ...................................................40
• Form: Model Order for Initial Commitment ...............................................................41
• Form: Model Order for Recommitment ......................................................................43
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I. Graduated Release .............................................................................................................44
II. Risk Assessment Factors Considered by the Panel ............................................................45
III. Factors Used to Determine Suitability for Less Restrictive Privileges ..............................46
IV. Guidelines for Specific Steps in Graduated Release .........................................................48
V. Notification to the Commonwealth's Attorney of Community Visits ...............................50
VI. Roles and Responsibilities of the Internal Forensic Privileging Committee .....................51
VII. Roles and Responsibilities of the Forensic Review Panel ................................................53
VIII. Facility Forensic Coordinator ............................................................................................58
IX. Facility Director .................................................................................................................59
X. Process for Privileges Granted by Internal Forensic Privileging Committee ....................60
XI. Process for Privileges Granted by Forensic Review Panel ................................................68
• Chart 4.1: Graduated Release Flow Chart ...................................................................77
• Table 4.2: Changes in Status: Whose Permission is Required? ...................................78
• Table 4.3: Forensic Review Panel and Internal Forensic Privileging Committee Responsibilities ...........................................................................................79
• Table 4.4: Roles of the Internal Forensic Privileging Committee and the Forensic Review Panel in the Acquittee Management Process .................................80
• Table 4.5: Internal Forensic Privileging Committee Privileging Process: Roles and Procedures ...................................................................................................81
• Table 4.6: Forensic Review Panel Privileging Process: Roles and Procedures ...........82
• Form: Forensic Review Panel Privilege Request and Decision Notice .......................84
• Form: Internal Forensic Privileging Committee Decision Notice ...............................86
• Form: Model Notification to Commonwealth’s Attorney of Community Visits ........87
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I. Legal Parameters of Conditional Release Planning Process ..............................................88
II. Initiating the Conditional Release Planning Process ........................................................89
III. Petitions for Release ..........................................................................................................89
IV. Victim Notifications ...........................................................................................................91
V. Guidelines for Requesting Conditional Release ................................................................92
VI. Development of a Conditional Release Plan .....................................................................93
VII. Components of a Conditional Release Plan .......................................................................95
VIII. Discharge Procedures .........................................................................................................97
IX. Plan to Monitor Compliance with Conditions of Release .................................................98
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I. Community Services Board NGRI Coordinator .............................................................100
II. Implementing the Conditional Release Plan ....................................................................100
III. Assistance from DBHDS Office of Forensic Services ...................................................101
IV. Reporting to the Courts - Six-Month Reports to the Court .............................................101
V. Acquittee Non-Compliance with the Conditional Release ..............................................102
VI. Modifying Conditional Release Orders/Plans .................................................................103
VII. Revocation of Conditional Release .................................................................................105
VIII. Civil Emergency Custody Orders, Temporary Detention Orders, or Hospitalization .....108
IX. Contempt of Court ...........................................................................................................109
X. Procedures Following Revocation of an Acquittee from Conditional Release ...............109
XI. Hospital Readmission of the Acquittee; Return to the Custody of the Commissioner ...110
XII. Review by the Forensic Review Panel after Return to the Custody of the Commissioner ..................................................................................................................110
XIII. Release without Conditions .............................................................................................112
• Form: Monthly Review of Conditional Release .......................................................114
• Form: Six-Month Report to Court ............................................................................125
INTRODUCTION
This manual provides guidelines for managing individuals found not guilty by reason of insanity (NGRI) in Virginia. It covers legal provisions, assessment procedures, treatment approaches, and post-adjudication management.
TABLE OF CONTENTS
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Chapter 1: The Insanity Defense in Virginia
I. The insanity defense and legal questions requiring psychological evidence
II. Use of the Insanity Defense
III. Tests for Insanity
IV. Expert Evaluations for Indigent Defendants
V. Presentation of Insanity Defense
VI. Use of the Insanity Defense in Juvenile Courts
VII. Disposition of Insanity Acquittees
VIII. Highlights of Virginia's Code - Mandated Disposition after a Finding of Not Guilty by Reason of Insanity
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Appendix A: Analysis of Risk
Appendix B: Working with the Virginia Courts
Appendix C: Commissioner Appointed Evaluations for the Court
Appendix D: Reports to the Court
Appendix E: Treatment Approaches for Insanity Acquittees
Appendix F: Conditional Release Plan
Appendix G: Forensic Coordinator Responsibilities
I. The insanity defense and legal questions requiring psychological evidence
This defense focuses on the defendant's mental state at the time of the offense and asks whether the defendant is criminally responsible for their behavior as a result of that mental state.
The insanity defense was designed to protect against the conviction and punishment of morally blameless persons.
Other legal questions requiring psychological evidence include:
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1. Competency to Stand Trial
a. Focuses on a defendant's current mental condition (rather than mental condition at the time of the offense)
b. Asks whether the defendant has an adequate understanding of the proceedings and an ability to assist in his/her defense
c. The goal is to assure a fair, accurate, and dignified trial
d. Most frequently asked referral question
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Ask whether there is anything about a defendant's mental condition that warrants consideration at sentencing
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"Voluntariness" of confessions and competency to waive rights
II. Use of the Insanity Defense
A. Infrequently used and rarely successful
B. National use
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1. Raised in approximately 1% of criminal cases
2. Successful only 25% of the time
3. Most states have an insanity defense.
C. Virginia use: Between 2017 and 2021, there was an average of 80 NGRI acquittals per year.
III. Tests for Insanity
A. Vary from state to state
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1. Examples: M'Naghten, Irresistible Impulse Test, American Law Institute Test, and Federal Test
2. Mental disorder alone is never sufficient
B. Virginia Test
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1. Product of case law (DeJarnette v. Commonwealth, 75 Va. 867 (1881); Price v. Commonwealth, 228 Va. 452, 323 S.E.2d 106 (1984); Thompson v. Commonwealth, 193 Va. 704, 70 S.E.2d 284 (1952))
2. Defendant is insane if, at time of the offense, because of mental disease or defect, they:
a. did not understand the nature, character, and consequences of their act
b. was unable to distinguish right from wrong
c. was unable to resist the impulse to commit the act
3. "Mental disease or defect" is defined as a disorder that "substantially impairs the defendant's capacity to understand or appreciate his conduct"
a. Psychotic disorders qualify
b. Intellectual disabilities qualify
c. Voluntary intoxication does not qualify: (1) "settled insanity" due to substance abuse may qualify. The criteria are organic impairment, with psychotic symptoms, resulting from long-term substance use (2) voluntary intoxication may negate "premeditation" to reduce homicide offense from first-degree or capital murder to second-degree murder
4. "Nature, character, and consequences" are not defined. It is not clear whether the defendant must have believed that the act was legally justified, or whether the belief that the act was morally justified suffices.
5. It is frequently unclear whether a defendant with a mental disorder was legally insane at the time of the offense.
6. The degree of impairment in cognitive or volitional capacity necessary for a finding of insanity is a social value judgment for the judge or jury.
IV. Expert Evaluations for Indigent Defendants
Indigent defendants who show "probable cause" to believe that sanity will be a significant factor in their defense are entitled to a state-funded expert (psychiatrist or psychologist) to perform evaluation and, "where appropriate, to assist in the development of an insanity defense" (Va. Code § 19.2-169.5; Ake v. Oklahoma, 470 U.S. 68 (1985)).
V. Presentation of Insanity Defense
A. Only the defendant may raise the defense of insanity at the time of the offense.
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1. At least sixty days prior to trial, the defendant must give notice to the attorney for the Commonwealth of the intention to put sanity at issue and to present testimony of an expert (§ 19.2-168).
B. After the defense attorney gives notice as described above, the Commonwealth's Attorney can then seek an evaluation of the defendant's sanity at the time of the offense (§ 19.2-168.1).
C. The defendant has the burden of proving insanity to the satisfaction of the judge or jury (Boswell v. Commonwealth, 61 Va. 860 [20 Gratt.] (1871)).
D. The judge or jury decides whether the defendant was insane at the time of the offense based on expert testimony and other evidence.
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1. Misdemeanor cases are typically tried in general district court where there are no jury trials.
2. Felony cases are tried in circuit court where the defendant may insist on a jury trial.
3. Misdemeanor cases may also be tried in the Juvenile & Domestic Relations court, as in the General District court.
E. The majority of cases are the result of plea bargains in which the defense and the prosecution agree to the finding of insanity at the time of the offense. "Battles of experts" are rare.
VI. Use of the Insanity Defense in Juvenile Courts
The Supreme Court of Virginia has held that the insanity defense is not available to juveniles in delinquency proceedings (Commonwealth v. Chatman, 260 Va. 562 (2000)).
Juveniles whose cases are transferred to Circuit court to be prosecuted as adults may raise the insanity defense.
VII. Disposition of Insanity Acquittees: What happens after an individual is found not guilty by reason of insanity?
A. Acquittees are not subject to penal sanctions (punishment) such as jail or prison sentences, probation, parole, and/or fines.
B. Acquittees may be committed for hospitalization pursuant to special commitment laws that are different than those that regulate civil commitment.
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1. Virginia civil commitment laws: Va. Code § 37.2-800 et seq.
2. Virginia insanity disposition and commitment laws: Va. Code §§ 19.2-182.2 through 19.2-182.16
C. Court controls management of the acquittee for an indeterminate period, as long as the acquittee continues to meet the criteria outlined in §§19.2-182.2 through 19.2-182.16.
D. Virginia Code §§ 19.2-182.2 through 19.2-182.16 address the post-adjudication stages, after a person has been found not guilty by reason of insanity.
VIII. Highlights of Virginia's Code - Mandated Disposition after a Finding of Not Guilty by Reason of Insanity
The following section provides a brief overview of Virginia’s law regarding the disposition of insanity acquittees. Further clarification regarding policy and practice in implementing the law is provided in the following chapters.
A. Initial period in the temporary custody of the Commissioner of the Department of Behavioral Health and Developmental Services (DBHDS) for the purpose of evaluation (§ 19.2-182.2)
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1. Two evaluators (one clinical psychologist and one psychiatrist) are appointed by the Commissioner to conduct independent evaluations to determine whether the acquittee has a mental illness or intellectual disability, and to assess the need for hospitalization considering the factors in § 19.2-182.3.
2. Goal: Assist the court in determining disposition
3. Based on criteria outlined in the Virginia Code, the evaluators can recommend:
a. Commitment for inpatient hospitalization
b. Conditional release
c. Release without conditions
4. If either evaluator recommends conditional release or release without conditions, the temporary custody period is extended for the
This manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI) under Virginia law. It covers court procedures, commitment criteria, treatment planning, conditional release, and jurisdictional issues to ensure proper legal and clinical management.
TABLE OF CONTENTS1. Court Proceedings and Hearings
2. Criteria for Commitment
3. Responsibilities of the Commissioner
4. Court Permissions and Review Timelines
5. Conditional Release Procedures
6. Release Without Conditions
7. Multiple Courts of Jurisdiction
8. Flowchart of Legal Process
[LARGE FONT]I. Court Proceedings and Hearings[/LARGE FONT]A. Post-evaluation hearing is held by the court in which the acquittee was found not guilty by reason of insanity (§ 19.2-182.3).
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1. Court's options:
a. Commitment to the custody of the Commissioner for inpatient hospitalization;
b. Conditional release; or
c. Release without conditions.
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a. Unlike a jail, probation, or prison sentence, persons found NGRI can be maintained under the court's jurisdiction indeterminately, as long as they meet statutory criteria.
b. Only the court can determine when the acquittee is released with or without conditions (see later discussion).
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a. All subsequent hearings are civil proceedings, not criminal (§19.2-182.3).
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a. The court shall appoint counsel unless the acquittee waives his right to counsel (§§ 19.2-182.3 and 19.2-182.12).
b. The acquittee is represented at initial commitment by the attorney from criminal proceedings unless otherwise ordered (§ 19.2-182.3).
c. For subsequent hearings, the court considers appointing the attorney from the last proceeding (§ 19.2-182.12).
A. The individual must have a mental illness or intellectual disability and require inpatient hospitalization based on the following factors:
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a. Extent of mental illness or intellectual disability: as defined in § 37.2-100.
b. Risk of harm: Likelihood of engaging in conduct presenting substantial risk of bodily harm to others or self in the foreseeable future.
c. Outpatient control: Likelihood that the individual can be adequately controlled with outpatient supervision and treatment.
d. Other factors: Such as deemed relevant by the court.
B. A finding of mental illness or intellectual disability is required for inpatient commitment. Mental illness includes any condition defined in § 37.2-100, including remission states with reasonable probability of becoming active.
[LARGE FONT]III. Responsibilities of the Commissioner[/LARGE FONT]A. The Commissioner determines placement, inter-facility transfers, and privileges (§ 19.2-182.4).
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1. Transfers and decisions: May be made without prior court approval.
2. Delegation: Authority delegated to the Forensic Review Panel (FRP) (§ 19.2-182.13) for privileges.
3. Temporary visits: Can grant visits up to 48 hours if therapeutic and safe, without court approval.
4. Notification: Written notice to the Commonwealth's Attorney when the acquittee leaves hospital grounds (§ 19.2-182.4). Also, notice to victims or next-of-kin of felony victims, upon request.
A. An escape from custody may result in a Class 6 felony charge (§ 19.2-182.14).
[LARGE FONT]V. Court Permissions and Review Timelines[/LARGE FONT]A. Judicial review hearings are annual for the first five years, then biennial thereafter (§ 19.2-182.5).
B. Petitions and requests for release (§ 19.2-182.6 and § 19.2-182.5(B)):
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1. Annual petitions: Acquittee may petition once per year; can request release at the annual review. Court orders two evaluations if requested outside scheduled review (§ 19.2-182.5(B)).
2. Court petitions: The DBHDS Commissioner may petition for release at any time if criteria are met.
3. Victim notification: Must notify victims or next-of-kin upon filing petitions, if requested.
A. Jurisdiction:
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1. Court maintains jurisdiction over community release (§ 19.2-182.7).
2. Custody: Acquittee discharged from the Commissioner’s custody upon conditional release.
3. Planning: CSB/BHA actively involved in planning.
4. Criteria:
a. The individual does not need inpatient hospitalization but requires outpatient treatment or monitoring to prevent deterioration.
b. Outpatient supervision and treatment are reasonably available.
c. There is significant reason to believe the individual will comply with conditions.
d. Conditional release does not pose undue risk to public safety.
B. Implementation and Reporting:
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1. Implementation: The CSB/BHA implements court orders and submits reports.
2. Reports:
a. Written progress reports to court every six months.
b. Monthly progress and compliance reports to the Office of Forensic Services for the first year.
C. Revocation:
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1. Return to custody: Due to violations or if the individual no longer meets criteria (§ 19.2-182.8, 19.2-182.9).
2. Criteria for revocation:
a. Violated conditions or no longer suitable; and
b. Requires inpatient hospitalization due to mental illness or disability.
D. Emergency Custody and Escape:
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1. Emergency custody: Taken into custody under § 19.2-182.9 if necessary.
2. Escape: Leaving the Commonwealth without court permission is a Class 6 felony (§ 19.2-182.15).
A. Conditions may be modified or removed upon petition by:
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(1) CSB/BHA;
(2) Commonwealth's Attorney; or
(3) The acquittee.
B. The court may also modify conditions on its own motion. The acquittee can petition once a year, starting six months after release begins.
[LARGE FONT]VIII. Release Without Conditions[/LARGE FONT]A. Criteria:
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a. Does not need inpatient hospitalization;
b. Does not meet criteria for conditional release.
B. Discharge plan must be approved jointly by CSB/BHA and the facility (§ 19.2-182.3, § 19.2-182.6).
[LARGE FONT]IX. Multiple Courts of Jurisdiction[/LARGE FONT]An individual can be found NGRI by multiple courts for separate offenses. Each court retains jurisdiction, and procedures outlined in this manual apply to all courts involved.
[LARGE FONT]X. Flowchart of Legal Process[/LARGE FONT]
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1. Judge issues order for sanity evaluation and appoints evaluator.
Evaluator provides opinion on sanity at the time of the offense and shares with defense.
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a. Pursue insanity defense:
No: Proceed to trial.
Yes: Defense files motion for insanity defense.
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No: Proceed with second evaluator.
Yes: Proceed to adjudication.
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Evaluator offers opinion regarding sanity.
If not guilty by reason of insanity, court commits individual to DBHDS or releases.
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Unconditional release; or
Conditional release; or
Commitment to DBHDS.
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DBHDS and CSB develop discharge or conditional release plans.
INTRODUCTION
This manual provides guidelines for managing individuals found not guilty by reason of insanity (NGRI), including procedures for temporary custody, evaluation, and community integration.
TABLE OF CONTENTS
The document is organized into sections covering legal procedures, evaluation protocols, and community services coordination.
CHAPTER 2: Temporary Custody For Evaluation (§ 19.2-182.2)I. Placement
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A. When a person is acquitted by reason of insanity, the court shall place the person so acquitted ("the acquittee") in the temporary custody of the Commissioner of the DBHDS for evaluation as to whether the acquittee may be:
1. Released with conditions ;
2. Released without conditions ; or
3. Committed for further treatment.
II. Inpatient Temporary Custody Evaluations
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1. All court orders for NGRI inpatient temporary custody will be sent to Central State Hospital (CSH). CSH will gather all required documents (minimum: court order and original sanity evaluation) and proceed with admission to CSH Maximum Security.
2. If treatment in a facility other than CSH Maximum Security is recommended, the Deputy Director of Forensic Services shall consult with the Temporary Custody triage team and respond within three working days via email with concerns, opinions, or recommendations.
3. Upon final decision, the Deputy Director shall notify the appropriate facility and the Chief Forensic Coordinator at CSH.
4. Upon the Commissioner’s assumption of custody, Central Office will assign evaluators and send necessary notifications.
5. CSH or designated hospital will complete the Initial Analysis of Risk Report (IARR) and send a copy to evaluators.
6. Evaluators will coordinate with CSH or the designated hospital to schedule evaluation appointments.
7. Each evaluator submits a completed evaluation to the facility’s Forensic Coordinator, who then sends a cover letter with the evaluation report to the court.
8. Once both reports are sent, the facility will follow up with a summary letter and guidance on next steps, including a model order.
III. Outpatient Temporary Evaluations
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1. All court orders for outpatient temporary custody are sent to the facility nearest the acquittee’s location. The facility gathers required documents (court order, sanity evaluation, competency evaluation if ordered, warrants, arrest reports, police reports, jail mental health records, and relevant DBHDS treatment records) and sends the packet to DBHDS Central Office within 5 days.
2. Within two working days, the Deputy Director of Forensic Services or designee reviews the case and makes a placement recommendation.
3. If outpatient evaluation is not appropriate, the responsible facility requests a change to inpatient evaluation from the court and follows up until a response or new order is received.
4. If outpatient evaluation is approved, the Deputy Director notifies the Forensic Coordinator, and evaluators are assigned to complete evaluations.
5. Evaluations are completed at the hospital or closest CSB/BHA if the acquittee is in the community, or at the location of residence or custody if in a nursing home or corrections.
6. The hospital completes the Initial Analysis of Risk Report (ARR) and sends it within 30 days.
7. Evaluators coordinate to schedule appointments, and evaluations are submitted to the court with a cover letter.
8. If the acquittee is non-compliant, the facility notifies Central Office and requests court action for hospital admission for evaluations.
IV. Legal and Administrative Requirements
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1. Before assuming custody, the court provides the Commissioner with:
a. The temporary custody order;
b. Names and addresses of attorneys and judge;
c. Warrant or indictment;
d. Criminal incident information or arrest report;
e. If unavailable prior to admission, these are provided within 96 hours of admission, extended if on holiday.
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a. Analysis of Risk (ARR) within 30 days;
b. Relevant mental health and legal records;
c. Copies of sanity and competency evaluations, if available.
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A. As required by Virginia Code §37.2-505 and detailed in the Collaborative Discharge Protocols, CSBs/BHAs shall ensure discharge planning services begin at admission to enable timely discharge and appropriate post-discharge community services.
B. All pre-discharge activities shall be conducted consistent with the issued protocols.
C. Upon placement in temporary custody, the responsible CSB shall assign a case manager to the acquittee.
D. The case manager must be prepared to provide information and plan for conditional or unconditional release.
E. The case manager shall provide pre-discharge planning for residents prior to and after discharge, in accordance with §37.2-505 and the Performance Contract.
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A. After placement, the Deputy Director of Forensic Services shall appoint two evaluators as soon as possible (see Table 2.1: Temporary Custody Evaluation).
B. Qualifications:
1. One psychiatrist;
2. One clinical psychologist.
INTRODUCTION
This manual provides guidelines for the evaluation, treatment, and management of individuals found not guilty by reason of insanity (NGRI). It outlines procedures for assessments, court processes, and conditions for release or commitment.
TABLE OF CONTENTS
I. Evaluation Procedures
II. Criteria for Commitment and Release
III. Orders and Court Procedures
IV. Cases Requiring Conditional Release or Discharge
V. Hearing and Disposition Procedures
VI. Appendices and Sample Orders
[LARGE FONT]III. EVALUATION PROCEDURES[/LARGE FONT]Valuators’ Responsibilities
Evaluators shall determine whether the acquittee currently has mental illness or intellectual disability and shall assess the acquittee and report on his condition and need for hospitalization with respect to the factors set forth in § 19.2-182.3.
Neither evaluator shall have provided previous court evaluation or consultation regarding the acquittee's insanity or mental state at the time of offense.
Evaluation Assessment
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1. Whether the acquittee has a mental illness or intellectual disability
2. The acquittee's condition
3. The acquittee's need for hospitalization based upon factors set forth in § 19.2-182.3
Parameters for the Evaluations
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The evaluators shall:
a. Conduct their examinations separately
b. Prepare separate reports
c. Report their findings to the court within 45 days of the Commissioner's assumption of temporary custody
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a. Judge having jurisdiction
b. Acquittee's attorney
c. Attorney for the Commonwealth for the jurisdiction where the person was acquitted
d. NGRI Coordinator of the CSB/BHA serving the locality or the case management CSB where the acquittee resides
e. Chair of the FRP
f. DBHDS Office of Forensic Services
g. Forensic Coordinator of the hospital where the acquittee is assigned
A. When the facility is made aware of an evaluator's recommendation for conditional release or release without conditions
Staff will begin developing an appropriate conditional release plan or discharge plan.
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1. Facility staff shall immediately contact the appropriate CSB/BHA staff (NGRI Coordinator) to make arrangements for prompt, joint development of the plan.
2. See also Chapter 5: Planning for Conditional Release.
B. Extension of Temporary Custody Evaluation Period
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1. Upon receipt of an evaluation recommending conditional release or release without conditions, the Forensic Coordinator should write the court requesting a court order extending temporary custody if more time is needed to prepare the conditional release plan or discharge plan. Typically an additional 45-day period is requested.
2. Virginia Code § 19.2-182.2 provides that the court shall extend the evaluation period to permit DBHDS and the appropriate CSB or BHA to jointly prepare a conditional release plan or discharge plan before the hearing.
C. Submission of Plans
The conditional release plan or discharge plan shall be submitted to the FRP for review before submission to the court.
If it is not possible to develop an appropriate plan, the treatment team shall make a referral to the FRP for consultation and guidance, containing:
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1. A complete description of attempts made to develop the plan
2. A discussion of why these attempts have not been successful
3. Alternative recommendation(s) for disposition of the acquittee
Upon receipt of the evaluators’ reports, and when applicable, a conditional release or discharge plan, the court will schedule a hearing to determine whether the acquittee should be committed to the custody of the Commissioner, conditionally released, or released without conditions.
(See Tables 2.2, 2.3, and 2.4 for the criteria for commitment to the Commissioner for inpatient hospitalization, conditional release, and release without conditions.)
[LARGE FONT]TABLE 2.1 Evaluation during Temporary Custody[/LARGE FONT]LEGAL CITATION: § 19.2-182.2
The court shall place the person so acquitted in temporary custody of the Commissioner of DBHDS for evaluation as to whether the acquittee may be released with or without conditions or requires commitment.
The court may authorize the evaluation to be conducted on an outpatient basis.
Evaluators
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2 evaluators appointed by the Commissioner. One psychiatrist, and one clinical psychologist.
Both shall be skilled in the diagnosis of mental illness and intellectual disability, and qualified by training and experience to perform these evaluations.
If the acquittee is confined in a hospital, at least one evaluator shall not be employed by the hospital in which the acquittee is primarily confined.
Evaluators shall conduct examinations and report findings separately.
Content
The evaluators shall:
-
Determine whether the acquittee currently has a mental illness or intellectual disability
Assess the acquittee and report on his condition and need for hospitalization with respect to the factors set forth in § 19.2-182.3
Time Frame
Report is due within 45 days of the Commissioner's assumption of custody.
[LARGE FONT]TABLE 2.2 Criteria for Commitment for Inpatient Hospitalization[/LARGE FONT]LEGAL CITATION: § 19.2-182.3
CRITERIA
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Has a mental illness or intellectual disability and is in need of inpatient hospitalization, based on consideration of the following factors:
To what extent the acquittee has a mental illness or intellectual disability, as those terms are defined in § 37.2-100
The likelihood that the acquittee will engage in conduct presenting a substantial risk of bodily harm to other persons or to himself in the foreseeable future
The likelihood that the acquittee can be adequately controlled with supervision and treatment on an outpatient basis
Such other factors as the court deems relevant
ADDITIONAL INFORMATION
If the court determines that an acquittee does not need inpatient hospitalization solely because of treatment or habilitation he or she is currently receiving, but the court is not persuaded that the acquittee will continue to receive such treatment or habilitation, it may commit him for inpatient hospitalization.
[LARGE FONT]TABLE 2.3 Criteria for Conditional Release[/LARGE FONT]LEGAL CITATION: § 19.2-182.7
CRITERIA
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Based on consideration of the factors which the court must consider in its commitment decision, the acquittee does not need inpatient hospitalization but needs outpatient treatment or monitoring to prevent his condition from deteriorating to a degree that he or she would need inpatient hospitalization
Appropriate outpatient supervision and treatment are reasonably available
There is significant reason to believe that the acquittee, if conditionally released, would comply with the conditions specified
Conditional release will not present an undue risk to public safety
ADDITIONAL INFORMATION
The court shall subject a conditionally released acquittee to such orders and conditions it deems will best meet the acquittee's need for treatment and supervision and best serve the interests of justice and society.
The acquittee must meet the criteria set forth above and the court must approve a conditional release plan prepared jointly by the hospital and the appropriate CSB/BHA.
[LARGE FONT]TABLE 2.4. Criteria for Release without Conditions[/LARGE FONT]LEGAL CITATION: § 19.2-182.3
CRITERIA
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Does not need inpatient hospitalization, nor
Meet criteria for conditional release
ADDITIONAL INFORMATION
The court must approve a discharge plan prepared jointly by the hospital staff and the appropriate CSB before the acquittee may be released without conditions.
[LARGE FONT]MODEL TEMPORARY CUSTODY ORDER[/LARGE FONT]Virginia: In the ________________________________ court of _____________________________________________
Commonwealth of Virginia vs ____________________________________
Case No.: ________________________
NOT GUILTY BY REASON OF INSANITY - INITIAL FINDING AND ORDER FOR EVALUATION
The Defendant having been found not guilty by reason of insanity of the charge(s) of _________________________________________________________________________________________________________________, it is hereby ORDERED AND ADJUDGED that:
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1. The Acquittee, pursuant to Virginia Code Section 19.2-182.2, shall be placed in the temporary custody of the Commissioner of the Department of Behavioral Health and Developmental Services (DBHDS) for evaluation, in accordance with the provisions of that section, as to whether the Acquittee may be released with or without conditions or requires commitment.
2. The court hereby authorizes/does not authorize (circle one) that such evaluations may be conducted on an outpatient basis.
3. The Clerk of the court is directed to contact the Chief Forensic Coordinator at Central State Hospital or his designee, for a designation of the appropriate facility, admission date and time.
4. The Sheriff of ___________________________ County, or his designee, shall transport the Acquittee to the designated facility on the agreed date and time, together with a copy of this Order and any other supporting legal and clinical documentation.
5. The evaluators' reports shall be sent to the court on or before forty-five days after the Commissioner's assumption of custody.
6. Copies of the reports shall be sent to the Acquittee's attorney, the attorney for the Commonwealth of the jurisdiction where the Acquittee was acquitted, and the Community Services Board serving the locality where the Acquittee was acquitted.
7. This cause is scheduled for a hearing at _____________ o'clock on the ________ day of 20________ to determine whether the Acquittee shall be released with or without conditions or requires commitment.
8. The Acquittee shall have the right to be present at the hearing, the right to the assistance of counsel in preparation for and during the hearing, and the right to introduce evidence and cross-examine witnesses at the hearing.
9. Copies of this order shall be sent to the Acquittee, the counsel for the Acquittee, the attorney for the Commonwealth of the jurisdiction where the Acquittee was acquitted, the Community Services Board serving the locality where the acquittee was acquitted, and the Commissioner of DBHDS.
10. In the event the Acquittee's presence is required at any hearing in this cause, the court shall issue an Order to Transport, directing the Sheriff of _______________________________ County, or his designee, to resume custody of and transport the Acquittee back to the jurisdiction of this court.
11. This court retains jurisdiction in this cause, and in the case where the acquittee has been admitted to a DBHDS facility he shall not be discharged or released from custody of the Commissioner without further Order of this court.
ENTERED: _________________ _____
SIGNATURE OF JUDGE
NAME OF JUDGE
cc: Commonwealth's Attorney, Acquittee's Attorney, Community Services Board, Commissioner of DBHDS, Attn: Forensic Section, Division of Forensic Services, P.O. Box 1797, Richmond, VA 23218
[LARGE FONT]MODEL ORDER FOR EXTENSION OF TEMPORARY CUSTODY[/LARGE FONT]VIRGINIA: IN THE _________________ COURT OF _________________, COMMONWEALTH OF VIRGINIA
VS. __________________________
DOCKET No. -CR___________________________
Not Guilty by Reason of Insanity Extension of Temporary Custody Period for Development of Conditional Release Plan or Discharge Plan and Hearing Date
The defendant previously having been found not guilty by reason of insanity and placed in the temporary custody of the Commissioner of the Department of Behavioral Health and Developmental Services for evaluation, and evaluations of the acquittee having been conducted resulting in a determination that the acquittee has a mental illness or intellectual disability and a recommendation by at least one evaluator that the acquittee be conditionally released or released without conditions;
Therefore, the court ORDERS that:
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1. Pursuant to Virginia Code § 19.2-182.2, the period of temporary custody for evaluation is extended.
2. The hospital to which the acquittee is assigned and the appropriate Community Services Board
INTRODUCTION
This manual provides guidelines for managing individuals found not guilty by reason of insanity (NGRI). It covers procedures for conditional release, discharge plans, commitment processes, and related court hearings.
TABLE OF CONTENTS
1. Commitment to the Commissioner for Inpatient Hospitalization (§§ 19.2-182.3 through 19.2-182.6)
2. Transfer from a Civil Unit back to the Maximum Security Unit of Central State Hospital
3. Continuation of Confinement Hearings (§ 19.2-182.5)
4. Acquittee Petition for Release (§ 19.2-182.6)
5. Planning for Conditional Release
6. Court Procedures and Evaluation Reports
[LARGE FONT]CHAPTER 3: Commitment to the Commissioner for Inpatient Hospitalization (§§ 19.2-182.3 through 19.2-182.6)[/LARGE FONT]I. Placement following commitment to the custody of the Commissioner
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A. If a court determines that the acquittee has a mental illness or intellectual disability and is in need of inpatient hospitalization and commits the acquittee to the custody of the Commissioner, the FRP, as designated by the Commissioner, shall determine the appropriate placement for the acquittee, based on the acquittee’s clinical needs and security requirements.
B. Placement may be in any state-operated DBHDS facility. Specific considerations shall include:
• Potential for violence to self or others, and
• Potential for escape.
C. The Office of Forensic Services is available to provide consultation and assistance in all matters regarding placement of acquittees.
II. Forensic Coordinator Responsibilities
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A. The Forensic Coordinator monitors the progress, management, conditional release planning, and discharge planning for acquittees for the duration of their placement in the custody of the Commissioner.
B. The Forensic Coordinator serves as a consultant to their facility’s treatment teams with regard to the hospital’s role with the courts in acquittee matters, and the acquittee privileging process.
C. The Forensic Coordinator ensures that the NGRI Coordinator of the appropriate CSB or BHA is notified of all court dates scheduled for acquittees in the custody of the Commissioner.
D. Each hospital shall develop its own internal procedures defining the role of the Forensic Coordinator in the processes described in this manual. The Forensic Coordinator Responsibilities, listed in Appendix G of this volume, should be a guide to this role definition. Specific tasks of Forensic Coordinators in the acquittee management process are described further in the succeeding chapters of this document.
E. The Forensic Coordinator shall provide written notification to the DBHDS Office of Forensic Services of any initial admission, escape, attempted escape, serious incident, death, transfer to another facility, revocation admission, conditional release, or discharge of an insanity acquittee immediately, but not later than 1 working day subsequent to the event. (See Appendix G for additional Forensic Coordinator responsibilities.)
III. Transfer from a Civil Unit back to the Maximum Security Unit of Central State Hospital
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A. In cases in which an acquittee requires a maximum-security environment, due to safety or security reasons, the Forensic Coordinator of the referring facility will initiate an immediate referral to the Central State Hospital Forensic Coordinator(s) with notification to the FRP, and to the Director of Forensic Services. The Forensic Coordinator of the referring hospital should notify the Office of Forensic Services of DBHDS within 24 hours of the transfer.
B. All privileges are suspended while the acquittee is placed in maximum security.
C. If the acquittee is returned to the referring facility or civil unit within 90 days, the FRP and the DBHDS Office of Forensic Services should be notified, but approval is not required. Privileges may be re-instated by the facility to which the acquittee is returned, following a review by the facility’s Internal Forensic Privileging Committee (IFPC).
D. If the stay on the Maximum Security Unit of Central State Hospital exceeds 90 days, the acquittee's eventual transfer to a civil unit will require the prior review and approval by the FRP. Review and approval by the Panel is required before any other privileges can be restored.
IV. Continuation of Confinement Hearings (§ 19.2-182.5) for those acquitted of felonies
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A. The committing court shall hold hearings assessing the need for continued inpatient hospitalization for individuals acquitted of a felony by reason of insanity.
1. A continuation of confinement hearing shall be conducted twelve months after the date of commitment.
2. Continuation of confinement hearings shall be conducted at yearly intervals for the first five years after commitment, and at biennial intervals thereafter.
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a. See Table 3.2: Annual Continuation of Confinement Hearing Report/Evaluation
b. The facility Forensic Coordinator shall:
• Review each final signed annual report to ensure that it evaluates the acquittee’s condition and makes treatment recommendations before it is provided to the court, and
• Attach a cover letter to the annual report, with a copy of model language to be considered by the court in drafting a new order if the report recommends inpatient treatment.
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a. If conditional release is requested by the treatment team, a complete conditional release or discharge plan shall be submitted to the FRP for review and approval, prior to submission to the court.
b. See Chapter 5: Planning For Conditional Release
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1. Upon such request, a second evaluation of the acquittee’s condition shall be completed by an appropriately qualified clinical psychologist or psychiatrist who is not treating the acquittee.
2. A copy of that second evaluation shall be sent to the Commonwealth’s Attorney for the jurisdiction from which the acquittee was committed.
3. The Commissioner shall appoint the second evaluator (§ 19.2-182.6(B)) to assess and report on the acquittee's need for inpatient hospitalization.
• Appointment of evaluators:
(1) The DBHDS Office of Forensic Services, or designee, acting for the Commissioner, shall make the appointments upon receipt of the court order.
(2) This evaluation is an independent evaluation and does not require the approval of the FRP when recommending conditional release or release without conditions.
(3) Evaluations shall be completed and findings reported within 45 days of issuance of the court's order.
(4) Recommendation of Conditional Release by the second evaluator: If the second evaluator recommends conditional release or unconditional release, the treatment team must develop a conditional release or discharge plan with the appropriate CSB or BHA, and submit the plan to the FRP. The FRP will, in turn, review and submit the conditional release or discharge plan to the court of jurisdiction along with the Panel’s recommendation.
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1. Order that the acquittee remain in the custody of the Commissioner if he or she has a mental illness or intellectual disability and continues to require inpatient hospitalization based on the factors set forth in Virginia Code § 19.2-182.3.
2. Place the acquittee on conditional release if:
• He or she meets the criteria for conditional release, and
• The court has approved a conditional release plan prepared jointly by the hospital staff and appropriate CSB/BHA.
3. Release the acquittee from confinement if:
• He or she does not need inpatient hospitalization,
• Does not meet the criteria for conditional release set forth in § 19.2-182.7, and
• The court has approved a discharge plan prepared jointly by the hospital staff and appropriate CSB/BHA.
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A. Upon receipt of an acquittee’s petition for release, the court shall order the Commissioner to appoint two evaluators (§ 19.2-182.6(B)) to assess and report on the acquittee's need for inpatient hospitalization.
a. The DBHDS Office of Forensic Services or designee, acting for the Commissioner, shall make the appointments upon receipt of the court order.
b. These evaluations are independent evaluations and do not require the approval of the FRP when recommending conditional release or release without conditions.
c. Evaluations shall be completed and findings reported within 45 days of issuance of the court's order.
d. Recommendation of Conditional Release by either appointed evaluator: If either of the evaluators recommends conditional release, the treatment team must develop a conditional release plan with the appropriate CSB or BHA, and submit the plan to the FRP. The FRP will review and submit the plan to the court along with the Panel’s recommendation.
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1. Order that the acquittee remain in the custody of the Commissioner if the acquittee continues to require inpatient hospitalization based on consideration of the factors set forth in § 19.2-182.3.
2. Place the acquittee on conditional release if:
• The acquittee meets the criteria for conditional release in § 19.2-182.7, and
• The court has approved a conditional release plan prepared jointly by the hospital staff and appropriate CSB or BHA.
3. Release the acquittee from confinement if:
• The acquittee does not need inpatient hospitalization,
• Does not meet the criteria for conditional release set forth in § 19.2-182.7, and
• The court has approved a discharge plan prepared jointly by the hospital staff and appropriate CSB/BHA.
This manual provides guidelines for the management of individuals found not guilty by reason of insanity, including procedures for discharge, escape, and court hearings.
TABLE OF CONTENTSThe document is organized into sections covering discharge plans, release procedures, escape protocols, court hearings, evaluations, and sample forms.
VI. Discharge without Conditions from the Custody of the Commissioner
A. The court shall release the acquittee from confinement if the following conditions are met:
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• The acquittee does not need inpatient hospitalization.
• The acquittee does not meet the criteria for conditional release set forth in § 19.2-182.7.
• The court has approved a discharge plan prepared jointly by the hospital staff and the appropriate community services board.
B. Only the court that found the acquittee not guilty by reason of insanity and placed the acquittee in the custody of the Commissioner has jurisdiction to discharge or release the acquittee without conditions.
C. Treatment team requests or recommendations for release without conditions shall occur only after review and approval of the FRP.
D. A discharge plan prepared jointly by the hospital staff and appropriate CSB or BHA shall be submitted to the FRP with the request for release without conditions.
E. If the FRP provisionally approves the treatment team’s request for unconditional release, the Panel shall follow the procedures set forth in Table 3.3 regarding the Commissioner’s petition for release of the acquittee.
VII. Escape from Custody of the Commissioner
A. When an acquittee is unaccounted for, the facility shall determine whether the acquittee has absconded from custody, including whether exigent circumstances have reasonably resulted in the acquittee’s delayed return to the facility, or if the acquittee is out of compliance with the requirements of their risk management plan.
The Forensic Coordinator, or designee, shall inform the Office of Forensic Services of the incident and the facility’s determination within 1 working day of the incident.
B. Virginia Code § 19.2-182.14 provides that any person who is placed in the temporary custody of the Commissioner or committed to the custody of the Commissioner after an acquittal by reason of insanity escapes from that custody shall be guilty of a Class 6 felony.
C. If it is determined that an acquittee has absconded from custody, the facility shall:
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1. Notify appropriate law enforcement officials
2. Notify the court of jurisdiction, the Commonwealth Attorney, the acquittee’s attorney, and CSB/BHA
3. Issue a warrant for the acquittee’s return
4. Notify Central Office (Office of Forensic Services)
5. Revoke all privileges of the acquittee
6. If a request for victim notification has been received, notify victims or next-of-kin of the victims.
7. Acquittees on escape status cannot be discharged from the hospital (including AVATAR) except by court order.
D. When it is determined that an acquittee’s absence is due to exigent circumstances or noncompliance with the risk management plan rather than escape, the treatment team shall suspend the acquittee’s privileges pending review by the treatment team and the facility’s IFPC.
The facility shall consider the appropriateness for continued exercise of privileges and develop a plan to mitigate the likelihood of similar behavior. The results and plan shall be forwarded to the DBHDS Office of Forensic Services.
E. Review by the FRP is required after an acquittee returns to the Commissioner's custody from escape:
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1. Within three weeks, the treatment team shall submit the following to the FRP:
(a) A review of the escape, behavior during escape, and circumstances of return, including perspectives of the acquittee, treatment team, family, victim, law enforcement, and other relevant parties.
(b) An updated Risk Assessment including an Analysis of Risk (ARR).
(c) Results of a current mental status exam.
(d) Recommendations for future treatment and management, including level of privileges.
(e) All privilege levels are considered “revoked” until reviewed and approved by the FRP.
TABLE 3.1 Required Court Hearings for Felony Acquittees after Commitment to the Commissioner
TIME AFTER DATE OF COMMITMENT TO COMMISSIONER | REQUIRED | CONTINUATION OF CONFINEMENT HEARING? | ACQUITTEE ALLOWED TO PETITION FOR RELEASE PURSUANT TO §19.2-182.6 (A)? | * | ACQUITTEE ALLOWED TO REQUEST RELEASE IN CONJUNCTION WITH JUDICIAL REVIEW PURSUANT TO
---|---|---|---|---|---
12 months (1 yr.) | yes | no | yes | * | yes
24 months (2 yrs.) | yes | no | yes | * | yes
36 months (3 yrs.) | yes | no | yes | * | yes
48 months (4 yrs.) | yes | no | yes | * | yes
60 months (5 yrs.) | yes | no | yes | * | yes
72 months (6 yrs.) | no | yes | no | * | no
84 months (7 yrs.) | yes | no | yes | * | yes
96 months (8 yrs.) | no | yes | no | * | no
108 months (9 yrs.) | yes | no | yes | * | yes
120 months (10 yrs.) | no | yes | no | * | no
132 months (11 yrs.) | yes | no | yes | * | yes
NOTE: The Commissioner may petition the committing court for conditional or unconditional release of the acquittee at any time he or she believes the acquittee no longer needs hospitalization (§ 19.2-182.6). | | | | |
* The acquittee may petition the committing court for release of felony acquittees only once in each year in which no annual judicial review is required (§ 19.2-182.6 (A)). | | | | |
** In years in which an annual judicial review is required, at the time of the judicial review, the felony acquittee may request release pursuant to § 19.2-182.5(B). | | | | |
TABLE 3.2 Procedures for Annual Continuation of Confinement Evaluations
LEGAL CITATION: § 19.2-182.5(A)
The court shall conduct a hearing 12 months after the date of commitment to assess each confined felony acquittee's need for inpatient hospitalization.
EVALUATOR FOR ANNUAL REPORT:
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• One evaluator (normally a person on the treatment team).
• Psychiatrist or Clinical Psychologist: skilled in diagnosing mental illness and intellectual disability, qualified by training and experience to perform forensic evaluations.
• A second evaluator will be appointed if the first recommends release or the acquittee requests release, with same credentials, not currently treating the acquittee.
CONTENT:
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• Each report must evaluate the felony acquittee's condition and recommend treatment.
• Reports recommending conditional release or release without conditions must be approved by the FRP prior to submission to the court.
TIME FRAME:
The annual report must be submitted 45 days prior to the hearing and sent to the court 30 days prior. Hearings are held annually for the first five years, then biennially.
TABLE 3.3 Procedures for Commissioner Petitions for Conditional or Unconditional Release
LEGAL CITATION: § 19.2-182.6
A. The Commissioner may petition the court for release at any time he or she believes the acquittee no longer needs hospitalization.
B. TREATMENT TEAM: Requests consideration by the FRP for release or conditional release.
C. FORENSIC REVIEW PANEL: If approved, petitions the court on behalf of the Commissioner.
D. THE PETITION:
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• Signed by the Panel Chair, accompanied by:
– Clinical findings supporting the petition.
– Conditional release plan or discharge plan jointly prepared by hospital and CSB/BHA.
E. TIME FRAME:
Any time the FRP, as designated by the Commissioner, believes the acquittee no longer needs hospitalization. Final decision rests with the Commissioner.
TABLE 3.4 Procedures for Acquittee Petition for Release Evaluations
LEGAL CITATION: § 19.2-182.6.B.
A. Upon receipt of a petition for release, unless otherwise required by the court.
B. EVALUATOR:
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• Two evaluators appointed by the Commissioner: one psychiatrist and one clinical psychologist.
• Both skilled in diagnosing mental illness and intellectual disability, qualified to perform evaluations.
• At least one evaluator shall not be employed by the hospital where the acquittee is primarily confined.
C. CONTENT:
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• Review the acquittee's condition with respect to factors in § 19.2-182.3.
• Conduct evaluations and report findings.
D. TIME FRAME:
Report due within 45 days of court order for evaluation.
Cover Letter for Annual Report to the CourtDate: ______________________
The Honorable ___________________________
Address
Re: ____________________ Case No.: _______________ Reg. No.: _______________
Dear Judge _________________________:
Enclosed is a copy of the annual report on the condition of ______________________________, previously found Not Guilty of a Felony by Reason of Insanity.
It is provided as required by Virginia Code Section 19.2-182.5.
The report recommends continued hospitalization.
For your convenience, I am enclosing a model order for re-commitment to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services, developed with the Office of the Attorney General.
Please contact me at _____________________ if you have questions or need assistance.
Sincerely yours,
Forensic Coordinator
xc: Commonwealth's Attorney, Acquittee's Attorney, Community Services Board, NGRI Coordinator, Office of Forensic Services, Virginia, DBHDS, Forensic Review Panel, Treatment Team
Model Order for Initial CommitmentVIRGINIA: IN THE __________________ COURT OF _____________________
COMMONWEALTH OF VIRGINIA v. _____________________________
DOCKET No.: ______________________
FELONY ______________________________ MISDEMEANOR _______________________
OFFENSE DATE(S): _____________________
Not Guilty by Reason of Insanity Hearing on Temporary Custody, Evaluation Reports, and Inpatient Hospitalization
The acquittee having been found not guilty by reason of insanity on ____________ and placed in temporary custody for evaluation.
This date came the attorney for the Commonwealth, ____________.
The acquittee _____________, was present in court and represented by counsel, ____________.
Based on evaluations and testimony, the court finds that the acquittee has ___ mental illness or ___ intellectual disability and needs hospitalization per Virginia Code § 19.2-182.3.
Therefore, the court orders that the acquittee be committed to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services.
The court further ORDERS that:
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1. On ____________, a hearing shall review the need for inpatient hospitalization unless scheduled earlier.
2. Prior to the hearing, the Commissioner shall provide a report evaluating the condition and recommending treatment, along with this order.
3. Copies of the items described in (2) shall
This section provides an overview of the procedures and guidelines for managing individuals found not guilty by reason of insanity, including legal, clinical, and administrative considerations.
TABLE OF CONTENTS1. Introduction
2. The Recommitment Process
3. The Privileging Process for Insanity Acquittees
4. Risk Assessment and Management
5. Community Transition and Supervision
6. Appendices and Forms
II. THE RECOMMITMENT PROCESS Model Order for RecommitmentVirginia: In the ______________________ court of ___________________________________
Commonwealth of Virginia v. _________________________
Case No: ___________________
NOT GUILTY BY REASON OF INSANITY - RECOMMITMENT FOR INPATIENT HOSPITALIZATION
This day came the Attorney for the Commonwealth, ______________________. The Acquittee, ______, was present in the court throughout the proceedings and was represented by Counsel, ______________________.
Based upon the evaluation(s) submitted by ______________________, the testimony of ______________________, and the arguments of counsel, the court finds that the Acquittee has a ___ mental illness or ___ intellectual disability, and is in need of hospitalization based on the factors in Virginia Code Section 19.2-182.3.
Therefore, the court ORDERS that the Acquittee be recommitted to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services.
THE COURT FURTHER ORDERS THAT:-
1. On ____________________, a hearing shall be held to review the Acquittee’s need for inpatient hospitalization unless an earlier hearing is scheduled as provided by law.
2. Prior to the hearing, the Commissioner shall provide a report to the court evaluating the Acquittee’s condition and recommending treatment, as provided in Virginia Code Section 19.2-182.5, together with a copy of this order.
3. Copies of the items described in (2) shall also be sent to the Attorney for the Commonwealth for the jurisdiction from which the Acquittee was committed and the Acquittee’s Attorney.
4. The Clerk shall notify the Judge of the receipt of the reports so that issues regarding Acquittee’s right to counsel may be timely addressed.
5. The Acquittee remains under the jurisdiction of this court and shall not be released from custody and inpatient hospitalization without further Order of the court.
6. This ORDER supersedes the prior ORDERS of this court in this case.
ENTERED: _____________________
SIGNATURE OF JUDGE: _____________________
cc: Commonwealth’s Attorney
NAME OF JUDGE: _____________________
Acquittee’s Attorney
Community Services Board
Commissioner of DBHDS; Attn: Forensic Services, P.O. Box 1797, Richmond, VA 23218
III. THE PRIVILEGING PROCESS FOR INSANITY ACQUITEES I. Graduated ReleaseThe acquittee management program in the DBHDS is based upon a graduated release approach. This approach is a “demonstration” model of clinical risk management, wherein each acquittee is afforded the opportunity to demonstrate their capability for functioning at increasing levels of community access.
The following are guidelines for requesting (i) transfers to less restrictive settings, (ii) increases in levels of privileges, and (iii) release from hospitalization.
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A. Virginia Code § 19.2-182.4.A allows the Commissioner to:
(a) make interfacility transfers and treatment and management decisions regarding acquittees in his custody without review by or approval of the court
(b) authorize a temporary pass from the hospital if the pass would be therapeutic for the acquittee, and would pose no substantial danger to others. Passes may not exceed 48 hours.
(c) Privileges may only be granted to insanity acquittees who have been committed to the custody of the Commissioner of the DBHDS.
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1. In all instances, the acquittee’s current functional level is to be taken into account when less restrictive privileges are recommended.
2. Graduated release prepares acquittees for conditional release by providing a careful, thoughtful progression in transitioning from the maximum security setting of the Forensic Unit to the freedom of community placement.
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Provide acquittees with privileges consistent with their level of functioning and need for security
Ensure adequate risk assessment is conducted before granting increased freedom
Provide opportunities for acquittees to demonstrate appropriate functioning at various levels of freedom
Provide treatment teams with information regarding an acquittees' ability to handle additional freedom and to comply with risk management plans. This information is critical in considering the appropriateness of conditional release, and whether an acquitt ee meets the statutory requirements for conditional release.
Minimize risk to public safety
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Transfer from Maximum Security Unit of Central State Hospital to a civil unit of a state-operated mental health facility
Escorted grounds privileges, accompanied by facility staff
Unescorted grounds privileges
Community visits, escorted by facility staff
Unescorted community visits, not overnight
Unescorted community visits, overnight, but less than 48 hours
Trial visits for greater than 48 hours.
Conditional release
Release without conditions
The FRP and the IFPCs base their evaluations of privilege and release requests explicitly on the following risk assessment criteria:
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A. Has the treatment team identified and articulated the factors that increase and/or decrease the probability that the acquittee will engage in behaviors that present an undue risk to self or others?
B. Has the treatment team developed a risk management plan that adequately manages the assessed risk?
C. Is the requested privilege supported by the treatment team's assessment of risk and their plan for risk management?
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A. A recommendation from the treatment team that such a transfer or less restrictive privilege is appropriate.
B. A review of the offense for which the individual was acquitted by reason of insanity, with particular attention to:
The nature and seriousness of the offense;
Evidence of similar offenses or behavior in the acquittee’s past record;
Reports of what the acquittee has said in regard to such behavior, particularly in regard to:
Remorsefulness,
Acceptance of responsibility for the behavior,
Insight into wrongful nature and precipitants of the behavior.
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The acquittee has conducted him or herself in an appropriate manner and has not engaged in any activity which could be interpreted as being dangerous to self or others during hospitalization, particularly during the past 90 days;
If granted increased privileges or access to less restrictive settings, the acquittee is not likely to present:
A danger to the community or other clients,
Risk of escape, or
Danger to self.
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Current thoughts about prior delusions, current delusions and/or hallucinations, NGRI offense, and risk to the general community, identified individuals, family, and/or friends;
Understanding of their mental illness and need for treatment.
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Assessment of how effectively and completely the acquittee has used the programs recommended by the treating team. For example, if the acquittee has not participated in the treatment and activities programs available, transfer or increased privileges for the purpose of making additional programs available would be seriously questioned.
Compliance with prescribed psychotropic medication treatment.
It is expected that less restrictive privileges will be integrated into the acquittee’s treatment plan, and used to facilitate a graduated transition toward conditional release.
In certain instances multiple privileges can be part of a single request. Examples of combining privileges include combining escorted community privileges with escorted grounds privileges or unescorted grounds privileges.
In certain instances privileges may be skipped, examples include individuals suffering from developmental issues, dementias or other neurocognitive issues that preclude their ability to exercise unescorted community privileges where allowing the acquittee to independently access the community would expose either the acquittee or the public to undue risk. G. Risk management plan that addresses both general risk conditions and specific risk factors for the individual acquittee.
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Risk management plans must be individualized based on:
Acquittee's unique risk factors;
Physical layout of the facility;
Management practices unique to the facility; and
Places to be avoided. Specific names and contact information for persons to be contacted if problems arise should be included.
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Previous aggressive behavior towards others;
Performance with prior privileges (including any prior restrictions on privileges);
Previous escape attempts; and
Risk of aggression the acquittee might present if an escape did occur.
This manual provides guidelines for the management of individuals found not guilty by reason of insanity (NGRI). It covers procedures for graduated release, community visits, privileges, and the roles of various committees involved in the process.
TABLE OF CONTENTSI. Introduction
II. Guidelines for specific steps in graduated release
III. Notification to the Commonwealth's Attorney regarding community visits
IV. Roles and responsibilities of the Internal Forensic Privileging Committee (IFPC)
V. Roles and responsibilities of the Forensic Review Panel in the privileging process
IV. Guidelines for specific steps in graduated release
A. Transfers from Maximum Security-
In cases where the acquittee is being transferred from Maximum Security at Central State Hospital to another facility, appropriate staff members in the receiving facility shall be involved in the decision-making process.
All instances of transfer from Maximum Security require the approval of the FRP.
The Forensic Coordinator from the referring or “sending” facility shall send a referral packet to the Forensic Coordinator of the potential receiving facility 14 days in advance of the FRP meeting with a request for review and feedback from the potential receiving facility by the date of the Panel review.
The Administrative Coordinator for the Panel shall notify the designated receiving facility of the date of the scheduled review by the Panel.
The potential receiving facility shall review the referral packet, review other records as needed, and provide written recommendations to the Panel before the Panel review date.
If the designated receiving facility objects to the transfer of an acquittee to that facility, written notification of that objection should be forwarded by that facility to the Forensic Coordinator for the sending facility, to the FRP, and to the DBHDS Office of Forensic Services, prior to the Panel review date.
The FRP will review the referral packet and any objections from the receiving facility. The sending facility will be notified of the decision.
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Requests for escorted grounds privileges, in conjunction with requests for civil transfer, revocation of conditional release, or following return from escape, must be reviewed and approved by the FRP. (The IFPC reviews all requests to the FRP prior to submission to the FRP.) All other requests for either escorted or unescorted grounds privileges must be reviewed by the IFPC and approved by the Committee and the Facility Director.
A clear rationale for the request must be included in the referral packet: it is expected that grounds privileges will be an integral part of the treatment plan and used to facilitate the transition to an eventual conditional release.
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Requests for escorted visits to the community must be reviewed and approved by the IFPC or the FRP.
Requests for unescorted community visits (not overnight) require review and approval by the IFPC and the FRP.
Following the granting of unescorted, non-overnight community privileges by the FRP, the IFPC must review and approve any subsequent request for unescorted community visits, up to 48 hours.
As with grounds privileges, community visits should be part of a thoughtful graduated release and an integral part of the treatment plan.
Emergency visits (Visits that include staff escort into the community involving acquittees who have not yet been approved for such a privilege level by the Panel), such as to attend the funeral of an immediate family member, require the prior review and approval of the FRP.
a. Treatment teams should immediately contact their Forensic Coordinator, who will then contact the Chair of the FRP with their request and provide a written risk management plan that includes a current risk assessment, mental status interview, and any victim notification requirements.
b. Recommendation from the treatment team is required before the Panel will consider such requests.
c. The Panel may require appropriate security measures to include, but not be restricted to, the use of physical restraints, security personnel, etc.
Trial visits (visits to the community of more than 48 hours) shall be included only in an overall plan for conditional release and, therefore, must be approved by the court as part of conditional release, following review and approval by the IFPC and the FRP.
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Virginia Code Section 19.2-182.4.C requires that the attorney for the Commonwealth for the committing jurisdiction be notified in writing of changes in an acquittee's course of treatment that will involve authorization for the acquittee to leave the grounds of the hospital in which he or she is confined.
Specifically, this includes:
Community visits (escorted by facility staff or unescorted), and
Trial visits (as part of a court approved overall conditional release plan).
Transfers from one DBHDS facility to another, including transfer from the Maximum-Security unit to another unit at Central State Hospital.
A. The role of the Internal Forensic Privileging Committee (IFPC, the “Committee”) includes the following:
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To review and recommend, with Facility Director approval, the following privileges:
Escorted Grounds
Unescorted Grounds
Escorted Community
Unescorted (48 hour) Community, (subsequent to prior FRP approval of Unescorted (not overnight) Community)
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When the court has ordered the facility to prepare a conditional release plan or a discharge plan for unconditional release, and the treatment team and/or the IFPC do not believe that the lessening of restrictions is clinically appropriate; or
When a Commissioner-appointed evaluator (appointed pursuant to § 19.2-182.2, 19.2-182.5, or 19.2-182.6) has recommended that the acquittee is ready for conditional release or unconditional release and the treatment team and/or the IFPC do not believe that the lessening of restrictions is clinically appropriate.
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Each IFPC is composed of at least five (5) members, appointed by the facility director. The membership must include the following:
Facility director or designee administrator
Medical director, psychiatrist, and Nurse Practitioner
Forensic coordinator
Licensed clinical psychologist (if Forensic Coordinator is not a clinical psychologist)
The facility director will also appoint an additional member (or members) from the following group: Psychology Director; Nursing Director; Social Work Director; additional psychiatrist or clinical psychologist. Staff from other disciplines may be appointed if approved in advance by the Office of Forensic Services.
The following qualifications are required of each IFPC member:
Completion of DBHDS-mandated training in forensics, including Basic Adult Forensic Evaluation, NGRI Management, and Violence Risk Assessment.
Appropriate clinical experience (clinical staff only)
Completion of prescribed privilege-granting training activities with the FRP, or other DBHDS-approved entity.
The following additional parameters apply to each IFPC:
The Chair of the IFPC must be a psychiatrist or clinical psychologist.
The Patient Advocate assigned to the facility may attend scheduled meetings.
A quorum of the IFPC is necessary to make a determination regarding any privilege request. A quorum consists of at least three members. A psychiatrist and one licensed clinical psychologist must be present at an IFPC meeting for a quorum to exist.
An IFPC meeting must be scheduled at least once per week.
A meeting of the IFPC must be held within 14 calendar days of receipt of a request for review of privileges from a treatment team or from an acquittee. The decision of the IFPC shall be provided to the Treatment Team within 2 working days following the IFPC’s review of a privilege request.
It is the IFPC’s responsibility to review the privileges of every insanity acquittee every 90 days and to document its review findings in the acquittee’s medical record. (The Office of Forensic Services is to be provided with a summary of each review, every 90 days.)
IFPCs will develop and maintain centralized files on acquittees. These files will include, at a minimum, the following:
Copies of all of the court, hospital, and evaluative documents that were provided to the FRP at the initial request for privileges for an acquittee. This information should include the Temporary Custody evaluations, the Initial Analysis of Risk Report, and the initial FRP privilege request packet, if applicable.
Privileging documents supporting all subsequent requests to either the FRP or the IFPC, up to and including the current request.
The Forensic Review Panel (FRP, the “Panel”) is an administrative board established by the Commissioner pursuant to Virginia Code § 19.2-182.13 to ensure:
NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY INTRODUCTIONThis manual provides comprehensive guidelines for the management of individuals found not guilty by reason of insanity (NGRI). It emphasizes clinical, safety, and security concerns, and outlines the authority, policies, and operational procedures involved in the process.
TABLE OF CONTENTSThe document is organized into sections covering authority, policy, review procedures, structural and operational parameters, facility coordination, and responsibilities of key personnel.
I. Release and Privilege Decisions for Insanity Acquittees-
1. Release and privilege decisions for insanity acquittees appropriately reflect relevant clinical, safety, and security concerns.
2. Standards for conditional release and release planning of insanity acquittees have been met.
3. Expert consultation is provided to treatment teams working with insanity acquittees.
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1. Virginia Code §19.2-182.13 provides the Commissioner of DBHDS with the authority to delegate duties or powers to an administrative panel composed of persons with demonstrated expertise in such matters.
2. The Division of Forensic Services, Office of Forensic Services, shall assist the Panel in its administrative and technical duties.
3. Members of the Panel shall exercise their powers and duties without compensation and shall be immune from personal liability while acting within the scope of their duties, except for intentional misconduct.
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1. Treatment team requests falling within the categories outlined below in D and E shall be presented to, reviewed by, and approved by the FRP, prior to implementation of status change.
2. The Panel shall consider the assessment of risk as a central issue in its decision-making.
[a.] The Panel's function is to assess whether the treatment team has adequately considered the issue of risk.[/a]
[b.] It is not the role of the Panel to provide an independent judgment on the issue of risk. Rather, it is the role of the Panel to review risk assessments completed by treatment teams and to recommend modifications if necessary.[/b]
3. The Panel shall review requests only regarding acquittees who are currently in the custody of the Commissioner (including outpatient temporary custody).
4. It is the policy of the DBHDS that acquittees with active court orders for conditional release awaiting placement shall remain under the supervision of the Panel regarding their privileging status.
[•] Acquittees in this category will be accorded all community access necessary for implementation of the conditional release plan.
5. Evaluations performed as a result of an appointment by the Commissioner ("Commissioner Appointed Evaluations") do not require review by the FRP prior to submission to the court.
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1. Whenever a committing court orders that the acquittee’s facility and the relevant CSB or BHA develop a conditional release plan, that plan shall be jointly developed by the treatment team and CSB or BHA and submitted for review to the FRP.
2. The FRP shall make a recommendation, either approving or disapproving the plan. Following review, the plan shall be submitted to the court, regardless of approval status.
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1. All requests from treatment teams for:
a. Conditional release status in the community, or
b. Release into the community without conditions or further court jurisdiction.
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a. Transfers to less restrictive units and/or hospitals.
b. Additional privileges in conjunction with transfer from maximum-security hospital placement.
c. Unescorted community visits, not overnight.
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a. Escorted Grounds Privileges
b. Unescorted Grounds Privileges
c. Escorted Community Privileges
d. Unescorted Community Privileges, up to 48 hours (with prior FRP approval of unescorted community visits, not overnight).
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1. Composition of the FRP
a. The membership shall include at least seven (7) members.
b. The membership shall include at least two members from each of the following categories:
i. Psychiatrist
ii. Licensed Clinical Psychologist
iii. Other licensed mental health practitioners, including CSB representatives, if available
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a. Quorum consists of half of the total members plus one, including a psychiatrist and a clinical psychologist.
b. Decisions require a majority vote of present and voting members.
c. Dissenting opinions shall be documented and reviewed as requested.
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a. The Chair establishes weekly meeting times.
b. Dates and deadlines are disseminated by the Chair.
c. If meetings are canceled, the Operations Manager is notified in advance.
d. Absences are communicated promptly; if quorum is not met, meetings may be rescheduled.
e. Additional meetings may be scheduled to complete reviews.
f. The administrative coordinator maintains a calendar of meetings.
g. Cancellation due to lack of quorum is communicated to the Office of Forensic Services.
h. The Chair or coordinator notifies of cancellations due to lack of packets.
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a. Appointed by the Commissioner; qualifications include forensic expertise.
b. Responsibilities include court communication and representing the Panel.
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Supports the Panel by setting agendas, distributing packets, taking minutes, ensuring quorum, reviewing referrals, notifying members of cancellations, and other support functions.
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1. The Forensic Coordinator reviews submissions from treatment teams and the facility for completeness and compliance.
2. The Coordinator provides information to the Office of Forensic Services regarding privilege activities.
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A. Ensures staff are trained and policies are in place for proper management.
INTRODUCTION
Members who are responsible for the safety and security of NGRI acquittees:
-
Are informed of, and have ready access to, information regarding the NGRI acquittee’s current level of privileges,
And continually monitor each NGRI acquittee’s level of functioning and only permit the acquittee to exercise privileges consistent with the acquittee’s level of functioning, in accord with current risk assessments and court orders.
C. The Facility Director also has final responsibility and signatory authority for approval of all privilege requests that are granted by the IFPC.
X. The Process for Privileges Granted by the Internal Forensic Privileging Committee (IFPC)
(See Table 4.5 for a summary of the procedures required for the granting of privileges by the IFPC.)
A. Roles and responsibilities:
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1. Insanity acquittee
The insanity acquittee may request an increase in privileges by completing the Acquittee Privilege Request Form.
This is done with the assistance of the treatment team psychologist, or other designee responsible for NGRI privileging at the treatment team level if the acquittee requests assistance.
This treatment team member will assist the acquittee in completing the request form, will obtain the acquittee’s signature, and will sign and date the form.
The form will then be presented at the next Treatment Team meeting.
The Treatment Team must meet and review all requests for privileges at least once every seven (7) calendar days.
The acquittee may only initiate a request for an increase in level of privileges once every 30 days. 2. The Treatment Team Procedures to be used for privilege requests from the treatment team to the IFPC: a. The treatment team shall submit the completed IFPC privilege request packet to the IFPC via the facility Forensic Coordinator. b. The Forensic Coordinator shall review the packet for the IFPC, and provide feedback regarding needed changes and clarifications, within seven (7) working days, prior to formal review of the packet by the IFPC. c. The treatment team shall submit the revised privilege request packet to the IFPC via the Forensic Coordinator within 10 working days.
b. Within one (1) working day of receipt of notification by the treatment team of a decision from the IFPC regarding a request for an increase in level of privileges, the designated member of the treatment team shall meet with the insanity acquittee and provide to him or her a copy of the written decision of the IFPC, explain the decision, and discuss expectations of the acquittee.
This meeting will be documented in the acquittee’s medical record. 3. The Forensic Coordinator.
The general responsibilities of the Forensic Coordinator regarding privileges granted by the IFPC include:
-
a. Review all submissions from treatment teams to the IFPC prior to the IFPC’s formal review.
b. Receive and deliver to the treatment team(s) all information received from the IFPC.
Specific responsibilities of the Forensic Coordinator include the following: a. Coordinate the submission of requests for increases in privilege levels to the IFPC. (1) Ensure that the packet of information is accurate and complete; (2) Ensure that approval of the request is consistent with Departmental policy; and (3) Verify that the treatment team has asserted that approval of the request will expose neither the NGRI acquittee, nor the community to substantial risk.
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The designated member of the Treatment Team will be instructed by the coordinator to inform the insanity acquittee of the Committee’s decision within one (1) working day of receipt of such notification.
B. Specific Operational Activities for Privileges Granted Directly by the IFPC
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1. As noted at the beginning of this chapter, the Commissioner has delegated the granting of the following privileges to the IFPCs at each DBHDS hospital:
a. Escorted Grounds Privileges (if not already approved by the FRP)
b. Unescorted Grounds Privileges
c. Escorted Community Privileges
d. Unescorted Community Access, up to 48 hours (following prior approval by the FRP of Unescorted Community Access, not overnight.)
The facility Forensic Coordinator shall have responsibility for the establishment and maintenance of these files.
(The Office of Forensic Services will provide copies of all relevant background case information.)
These files shall include, at the minimum:
-
a. All relevant court orders
b. The Initial Analysis of Risk Report, and any previously completed Updates
c. All Competency and Sanity evaluations completed with the acquittee
d. Temporary Custody Evaluations and other Commissioner-Appointed Evaluations
e. Any Annual Continuation of Confinement Reports
f. Reports of criminal investigations and other background case material
g. Letters to judges and attorneys
h. Copies of Privilege Request Packets previously submitted to the FRP
i. All additional materials related to IFPC privileging activities at the facility.
j. Any previously completed consultative, specialized medical or psychological evaluations.
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a. The facility forensic file of each acquittee to be reviewed at an IFPC meeting shall be available for review by the Committee, prior to and during its formal review of a privilege request.
b. An updated, concise Analysis of Risk Report completed by the treatment team within the 30 days immediately prior to the submission of the review packet (See Appendix A).
(1) Include risk management plan.
(2) An updated, Analysis of Risk Report (ARR) addressing all risk factors identified in the initial and subsequent ARR updates, and including and addressing all risk factors identified during the course of evaluation and treatment.
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(1) All documentation required by the IFPC submission summary sheet must be included.
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If the facility Forensic Coordinator determines that the packet is incomplete, the Coordinator will return the packet to the treatment team with recommendations for modifications or additions.
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The Chair of the IFPC will document any information provided to the IFPC that assisted in the IFPC's decision making, but was not included in the original referral packet.
This information will be documented in the written IFPC Decision Notification.
Participation of an acquittee’s family shall require the written authorization of the acquittee as a prerequisite to the convening of any meeting of this type.
The IFPC shall provide sufficient time to discuss the relevant concerns of the acquittee at such meetings. 12. IFPC Decision-Making Process
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a. The IFPC, in accordance with the parameters of the FRP, bases its decision-making explicitly on the following risk assessment criteria:
(1) Has the treatment team identified and articulated the factors that increase and/or decrease the probability that the acquittee will engage in behavior that presents a risk to others?
(2) Has the treatment team developed a risk management plan that adequately manages the assessed risk?
(3) Is the increased freedom requested justified by the treatment team's assessment of risk and their plan for risk management?
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(1) A quorum must be present before a final decision can be made.
(2) A quorum consists of three IFPC members, with a minimum of one (1) psychiatrist and one clinical psychologist required for a quorum vote.
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(1) As noted above, all decisions of the IFPC regarding privileges require the agreement of a majority of the quorum.
(2) The opinions and concerns of IFPC members who dissent from a majority decision on a privilege shall be documented at each meeting, and reviewed by the Office of Forensic Services for quality assurance purposes, and as requested by IFPC members.
(3) When a majority of the IFPC, as defined herein, has rendered a decision, the IFPC’s decision is referred to the Facility Director, by the Committee Chair, within one (1) working day.
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(1) Approve the team’s privilege request, no revisions required.
(2) Approve with revisions (related to improving the risk assessment and management process) to be reviewed by the IFPC Chair and the Facility Director. The IFPC returns the case to the treatment team for revision with specific recommendations for additions or deletions. All revisions by the treatment team must be reviewed and approved by the head of that treatment team, prior to resubmission.
(3) Defer approval, pending revisions and further review by the IFPC. The IFPC returns the case to the treatment team for revision, with the requirement that the case be again reviewed, by the IFPC and the Facility Director, after the changes have been made. All
INTRODUCTION
This manual provides comprehensive guidelines for the management of individuals found not guilty by reason of insanity (NGRI). It outlines procedures for privilege requests, review processes, and operational activities related to the treatment and legal oversight of these individuals.
TABLE OF CONTENTS
I. Review process for Privilege Requests Disapproved by the IFPC to the FRP
II. The Process for Privileges Granted by the Forensic Review Panel (FRP)
Additional sections and subsections are included in the full manual.
[LARGE FONT]III. Review process for Privilege Requests Disapproved by the IFPC to the FRP[/LARGE FONT]a. Documentation of Review Request
• At the request of the acquittee, the treatment team shall document in the patient’s record, the team’s or the acquittee’s request for review of an IFPC privilege request denial.
• The request shall be forwarded to the Forensic Coordinator (and copied to the IFPC) on behalf of the acquittee (or the team), within three (3) working days of the acquittee’s initial request.
b. Development of Formal Review Request
• The Forensic Coordinator will work with the treatment team in developing a formal review request of an IFPC decision.
• The coordinator will obtain written documentation from the treatment team, addressing and requesting review and revision of the IFPC’s decision, within ten (10) working days of receiving notification of the review request.
c. Provision of Documentation for Review
• The FRP shall be provided with all additional documentation required for a thorough review, by the Forensic Coordinator.
• The provision of this documentation shall be coordinated with the administrative coordinator for the FRP.
d. Review and Decision by FRP
• The FRP will review the documentation. Following that review, the FRP will render one of the following decisions:
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A finding upholding the IFPC’s original decision on the matter.
A directive to the IFPC, to reconsider the original privilege request of the acquittee.
A directive rescinding the original decision of the IFPC, and granting the privilege request of the acquittee.
e. Notification of Review Decision
• The administrative coordinator will notify both the Chair of the IFPC and the Forensic Coordinator of the review decision within two (2) working days of receipt of the decision from the Chair of the FRP.
• The Forensic Coordinator will notify the treatment team of the review decision within one (1) working day of receiving notification of that decision.
• The treatment team will notify the acquittee of the decision of the FRP within one (1) working day of notification by the Forensic Coordinator.
f. Reconsideration of Privilege Requests
• If the IFPC is directed to reconsider the request by the FRP, the Forensic Coordinator will notify the acquittee’s treatment team of that decision within two (2) working days.
• A treatment team member will inform the acquittee of the Committee’s decision regarding a review, within one (1) working day of notification by the Forensic Coordinator.
[LARGE FONT]IV. The Process for Privileges Granted by the Forensic Review Panel (FRP)[/LARGE FONT][I. Overview]
• The FRP must review all requests for the following privilege levels for all acquittees committed to the Custody of the Commissioner:
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Transfer from Maximum Security to a Civil facility (with or without additional privileges)
Initial Unescorted Community Access (8 hour passes)
Conditional Release (all cases, including Temporary Custody)
Unconditional Release (all cases, including Temporary Custody)
[II. Roles and Responsibilities]
• The NGRI privileging process at the FRP level involves the active participation of the acquittee, the Treatment Team, the IFPC, the Forensic Coordinator, the Facility Director, the Office of Forensic Services, and the CSB.
• The roles and responsibilities of each entity remain as described in Section VII of this manual, with additional or alternative actions as required for FRP privileges.
The Treatment Team-
Prepares the privilege request packet for review by the FRP within 30 calendar days of the decision to request a privilege increase for an acquittee.
The completed privilege packet must be reviewed and approved by the IFPC prior to submission to the FRP.
At least once every 365 days, submits to the IFPC an annual report for each insanity acquittee who has not had a privilege increase during the preceding 365 days. This report shall be the same as the report submitted to the committing court, as described in Appendix D, including all components and a statement summarizing reasons for not requesting an increase.
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The IFPC shall review all requests for endorsement of privilege increase within seven calendar days. The final decision will be made within that same period unless additional information is requested. Feedback is provided within 72 hours.
All approvals require a majority of the quorum of the IFPC, including one psychiatrist and one clinical psychologist. If not, the request is disapproved.
The IFPC shall approve all modifications made to the privilege request packet before submission to the FRP.
The Chair of the IFPC shall sign and date the FRP Submission Summary Sheet for each submission.
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Submits the privilege packet to the FRP within 3 working days after receiving the completed request.
Ensures all modifications approved by the IFPC are incorporated before submission.
Provides quarterly summaries of decisions to the Facility Director, the Chair of the FRP, and the Office of Forensic Services, on or before January 10, April 10, July 10, and October 10.
For transfer requests to less restrictive facilities, sends referral packets 14 days in advance of the FRP review.
For conditional or unconditional releases, forwards complete packets to the FRP, with possible extensions as authorized by the court.
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The FRP shall open a file for each new acquittee upon admission for temporary custody, stored in the DBHDS Office of Forensic Services.
The following information (Review Packet) shall be submitted to the FRP’s administrative coordinator:
• FRP report (template, narrative report for requesting release)
• Recent Annual Review Report (for cases without privilege increase in the past year)
End of Document
NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITYINTRODUCTION
This section provides an overview of the procedures and guidelines for managing individuals found not guilty by reason of insanity, including risk assessments, treatment planning, and legal considerations.
TABLE OF CONTENTS
1. Risk Assessment and Reports
2. Treatment and Release Procedures
3. Review and Decision-Making Processes
4. Appendices and Supporting Documentation
I. RISK ASSESSMENT AND REPORTS
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a. Report to the court (See Appendix D)
b. An Initial Analysis of Risk Report (Required for all newly committed patients, and with court-ordered conditional release plans.) (See Appendix A)
c. Updated Analysis of Risk Report completed within 30 days of receipt by the Forensic Coordinator for submission to the FRP (See Appendix A). The updated Analysis of Risk Report (ARR) will include and address all risk factors identified in the initial and subsequent ARR updates, and will include and address all risk factors identified during the course of evaluation and treatment.
d. Include current risk management plan.
e. Mental Status Evaluation (MSE) completed within 30 days of receipt by the Forensic Coordinator for submission to the FRP.
f. Completed FRP Submission Summary Sheet
• All documentation required by the submission summary sheet must be included.
• Each item of documentation should be dated and signed.
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• Conditional release or discharge plan with components specified on the template.
• Completed CSB agreement and recommendations/comments regarding the proposed conditional or unconditional release.
• Completed acquittee review and agreement to terms of proposed conditional release or unconditional release.
• Letters of support and consent from others involved in proposed conditional release plan. May include: i. Family, ii. Providers other than CSB, and iii. Friends.
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• Invite or require attendance by the acquittee's Forensic Coordinator or members of the acquittee’s treatment team.
• Require submission of medical and/or legal records for review.
II. FRP DECISION-MAKING AND PROCEDURES
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a. The FRP bases its decision explicitly on the following risk assessment criteria:
(1) Has the treatment team identified and articulated the factors that increase and/or decrease the probability that the acquittee will engage in behavior that presents a risk to others?
(2) Has the treatment team developed a risk management plan that adequately manages the assessed risk?
(3) Is the increased freedom requested justified by the treatment team's assessment of risk and their plan for risk management?
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(1) A quorum of the FRP membership must be present before a final decision can be made.
(2) A quorum consists of one half of the total number of FRP members plus one. The quorum must include a psychiatrist and a clinical psychologist to approve an increase in privileges.
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(1) The Chair shall take a vote for each decision and record the number and names of members voting to approve or disapprove in the minutes.
(2) All decisions regarding privileges and/or Conditional Release require a majority of the quorum. Members will sign all decisions, indicating participation.
(3) Dissenting opinions shall be documented and reviewed for quality assurance.
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(1) Approve the team’s privilege or release request, no revisions required.
(2) Approve with revisions, to be reviewed by the Chair and/or FRP members. The case is returned for revision with specific recommendations.
(3) Defer for revisions and further review, with specific recommendations for modifications.
(4) Disapprove the request, with reasons and conditions for future approval.
(5) Endorse the team’s conclusions or recommendations during annual reviews.
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(1) The FRP Chair completes the FRP Decision Notification, including:
• The request to the FRP
• The FRP’s assessment and justification
• The decision of the FRP
• Comments to the treatment team, if appropriate
-
• The Forensic Coordinator
• The CSB's NGRI Coordinator
• The Office of Forensic Services
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(1) If the FRP disapproves a request, the treatment team can request a review within three days.
(2) The Forensic Coordinator will develop and forward a formal review request within ten days.
(3) All supporting documentation is forwarded to the administrative coordinator and copies to the Deputy Director and FRP Chair within one day.
(4) The Deputy Director reviews and responds within seven days, with possible decisions:
• Agree with the original decision.
• Reconsider the request, possibly requesting additional info.
• Rescind the original decision and grant the request.
This manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI). It covers procedures, privileges, and responsibilities of various panels and committees involved in the process.
TABLE OF CONTENTSThe following sections outline the key components of the NGRI management process:
-
Section 1: Decision Notification Procedures
Section 2: Changes in Status and Permissions
Section 3: Responsibilities of the Forensic Review Panel (FRP) and Internal Forensic Privileging Committee (IFPC)
Section 4: Roles in Acquittee Management Process
Section 5: Privileging Process and Procedures
Section 6: Privilege Request and Decision Notification Forms
The administrative coordinator for the FRP will notify the Forensic Coordinator of the revised decision within two (2) working days.
The Forensic Coordinator shall inform the treatment team of all decisions of this type within one (1) working day.
A treatment team member will inform the acquittee of the FRP’s decision regarding an appeal, within one (1) working day of notification by the coordinator.
[SIZE=21.96pt]Chart 4.1 Graduated Release Flow Chart-
Denied: Individual remains in the hospital and an alternative CRP is developed and must be approved by IFPC, FRP, and Judge.
Approved: Individual is Conditionally Released and is monitored by the CSB, with updates provided by the CSB to the Court and DBHDS.
Individual is Committed to DBHDS for inpatient treatment and begins to proceed through a graduated release process involving multiple privilege levels.
Civil Transfer: The Forensic Review Panel (FRP) will approve requests for transfer to a civil unit.
Escorted Grounds: The FRP may approve this level at the same time they approve civil transfer (if recommended simultaneously), or the Internal Forensic Review Panel (IFPC) at the hospital can approve this privilege increase if it occurs after civil transfer.
Unescorted Community -- Not Overnight: The FRP reviews and approves this privilege level request, allowing the individual to go on passes in the community without hospital staff, typically up to 8 hours at a time.
Unescorted Grounds: The IFPC reviews and approves this privilege request, allowing the individual to walk the hospital grounds without staff supervision.
Escorted Community: The IFPC approves this privilege request, allowing the individual to go on passes in the community with DBHDS hospital staff supervision.
Unescorted Community -- Overnight: The IFPC reviews and approves this privilege level request, allowing the individual to go on unescorted overnight passes, typically up to 48 hours.
Conditional Release: The IFPC then the FRP review and approve the individual’s request for conditional release from the hospital. A hearing is held before the Judge, who reviews the CRP and recommendations from the FRP and decides to approve or deny the request.
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IFPC | FORENSIC REVIEW PANEL | COMMITTING COURT | COMMONWEALTH'S ATTORNEY (NOTIFICATION ONLY)**
Yes | Yes | No | No | GROUND PRIVILEGES
Yes | Yes (with transfer) | No | No | COMMUNITY VISITS (ESCORTED BY FACILITY STAFF)
Yes | No | No | Yes | UNESCORTED COMMUNITY VISITS; NOT OVERNIGHT
Yes | No | No | Yes | OVERNIGHT COMMUNITY VISITS (UP TO 48 HOURS)
Yes | Yes* | Yes | Yes | CONDITIONAL RELEASE
Yes | Yes* | Yes | Yes | RELEASE WITHOUT CONDITIONS
No | No | Yes | Yes*** | Civil Commitment (Misdemeanant NGRIs only)
* Review by and approval from the Forensic Review Panel is required before making a recommendation/request to the court for release from hospitalization, Conditional Release, or Release Without Conditions.
** Notification to the Commonwealth's Attorney is mandated by § 19.2-182.4
*** Notification to the Commonwealth’s Attorney is mandated by § 19.2-182.5 (D)
[SIZE=36pt]Table 4.3 Forensic Review Panel and Internal Forensic Privileging Committee Responsibilities-
Entity | Authority | Membership | Meetings | Decision Making
Forensic Review Panel (FRP) | Appointed By Commissioner, pursuant to §19.2-182.13 of the Code | At least 7 members, including: 2 psychiatrists, 2 clinical psychologists, 1 CSB member (if possible), other MH professionals | Weekly | Grants privileges at various levels for all acquittees: Civil transfer, Unescorted (not overnight) Community, Conditional Release. Formal review of all Conditional Release Plans ordered by the court. Voting: Approval/Disapproval. Requires majority concurrence.
Internal Forensic Privileging Committee (IFPC) | Delegated by the DBHDS Commissioner, pursuant to § 19.2-182.13 of the Code | 5 members: Facility Director or designee, Medical Director or designee, Psychiatrist, Forensic Coordinator, Other Professionals | Weekly | Grants privileges at levels: Escorted Grounds, Unescorted Grounds (with/without Escorted Community), Escorted Community, 48 Hour Unescorted Community (after FRP approval). Voting: Approval/Disapproval. Requires 3/5 concurrence. Provides leadership and quality control.
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Entity | Responsibilities
Internal Forensic Privileging Committee (IFPC)
• Reviews and approves for submission to the FRP court-ordered Conditional Release Plans.
• Reviews/approves Treatment Team requests for civil transfer (Maximum only).
• Reviews requests for privileges: Escorted Grounds, Unescorted Grounds, Escorted Community, 48 hours community.
• Reviews and approves all Conditional Release Plans developed by Treatment Teams.
• Reviews/approves requests for increased privilege levels from treatment teams.
Forensic Review Panel (FRP)
• Reviews all court-ordered Conditional Release Plans.
• Determines initial placement.
• Reviews transfers from Maximum to Civil, initial 8-hour Unescorted Community, and Conditional Release.
• Sends CR plan to the court with recommendations.
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Stage | Entity | Privilege Request Development | Timeline | Documentation Required
One | Acquittee | Submit formal request for increase in privilege to treatment team | Once per 30 calendar days | Privilege increase request form
Two | Treatment Team | Receives and reviews request for increased privileges from acquittee. Review within 7 days. | Review within 7 calendar days | Documentation of team review in the medical record.
Three | Treatment Team | Develops Privilege Request Packet for IFPC; submits to IFPC. | 30 days to prepare for IFPC review | Complete IFPC Privilege Request Submission Packet
Four | IFPC | Reviews packet received from treatment team. Reviews within 7 working days. | 7 working days | Initial written feedback and clarification requests from IFPC.
Five | Treatment Team | Reviews and edits privilege request packet, submits revised packet within 10 days. | 10 days | Documentation of revisions.
Six | IFPC | Completes formal review after receipt of complete packet. Notifies Facility Director within 1 working day. | 1 working day | Decision Notification forwarded to Facility Director.
Seven | Facility Director | Reviews, approves/disapproves within 2 working days. Submits documentation within 1 working day. | 2 working days | Signed approval/disapproval.
Eight | Treatment Team | Informs acquittee of results. When disapproved, informs of appeal process. | 1 working day | Copy of Decision Notification.
Nine | Acquittee | Exercises additional privileges if granted. Document in medical record. | As determined | Privilege implementation documented.
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Stage | Entity | Privilege Request Development | Timeline | Documentation Required
One | Acquittee | Submit formal request for increase in privilege. | Once per 30 days | Privilege increase request form
Two | Treatment Team | Reviews request for privileges; submits Annual Review packet if applicable. | 7 days | Written report of review.
Three | Treatment Team | Informs IFPC of decision. Reports results within 3 working days. | 3 working days | Written report.
Four | IFPC | Approves/Disapproves request; provides initial feedback within 7 days. | 7 days | Approval/disapproval documentation.
Five | Treatment Team | Notifies acquittee of decision within 1 day. | 1 working day | Copy of decision.
Six | Forensic Coordinator | Informs treatment team of FRP decision within 1 day. | 1 day | Copies of decision notification.
Seven | Treatment Team | Notifies acquittee of FRP approval/disapproval. | 1 day | Notification to acquittee.
Eight | Acquittee | Exercises privileges if granted. Document in medical record. | As determined | Privilege implementation documented.
Last Name:
First Name:
Reg. No:
Date Request Received:
Date Reviewed:
-
Transfer to Civil Facility:
-
Transfer to Civil:
This manual provides comprehensive guidelines for managing individuals found Not Guilty by Reason of Insanity (NGRI). It covers procedures for review, decision-making, and notification processes to ensure proper treatment and legal compliance.
TABLE OF CONTENTS1. Unconditional Release Procedures
2. Notification to Commonwealth's Attorney
3. Planning for Conditional Release (§ 19.2-182.7)
4. Victim Notification (§ 19.2-182.6(B), §19.2-182.4)
1. UNCONDITIONAL RELEASE PROCEDURES• Unconditional Release: Escorted Community
• Annual Review
• Unescorted Community (not overnight)
• Other: 85 PACKET CONTENTS: (Check all that apply)
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FRP Report
UPDATED Analysis of Risk (ARR)
Initial Analysis of Risk (IARR)
Temporary Custody Evaluation(s)
Risk Management Plan(s)
Annual Report
Conditional Release Plan
Discharge Plan (Unconditional Release)
Other
( Yes / No) HAS THE TREATMENT TEAM IDENTIFIED AND ARTICULATED THE FACTORS THAT INCREASE AND/OR DECREASE THE PROBABILITY THAT THE NGRI WILL ENGAGE IN BEHAVIORS THAT PRESENT A RISK TO OTHERS?
( Yes / No) HAS THE TREATMENT TEAM DEVELOPED A RISK MANAGEMENT PLAN THAT ADEQUATELY MANAGES THE ASSESSED RISK?
( Yes / No) IS THE INCREASED FREEDOM REQUESTED JUSTIFIED BY THE TREATMENT TEAM’S ASSESSMENT OF RISK AND PLAN FOR RISK MANAGEMENT?
DECISION: APPROVED / PENDING REVISION, FURTHER REVIEW REQUIRED BY: ____________________________
DEFERRED FOR REVISION OR MORE INFORMATION; ANOTHER REVIEW REQUIRED BY: ____________________________
DISAPPROVED
REMARKS (See Comments on page 2): ____________________________
CHAIR, Forensic Review Panel Date: ____________________________
2. INTERNAL FORENSIC PRIVILEGING COMMITTEE DECISION NOTICEFACILITY: ____________________________
Last Name: ____________________________ First Name: ____________________________
Reg. No.: ____________________________
Date Request Received: ____________________________
Date Reviewed: ____________________________
Privilege Requested: Restricted Privilege / Transfer to Civil (Facility: ____________________________)
Privileges: Unescorted Community (up to 48 hrs) / Conditional Release / Unescorted Grounds / Unconditional Release / Escorted Community / Annual Review / Unescorted Community (not overnight) / Consultation
Privileges allowing access to the community require notification to Commonwealth Attorney (VA Code δ19.2-182.4c): Yes / No
HAS THE TREATMENT TEAM IDENTIFIED AND ARTICULATED THE FACTORS THAT INCREASE AND/OR DECREASE THE PROBABILITY THAT THE NGRI WILL ENGAGE IN BEHAVIORS THAT PRESENT A RISK TO OTHERS?
( Yes / No)
HAS THE TREATMENT TEAM DEVELOPED A RISK MANAGEMENT PLAN THAT ADEQUATELY MANAGES THE ASSESSED RISK?
( Yes / No)
IS THE INCREASED FREEDOM REQUESTED JUSTIFIED BY THE TREATMENT TEAM’S ASSESSMENT OF RISK AND PLAN FOR RISK MANAGEMENT?
( Yes / No)
DECISION: APPROVED / PENDING REVISION, FURTHER REVIEW REQUIRED BY: ____________________________
DEFERRED FOR REVISION OR MORE INFORMATION; ANOTHER REVIEW REQUIRED BY: ____________________________
DISAPPROVED
REMARKS (SEE COMMENTS ON PAGE 2): ____________________________
PRIVILEGING COMMITTEE MEMBER SIGNATURES: ____________________________
FACILITY DIRECTOR (or Designee) ____________________________
CHAIR, Internal Forensic Privileging Committee Date: ____________________________
Facility: ____________________________
ANY PRIVILEGES GRANTED ARE TO BE VIEWED ONLY AS A CEILING LEVEL; THE TREATMENT TEAM HAS THE AUTHORITY AND RESPONSIBILITY FOR MONITORING THE NGRI’S CONDITION AND TO REDUCE THE LEVEL OF PRIVILEGES APPROPRIATE TO THE NGRI’S FUNCTIONING.
SEE THE NGRI MANUAL FOR A DESCRIPTION OF THE REVIEW PROCESS IN CASES WHERE A REQUEST FOR A PRIVILEGE INCREASE HAS BEEN DISAPPROVED.
3. NOTIFICATION TO COMMONWEALTH'S ATTORNEYDate: ____________________________
Commonwealth's Attorney Address: ____________________________
Dear ____________________________:
Under the provisions of Virginia Code § 19.2-182.4, this facility is required to notify you in writing when an individual who has been found Not Guilty by Reason of Insanity and placed in the custody of the Commissioner of the Department of Behavioral Health and Developmental Services has been authorized to leave the grounds of the hospital in which he or she is confined.
The individual noted below has been so authorized:
-
Acquittee: ____________________________
Case No.: ____________________________
Court of Jurisdiction: ____________________________
Register No.: ____________________________
Date of Birth: ____________________________
Date of NGRI Finding: ____________________________
This individual has been approved for community visits by the Forensic Review Panel.
During community visits, the individual will:
-
______ be accompanied by hospital staff.
______ not be accompanied by hospital staff.
The length of the community visits will be:
-
______ no longer than eight hours.
______ no longer than 48 hours.
______ as described in the court approved conditional release plan.
If you have any questions regarding the above, please contact me at ____________________________.
_____________________________
Forensic Coordinator
xc: Office of Forensic Services, DBHDS
Acquittee’s Attorney
Judge
CSB NGRI Coordinator
4. CHAPTER 5: PLANNING FOR CONDITIONAL RELEASE (§ 19.2-182.7) I. Legal parameters of the Conditional Release planning process.Virginia Code § 19.2-182.7 stipulates that at any time the court considers the acquittee's need for inpatient hospitalization, it shall place the acquittee on conditional release if it determines that:
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Based on consideration of the factors which the court must consider in its commitment decision:
The acquittee does not need inpatient hospitalization but needs outpatient treatment or monitoring to prevent his or her condition from deteriorating to a degree that he or she would need inpatient hospitalization;
Appropriate outpatient supervision and treatment are reasonably available;
There is significant reason to believe that the acquittee, if conditionally released, would comply with the conditions specified;
Conditional release will not present an undue risk to public safety.
At any time the hospital receives a recommendation for conditional release from the following sources, it must initiate the process:
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An order for conditional release from the committing NGRI court.
A recommendation for conditional release as a result of an evaluation pursuant to Virginia Code § 19.2-182.2 or § 19.2-182.5 (acquittee petition).
A treatment team recommendation for conditional release approved by the IFPC.
Regardless of the reason for the request, the hospital must submit all requests for conditional release to the FRP for review and recommendations to the court.
III. Petitions for Release (§ 19.2-182.6.A)• By Commissioner, pursuant to § 19.2-182.6.A
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On behalf of the Commissioner, the FRP may petition the committing court for an acquittee’s conditional or unconditional release at any time it concludes hospitalization of the acquittee is no longer needed. See Table 3.3: Procedures for Petition For Release By the Commissioner.
After reviewing the submission packet from the treatment team requesting conditional release, if the FRP approves the submission, it will petition the court for the release of the acquittee. The petition shall be accompanied by:
A report of clinical findings supporting the petition, and
A conditional release or discharge plan, as appropriate, prepared jointly by the hospital and the appropriate CSB or BHA.
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Judge having jurisdiction
Acquittee's attorney
Attorney for the Commonwealth for the jurisdiction in which the acquittee was committed
NGRI Coordinator of the CSB or BHA serving the locality to which the acquittee has been proposed for conditional release (and the original CSB or BHA if these are not the same).
Administrative Coordinator of the FRP.
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Upon receipt of a petition for release from the Commissioner, no further evaluations are required unless deemed necessary by the court, in which case the court shall order the Commissioner to appoint two persons to assess and report on the acquittee's need for inpatient hospitalization (§19.2-182.6.B.2).
(1) See Table 3.4: Petition For Release Hearing Evaluation
(2) The Deputy Director of the Office of Forensic Services (or designee), acting for the Commissioner, shall make the appointments upon receipt of the court order.
(3) As in other "Commissioner appointed" evaluations, these are independent evaluations and do not require the approval of the FRP when recommending conditional release or release without conditions.
• The acquittee may petition the committing court for release only once in each year in which no annual judicial review is required.
• A copy of the acquittee’s petition shall be sent to the attorney for the Commonwealth in the committing jurisdiction.
• Appointment of evaluators:
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Upon receipt of an acquittee’s petition for release, the court shall order the Commissioner to appoint two persons (§ 19.2-182.6.B.1) to assess and report on the acquittee's need for inpatient hospitalization.
(1) See Table 3.4: Petition For Release Hearing Evaluation
(2) The DBHDS Office of Forensic Services, acting for the Commissioner, shall make the appointments upon receipt of the court order.
(3) These evaluations are independent and do not require FRP approval when recommending release.
• Recommendation of Conditional or Unconditional Release by an evaluator:
If either Commissioner-appointed evaluator recommends conditional or unconditional release, the treatment team must develop a release or discharge plan with the appropriate CSB or BHA, and submit it to the FRP. The FRP will review and submit the plan to the court with its recommendation.
V. Court Hearing• The court shall conduct a hearing upon receipt of evaluation reports.
• The treatment team should notify the CSB or BHA of the scheduled hearing date and time as soon as known.
• Based on the reports and evidence, the court shall:
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Order that the acquittee remain in custody if he or she has a mental illness or intellectual disability and continues inpatient needs (§19.2-182.3).
Order conditional release if criteria are met (§19.2-182.7) and a joint plan has been approved.
Release from confinement if the individual does not need inpatient hospitalization, does not meet criteria for conditional release, and a joint discharge plan has been approved.
• Section § 19.2-182.6(B) requires the Commissioner to notify victims or next of kin of victims of the hearing on the petition for release if they submit a written request.
• Section § 19.2-182.4.B mandates notification of unescorted community visits to victims of felony offenses against persons punishable by more than five years.
[LARGE FONT]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY[/LARGE FONT] INTRODUCTIONThis manual provides guidelines for managing individuals found not guilty by reason of insanity (NGRI). It covers procedures for victim notification, conditional release, community planning, and discharge procedures to ensure safety, legal compliance, and effective treatment.
TABLE OF CONTENTSI. Victim Notification Procedures
II. Guidelines for Requesting Conditional Release
III. Development of the Conditional Release Plan
IV. Components of Conditional Release Plan
V. Discharge Procedures
I. Victim Notification Procedures-
A. The victim or interested party shall submit a written request for notification to the Commissioner.
B. Victims interested in receiving notification shall write the Commissioner, expressing their interest and providing their contact information, such as names and addresses, or other means of contact, in a timely manner.
C. Upon receipt of a written request, the DBHDS Office of Forensic Services shall:
1. Notify the acquittee's facility Forensic Coordinator of the request.
2. Write to the individual requesting notification, informing them of the contact information for the facility where the acquittee is receiving treatment.
3. Send a copy of the letter to the Forensic Coordinator of the facility where the acquittee is receiving treatment.
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1. Work closely with the treatment team and the court to monitor hearings pursuant to §§19.2-182.5 & 19.2-182.6(B).
2. Notify the person requesting victim notification in writing (and by phone if time before the hearing is limited) as soon as possible after becoming aware of the likelihood of a hearing pursuant to §19.2-182.6(B) or §19.2-182.5.
3. Make contact with the Commonwealth's Attorney or the court clerk for the specific date and time of the hearing.
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A. All requests for conditional or unconditional release must be reviewed and approved by the FRP.
B. General guidelines used by the FRP to determine suitability for conditional release include:
1. Successful progression through the graduated release process. Most acquittees, with the exception of those the judge may conditionally release from temporary custody, will have progressed through graduated levels of treatment and freedom before becoming eligible for recommendation for conditional release. The ability to demonstrate safe behavior and compliance with risk management plans in an environment substantially similar to what is recommended for conditional release is important to the public and the courts and provides a stronger case for conditional release.
2. Acquittee compliance and collaborative involvement with the comprehensive treatment program implemented at the facility. This includes adherence to prescribed medication regimens. Evidence from hospital documentation showing active participation in treatment and willingness to take medication without coercion or supervision is useful.
3. Clinical stability of the acquittee.
4. Acquittee shows:
a. An understanding of his or her mental illness and its link to the offense for which they were acquitted.
b. An ability to manage their mental illness to avoid future offenses.
c. An understanding of how they have changed since the time of the NGRI offense.
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A. Joint work with CSB or BHA:
1. Virginia Code §§19.2-182.2, 19.2-182.5 (C), and 19.2-182.6(C) explicitly require CSBs or BHAs to plan for conditional release in conjunction with hospital staff and to implement the court-approved plan.
2. The plan shall be prepared jointly by the hospital and the CSB or BHA where the acquittee shall reside upon release.
3. Successful planning involves:
a. Close working relationships early in the process.
b. Trust in each other's judgments and perspectives.
c. Fully considering community concerns.
d. Mutual effort toward a timely, comprehensive, and safe release.
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1. Other providers may contribute but the oversight and responsibility for implementation rest with the CSB/BHA.
2. Providers may be asked to provide written confirmation of their willingness to contribute components of the plan, provide progress updates, and share information per mutually agreed guidelines. Confirmation should be obtained prior to court submission.
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1. Acquittees may be conditionally released to CSB/BHA catchment areas different from the jurisdiction of the court if:
a. The offense was committed outside the current jurisdiction.
b. The acquittee changes residence.
c. The family agrees to placement in a different county or city.
d. The change of residence aligns with clinical and legal recommendations.
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a. The CSB/BHA in the new area is responsible for implementing and supervising the plan.
b. The original jurisdiction's CSB/BHA may provide consultation.
c. The implementing CSB/BHA is responsible for supervision and reporting.
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1. It is essential to meet with the acquittee early during hospitalization to plan for community resources needed upon conditional release.
2. Planning should begin promptly, especially for residential resources, as it can take significant time.
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A. Conditions of Release
1. Refer to the format in Appendix F (electronic files available from the Office of Forensic Services).
2. General conditions include:
a. Abide by all laws (municipal, county, state, federal).
b. Not leave Virginia without court and CSB approval; leaving without permission is a class 6 felony (§19.2-182.15).
c. Not use alcohol.
d. Not use or possess illegal drugs or unprescribed medication.
e. Not possess or use weapons.
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a. Substance use counseling and monitoring.
b. Alcoholics Anonymous, Narcotics Anonymous, or other substance treatment groups.
c. Anger and aggression control groups.
d. Group psychotherapy.
e. Individual therapy.
f. Forensic support groups.
g. Vocational programming.
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a. Limitations on visits to family, especially if there are longstanding issues.
b. Limitations on unsupervised contact with children, especially if there is a history of offenses.
c. Supervision by probation or parole officers, with details specified.
d. Restrictions from other law enforcement entities (e.g., Secret Service, Homeland Security).
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a. Community visits (escorted and unescorted, day and overnight up to 48 hours) facilitate transition.
b. Court-ordered visits longer than 48 hours (trial visits) may occur during hospitalization to test the plan.
c. Trial visits help acclimate the acquittee and prevent revocation.
d. Hospital staff must coordinate all community visits with CSB/BHA and notify them once the acquittee reaches unescorted privileges.
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a. It is recommended but not required that the acquittee review and agree to conditions.
b. The acquittee should actively participate in plan development, considering their interests and desires.
c. The acquittee should be familiar with and willing to comply with the plan.
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a. Supervising staff should collaborate on the plan and sign it.
b. A section is provided for independent recommendations or comments from CSB/BHA staff, signed and dated.
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A. Court Orders
1. A signed court order for conditional release or unconditional release is required before discharge.
2. The court order must be reviewed by the Forensic Coordinator prior to discharge. Any ambiguities should be addressed immediately in coordination with the court.
NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY
INTRODUCTION
This manual provides guidelines for managing individuals found not guilty by reason of insanity (NGRI), including procedures for discharge, notification, compliance monitoring, and legal modifications of conditional release plans.
TABLE OF CONTENTS
The document is organized into sections covering discharge procedures, monitoring compliance, community release planning, and legal processes for modifying release conditions.
IX. Discharge Procedures and NotificationA. Discharge of the Acquittee
Before the discharge of the acquittee:
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a. The Office of Forensic Services is available to provide technical assistance.
b. The facility Forensic Coordinator shall provide a notice of discharge and a copy of the court order to the Office of Forensic Services no later than one working day after discharge.
3. Formal Notification to Judge and Others upon Discharge
a. As most acquittees are discharged from the hospital to conditional release or release without conditions after the court order is signed, the Forensic Coordinator shall send a formal letter to the judge and shall send copies to the attorneys, the CSB(s), and the Director of Forensic Services noting:
b. A formal letter to the court clarifies the acquittee's change in status and ensures that the court and all interested parties are fully informed about this important transition to the community.
B. Unexpected Discharges
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1. If an unexpected discharge occurs (such as those unusual instances where an acquittee is released by the judge directly from the courtroom), the CSB or BHA where the acquittee was released shall be immediately notified by the facility staff.
2. The released acquittee should be provided appropriate information and encouraged to make immediate contact with service providers in the community in which he will reside.
A. Development of Monitoring Plan
A plan to monitor compliance, supporting the proposed conditions of release, shall also be part of the conditional release package. See format provided in Appendix F.
B. Purposes of the Monitoring Plan:
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1. Clarify expectations regarding the conditions of release.
2. Set up standards for monitoring the conditional release.
3. Specify what noncompliance with the conditions would entail.
4. Determine, in advance, appropriate responses to noncompliance with the conditions of release.
C. The goal is to discuss these issues in advance with the acquittee, the acquittee’s family and support system, the facility treatment team, and the CSB/BHA staff responsible for supervising the acquittee.
D. The plan to monitor compliance is intended to "inoculate against setbacks" by helping the acquittee and supervising staff think through possible setbacks and develop a variety of solutions to barriers that might be encountered.
E. The plan to monitor compliance should be closely tied to the risk factors identified in the Analysis of Risk Report. Responses to noncompliance with the conditions of release should be developed keeping in mind the seriousness of individual risk factors.
In order to promote continuity of care for acquittees on conditional release, hospital staff should provide copies of the Analysis of Risk Report, along with other risk assessment instruments and documents, to the NGRI Coordinator for the CSB/BHA.
CHAPTER 6: Conditional Release and Release Without ConditionsI. Community Services Board / Behavioral Health Authority (CSB/BHA) NGRI Coordinator
A. The Executive Director of each CSB/BHA shall designate a member of his/her staff to serve as the NGRI Coordinator. The CSB/BHA NGRI Coordinator will:
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1. Oversee compliance of the CSB/BHA and the acquittee with court orders for conditional release.
2. Coordinate the provision of reports to the courts in a timely fashion.
3. Maintain training and expertise needed for this role.
B. The CSB/BHA NGRI Coordinator is the single point to coordinate all NGRI cases.
II. Implementing the Conditional Release Plan
The conditional release plan is attached to or referenced in the conditional release order for the acquittee. The plan itself is, therefore, a court order in its entirety. Changing any of the general or special conditions in the plan must be pre-approved by the court of jurisdiction.
Virginia Code §19.2-182.7 requires the CSB/BHA serving the locality in which the acquittee will reside upon release to:
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A. Implement the court's conditional release orders.
B. Submit written reports to the court no less frequently than every six months on the acquittee's:
III. Assistance from the DBHDS Office of Forensic Services
A. Technical assistance and consultation are available from the DBHDS Office of Forensic Services regarding all acquittees placed on conditional release.
B. Copies of the following should be sent to the DBHDS Office of Forensic Services in a timely fashion:
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1. Monthly reviews of conditional release (See format and instructions at end of this chapter), for the first twelve months following release.
2. Six-month reports to the court (See format and instructions at end of this chapter), for the duration of conditional release.
3. Correspondence with the court, including:
IV. Reporting to the Courts - Six-Month Reports to the Court
A. Written reports shall be submitted to the court, pursuant to Virginia Code §19.2-182.7, by the CSB/BHA no less frequently than once every six months, starting six months after the acquittee’s discharge date on conditional release from the hospital.
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1. Consult the conditional release order for more specific requirements regarding reporting that the court might impose.
2. The court has the option to request these reports more often.
B. Format for the six-month court reports:
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1. The CSB/BHA staff member responsible for supervising the implementation of the conditional release plan should complete these reports.
V. Acquittee Non-Compliance with the Conditional Release Plan
A. Deciding when to pursue revocation of conditional release, modification of the conditional release order, or other interventions with the acquittee can be difficult.
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1. Many scenarios and consequences regarding compliance or lack thereof should be anticipated and discussed with the acquittee during planning. These outcomes and consequences should be described in the conditional release compliance-monitoring plan.
2. Responses to the acquittee's lack of compliance should be closely tied to the seriousness of individual risk factors identified in the hospital-generated risk assessment, i.e., Analysis of Risk Report.
3. In each case, clinical judgment and consultation with supervisors and colleagues may be necessary to resolve problems with noncompliance.
VI. Modifying Conditional Release Orders/Plans (§ 19.2-182.11)
A. Reasons for modification:
The assigned CSB/BHA case manager must monitor the entire conditional release plan (all general and special conditions). When the CSB/BHA case manager determines that the plan needs to be modified, it is incumbent upon the case manager to recommend that the court of jurisdiction modify the plan. Only the court has the authority to modify the plan and any of its conditions. The reasons for modification may result from positive or negative compliance factors.
B. Examples of when to recommend modification include:
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1. When the specific service needs in the plan change, e.g., the acquittee now returns to full-time work and no longer needs to attend the psychosocial program full-time, or only needs to attend 3 days/week instead of 5.
2. When the acquittee has improved and no longer requires certain services described in the conditions.
3. When the acquittee’s compliance and community adjustment are poor, and additional conditions are needed before considering revocation.
C. Procedures for modification:
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1. The court may modify conditions upon its own motion based on reports from the CSB/BHA or upon petition from:
INTRODUCTION
This manual provides guidelines for the management of individuals found not guilty by reason of insanity (NGRI), including procedures for conditional release, revocation, and hospitalization.
TABLE OF CONTENTS
The document is organized into sections covering legal procedures, treatment options, and administrative processes related to NGRI acquittees.
[LARGE FONT]Section VII. Revocation of Conditional Release[/LARGE FONT]When revocation is being considered by the CSB/BHA, it is recommended that the NGRI Coordinator or the case manager discuss the acquittee’s situation with the Forensic Coordinator of the last discharge hospital.
This discussion would include the reasons for the revocation, risk factors, and the appropriate DBHDS hospital for revocation admission.
An acquittee in need of inpatient treatment may elect voluntary admission to a DBHDS facility.
In those cases, discharge to conditional release from the hospital within 60 days does not require FRP review.
If the treatment team is recommending revocation of conditional release for acquittees voluntarily admitted who were unable to resume conditional release within the initial 60 days, then FRP review is required.
Once the acquittee is revoked, the NGRI Coordinator of the CSB/BHA should ensure that the admitting hospital receives appropriate information about the reasons for revocation and that ongoing communication is established to discuss planning for the acquittee after the revocation admission.
Reasons for the acquittee’s revocation of conditional release should include the need for psychiatric hospitalization.
If the acquittee is in violation of his or her conditional release plan and does not need hospitalization, the CSB/BHA and the court have different options, such as modification of the conditional release plan, or citation of the acquittee for contempt of court.
[LARGE FONT]A. Regular (Non-Emergency) Process (§ 19.2-182.8)[/LARGE FONT]-
The court may order an evaluation of the acquittee if at any time the court that ordered conditional release finds reasonable ground to believe that the acquittee on conditional release has:
Viol ated the conditions of release, or is no longer a proper subject for conditional release based on application of the criteria for conditional release, and
Requires inpatient hospitalization.
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Viol ated the conditions of release, or is no longer a proper subject for conditional release based on application of the criteria for conditional release, and
Has a mental illness or intellectual disability and requires inpatient hospitalization.
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When exigent circumstances do not permit compliance with revocation procedures set forth in § 19.2-182.8:
Any district court judge or special justice as defined in § 37.2-100 may issue an emergency custody order (ECO), upon the sworn petition of any responsible person or upon the court’s own motion based upon probable cause to believe that an acquittee on conditional release (1) has violated the conditions of his or her release, or is no longer a proper subject for conditional release, and (2) requires inpatient hospitalization.
The Emergency Custody Order (ECO) shall:
(1) require the acquittee to be taken into custody, and
(2) transported to a convenient location where a person designated by the CSB/BHA who is skilled in the diagnosis and treatment of mental illness shall evaluate the acquittee and assess his or her need for hospitalization.
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The evaluation shall be conducted immediately.
The acquittee shall remain in custody until a temporary detention order (TDO) is issued or until released, but in no event shall the period of custody exceed eight (8) hours.
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Has violated the conditions of release, or is no longer a proper subject for conditional release, and
Requires inpatient hospitalization.
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Before the hearing, the acquittee shall be examined by a psychiatrist or a clinical psychologist who shall certify whether the person is in need of hospitalization.
Following the hearing, the court shall revoke the acquittee’s conditional release and place him or her in the custody of the Commissioner if the court, based on the preponderance of the evidence presented at the hearing, finds that:
(1) has violated the conditions of release, or is no longer a proper subject for conditional release; and
(2) has a mental illness or intellectual disability and is in need of inpatient hospitalization.
Placement into custody of the Commissioner after revocation does not require hospitalization in the Forensic Unit of Central State Hospital, even if the acquittee was placed on conditional release directly from the Forensic Unit at Central State Hospital.
The decision to place the acquittee in a particular hospital setting is made by the Office of Forensic Services, in consultation with the Forensic Coordinator at the hospital in which the acquittee was resident immediately prior to conditional release.
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First consideration should be given to returning the acquittee to the facility that serves the region to which the acquittee was conditionally released, thus facilitating continuity of care.
In cases where the acquittee was discharged directly from the CSH Forensic Unit, consideration should be given to placing the acquittee at the facility serving the region to which the acquittee was conditionally released.
The decision to place the revoked acquittee in the Maximum Security Unit of Central State Hospital or another unit should be based upon an assessment of risk to include (i) danger to self or others, and (ii) risk of escape.
In those cases where a joint assessment of risk by the responsible CSB and the regional DBHDS facility indicates that an acquittee requires a secure forensic treatment setting, due to safety or security reasons, an immediate referral should be made to the Forensic Coordinator of the Forensic Unit at Central State Hospital.
If there is disagreement between the Forensic Coordinator of the regional DBHDS facility and the Forensic Coordinator of the Secure Forensic Unit, the DBHDS Office of Forensic Services will make the decision regarding placement.
A. When an acquittee on conditional release is taken into emergency custody, detained, or hospitalized, such action shall be considered to have been taken pursuant to Virginia Code § 19.2-182.9, notwithstanding the fact that his or her status as an insanity acquittee was not known at the time of custody, detention, or hospitalization.
B. Detention or hospitalization of an acquittee pursuant to provisions of law other than those applicable to insanity acquittees under Chapter 11.1 of Title 19.2 of the Code of Virginia shall not render the detention or hospitalization invalid.
C. If a person's status as an insanity acquittee on conditional release is not recognized at the time of the civil emergency custody or detention, at the time his or her status as such is verified, the provisions applicable to such persons shall be applied and the court hearing the matters shall notify the committing court of the proceedings.
D. Based on a risk assessment conducted by the CSB/BHA, an acquittee can be admitted to a local psychiatric hospital on a temporary detention order or could remain on a voluntary admission, or can be voluntarily admitted to a DBHDS facility.
If the acquittee requires involuntary hospitalization and needs to be committed, however, the acquittee should be admitted to a state hospital and to the custody of the Commissioner.
[LARGE FONT]IX. Contempt of court (§ 19.2-182.7)[/LARGE FONT]Under Virginia Code § 19.2-182.7, after a finding by the court that the acquittee has violated the conditions of his release but does not require inpatient hospitalization, the court may hold the acquittee in contempt.
[LARGE FONT]X. Procedures following revocation of an acquittee from conditional release[/LARGE FONT]-
Required admitting court orders:
When an acquittee is involuntarily admitted back into the state hospital following conditional release, the acquittee’s conditional release is considered revoked regardless of the Virginia Code Section upon which the admission was based.
The acquittee can be placed back into the custody of the Commissioner pursuant to Virginia Code Sections 19.2-182.8 (non-emergency revocation), 19.2-182.9 (emergency revocation), a civil TDO, or a civil commitment order.
If the acquittee is rehospitalized on the basis of a civil TDO or a civil commitment order because his status as an insanity acquittee on conditional release was not known at the time of the emergency custody or detention, the provisions for the revocation of acquittees apply once the acquittee’s
INTRODUCTION
This manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI). It covers procedures for hospital admission, readmission, conditional release, revocation, and discharge, ensuring proper legal and clinical oversight throughout the process.
TABLE OF CONTENTS
The document is organized into sections detailing legal procedures, treatment protocols, review processes, and reporting requirements for NGRI acquittees.
[SIZE=21.96pt]XI. Hospital readmission of the acquittee; return to the custody of the CommissionerAs soon as possible after the revocation of the acquittee back into the custody of the Commissioner, the CSB staff and the treatment team will need to develop a recommendation regarding continued hospitalization or resuming conditional release.
It is important for the CSB and treatment team staff to maintain close communication during this time in order to provide a joint recommendation based on information from the acquittee’s previous experience on conditional release.
The joint recommendation will be submitted to the FRP by the hospital staff within thirty (30) days of revocation.
The Forensic Coordinator should designate a due date to accommodate IFPC review prior to FRP review.
If the recommendation to the FRP is conditional release, the previous conditional release plan will need to be reviewed and updated/revised as appropriate.
If the court approves conditional release, a new court order for conditional release must be signed before the acquittee can be discharged back on conditional release.
If the recommendation is to continue hospitalization at this time, a proper court order may be necessary to continue hospitalization.
The CSB staff will remain involved with the NGRI acquittee as a member of the treatment team.
[SIZE=21.96pt]XII. Review by the Forensic Review Panel after acquittee is returned from conditional release to the Commissioner's custodyA. Within thirty (30) days of the acquittee's return to the Commissioner's custody, the treatment team shall submit a packet of information to the FRP with recommendations for future treatment and management.
The packet should clearly state whether the treatment team:
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1. Recommends continued hospitalization and the recommended privilege level if any, or
2. Recommends the return to conditional release within the first 60 days after resumption of Commissioner's custody
B. All packets should include the following:
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1. A review of the acquittee's progress on conditional release and a description of the circumstances of the return to hospitalization. This should include:
C. FRP recommendations to the court
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1. If the FRP approves conditional release, the FRP shall make that recommendation to the court and submit the revised conditional release plan; or
2. If the FRP approves recommitment to the custody of the Commissioner, the FRP shall make that recommendation to the court with its reasons.
D. Forensic Coordinator responsibilities following FRP recommendations to the court
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1. If the court determines that the acquittee can be conditionally released following the recommendations of the FRP, the court must issue a new order for conditional release pursuant to § 19.2-182.7 before the acquittee can be discharged from the hospital on conditional release.
2. The Forensic Coordinator will:
• Provide a written request to the court to arrange for a commitment hearing if the acquittee was revoked on a court order pursuant to §19.2-182.9 or a civil commitment order, if such a hearing is necessary to maintain the hospitalization of the acquittee.
• A court order pursuant to §19.2-182.8 does not necessitate this request to the court following the continued hospitalization recommendation of the FRP.
• In all revocation cases, the Forensic Coordinator will request that the annual/biennial commitment hearing process be implemented even if the acquittee had previously been in the custody of the Commissioner for more than 5 years prior to the conditional release from which he was revoked.
Acquittees can be released without conditions by the court of jurisdiction from conditional release, or directly from the custody of the Commissioner.
An individual who is released without conditions is no longer under the jurisdiction of the court.
The responsibility of the DBHDS and of the CSB for reporting to the court regarding acquittee status ceases with unconditional release.
A. Release without conditions and the discontinuance of court jurisdiction occurs only at the committing court's discretion.
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1. Criteria for release without conditions: acquittee does not need inpatient hospitalization and does not meet the criteria for conditional release set forth in § 19.2-182.7.
2. The CSB may recommend removal of conditions to the court through the 6-month court reporting process or through other formal communication with the court.
3. As release without conditions is the final step in the graduated release of an insanity acquittee, careful consideration should be given to whether the acquittee is now ready and able to manage his/her mental illness and potential for violence without the court-ordered monitoring by the CSB.
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1. See Section VI. Modifying Conditional Release Orders/Plans in this chapter.
2. At the end of this process, the court may issue an order removing conditions on the acquittee's conditional release and discontinuing the court’s jurisdiction.
a. Acquittee,
b. Supervising CSB,
c. Attorney for the Commonwealth for the committing jurisdiction,
d. Attorney for the Commonwealth where the acquittee was residing on conditional release (if that locality is not the same as the committing jurisdiction), and
e. DBHDS Office of Forensic Services.
THE MONTHLY REVIEW OF CONDITIONAL RELEASE REPORT INSTRUCTIONS FOR COMPLETING THE FORM:
I. GENERAL GUIDANCE:
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A. Read the currently approved conditional release plan carefully. Do not assume that any of the general or special conditions have been modified or deleted unless you have a court order or letter from the NGRI judge of jurisdiction confirming that status. If the court has deleted or modified a condition, label that status in the comment section. If the conditional release plan was written so that the CSB has the authority to discontinue a service, only then it is allowed to discontinue the condition(s) without the court’s specific approval. Note these 2 distinctions appropriately in the comment section.
B. Don’t use local names of programs, i.e., Rainbow House or abbreviations, i.e., ACR. Describe the program type instead, i.e., clubhouse, detox program, adult home, etc.
C. The 6-month report to the court does NOT substitute for the monthly report.
D. The reporting form is available in an electronic format for your convenience.
II. SPECIFIC INSTRUCTIONS FOR THE FORM:
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A. NAME OF ACQUITTEE - Complete the full name of the acquittee.
B. COURT HOLDING JURISDICTION - Complete the name of the court that holds jurisdiction for the acquittee. If there are 2 or more courts of jurisdiction, complete all that apply.
C. DATE OF HOSPITAL DISCHARGE
D. SUPERVISING CSB
E. MONTH OF REVIEW - Complete the Month/Year being reviewed.
F. GENERAL CONDITIONS OF RELEASE - Read the currently approved conditional release plan and write/type all general conditions in detail and by their number on the left side column. If the general conditions are not written/typed in their entirety, write/type meaningful phrases for each general condition that represents the court’s intent of the general conditions.
1. Check off “never compliant”, “sometimes compliant”, or “always compliant” to describe the acquittee’s compliance with each general condition of their release.
2. Write/type in comments as needed to describe the acquittee’s compliance with the general conditions of their release.
3. If you condense the wording of the general condition on the report, ensure that your version of the condition still represents the court’s intent and that it can be appropriately answered by the choices - “never”, “sometimes” or “always”. Do not just write/type in a number without a description of the general condition. Do not just write/type in that “all general conditions are fine”.
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1. Check off “never compliant”, “sometimes compliant”, or “always compliant” to describe the acquittee’s compliance with each special condition of their release.
2. Write/type in comments as needed to describe the acquittee’s compliance with each special condition of their release.
3. If you condense the wording of the special condition on the report, ensure that your version of the condition still represents the court’s intent and that it can be appropriately answered by the choices - “never”, “sometimes” or “always”. Do not just write/type in a number without a description of the special condition. Do not just write/type in that “all special conditions are fine”.
III. OTHER INFORMATION:
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A. The Monthly Review of Conditional Release form is due on the 10th of the month following the reporting month. An example is that the November 2020 report is due on December 10, 2020.
B. Only email (preferred), fax or mail the Monthly Review of Conditional Release report. Do not send both faxed and mailed.
NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY
INTRODUCTION
This manual provides guidelines for managing individuals found not guilty by reason of insanity (NGRI) and placed on conditional release. It covers procedures, reporting requirements, and legal considerations for both felony and misdemeanor offenses.
TABLE OF CONTENTS
1. Six-Month Report to Court Reviewing Conditional Release of Insanity Acquittees
2. Petition for Revocation of Conditional Release
3. Procedures for the Management of Persons Found Not Guilty by Reason of Insanity of a Misdemeanor Offense
SIX-MONTH REPORT TO COURT REVIEWING CONDITIONAL RELEASE OF INSANITY ACQUITTEES
INSTRUCTIONS FOR COMPLETING THE FORM:
I. GENERAL GUIDANCE-
A. Report is submitted to the NGRI judge of jurisdiction. If there are two or more courts of jurisdiction, one report should be addressed to all judges or separate reports can be submitted to each NGRI judge of jurisdiction.
B. The report should be completed and submitted every 6 months after the acquittee is placed on conditional release.
C. Read the currently approved conditional release plan carefully. Do not assume that any of the general or special conditions have been modified or deleted unless you have a court order or letter from the NGRI judge of jurisdiction confirming that status. If the court has deleted or modified a condition, label that status in the comment section. If the conditional release plan was written so that the CSB has the authority to discontinue a service, only then it is allowed to discontinue the condition without the court’s specific approval. Note the 2 distinctions appropriately in the comment section.
D. Do not use local names of programs, i.e., Rainbow House or abbreviations, i.e., ACR. Describe the program type instead, i.e., clubhouse, detox program, adult home, etc.
E. The 6-month report to the court does NOT substitute for the monthly report.
F. The reporting form is available electronically for your convenience.
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A. DATE - Complete the date that the report is written.
B. TO - Complete the name(s) of the NGRI judge(s) of jurisdiction and their address(es).
C. RE - Complete the full name of the acquittee, the court case number, and the date of the conditional release order.
D. CONDITIONS OF RELEASE - Complete all the general and special conditions of release in this section.
E. GENERAL CONDITIONS OF RELEASE - Read the currently approved conditional release plan and write/type all general conditions in detail and by their number on the left side column. If the general conditions are not written/typed in their entirety, write/type meaningful phrases for each general condition that represents the court’s intent. Check off “never compliant”, “sometimes compliant”, or “always compliant” to describe the acquittee’s compliance. Write/type comments as needed to describe compliance. If condensing wording, ensure the version still reflects the court’s intent and can be answered by the choices - “never”, “sometimes”, or “always”. Do not just write “all conditions are fine”.
F. SPECIAL CONDITIONS OF RELEASE - List all special conditions in detail and by their number. If not fully written, provide meaningful phrases. Check compliance as above and add comments for variations. Ensure condensed wording still reflects court’s intent and can be answered by “never”, “sometimes”, or “always”. Do not just write “all conditions are fine”.
G. OTHER COMMENTS ON ACQUITTEE’S PROGRESS AND ADJUSTMENT IN THE COMMUNITY - Use this space for additional information about progress, compliance, or other factors affecting adjustment.
H. CSB RECOMMENDATION TO THE COURT - Clearly state the recommendation. Only one recommendation can be made. Discuss with supervisor or NGRI Coordinator if needed. Usually share with the acquittee.
I. IF MAKING A REQUEST, PROVIDE SPECIFICS OF REQUEST AND RATIONALE - Detail any requests to modify, revoke, or remove conditions of release.
J. SIGNATURE - The case manager signs their name, including credentials (e.g., LPC, MSW, BS, RN).
K. NAME - Print/type the case manager’s name.
L. ADDRESS - Print/type the CSB name and mailing address.
M. PHONE, FAX, EMAIL - Print/type contact information.
N. CC - Send copies to the acquittee’s attorney, the attorney for the commonwealth, and the Forensic Office of DBHDS every 6 months. Send to all involved attorneys if multiple judges.
O. OTHER INFORMATION - Only email, fax, or mail the report. Do not send by both mail and fax. Mailing address: DBHDS, Office of Forensic Services P.O. Box 1797 Richmond, Virginia 23218-1797 Email: csb.ngri@dbhds.virginia.gov Fax: 804-786-9621
PETITION FOR REVOCATION OF CONDITIONAL RELEASE, PURSUANT TO § 19.2-182.8 OF THE CODE OF VIRGINIA
NOT GUILTY BY REASON OF INSANITY
VIRGINIA: IN THE CIRCUIT COURT OF ________________________________________________, or IN THE GENERAL DISTRICT COURT OF ________________________________________
COMMONWEALTH OF VIRGINIA
VS. ____________________________
DOCKET NO. -CR ____________________
FELONY ____________________________
DATE OF BIRTH _____________________
MISDEMEANOR _______________________
OFFENSE DATE(S) _____________________
The undersigned petitioner alleges that ____________________, an acquittee who was previously found not guilty by reason of insanity and later placed on conditional release, pursuant to Virginia Code § 19.2-182.7 (see attached court order), has:
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______ violated the conditions of his release, and/or
______ is no longer a proper subject for conditional release and requires inpatient hospitalization.
In support of the allegation, your petitioner submits the following facts:
_________________________________________________
_________________________________________________
_________________________________________________
Wherefore, your petitioner prays that the said acquittee be evaluated with respect to his suitability for conditional release and need for inpatient hospitalization.
Signed ________________________________________Date_____________
The foregoing petitioner, being duly sworn, deposes and says that the statements set forth above are true and correct to the best of his knowledge and belief.
Subscribed and sworn to before me on this _________ day of _____________________.
___________________________________________ Judge, Special Justice, or Notary Public
xc: Acquittee's Attorney, Commonwealth's Attorney, DBHDS Office of Forensic Services
CHAPTER 7 Procedures for the Management of Persons Found Not Guilty by Reason of Insanity of a Misdemeanor Offense, Pursuant to VA Code § 19.2-182.5(D)
I. The provisions of this chapter are restricted to individuals who have been acquitted only of a misdemeanor offense. Those individuals who have been acquitted by the courts as NGRI of both a felony and misdemeanor offense shall be subject to the provisions of this manual that apply to felony acquittees.
II. VA Code Section 19.2-182.5 (D) places statutory limitations upon the period of confinement in the custody of the Commissioner for individuals who have been found not guilty by reason of insanity of a misdemeanor offense.
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A. Acquittees found not guilty of a misdemeanor by reason of insanity on or after July 1, 2002 shall remain in the custody of the Commissioner for a period not to exceed one year from the date of acquittal.
B. If the Commissioner determines, prior to, or at the conclusion of one year, that the acquittee meets the criteria for:
• conditional release;
• release without conditions (unconditional release);
• emergency custody pursuant to § 37.2-808;
• temporary detention pursuant to § 37.2-809; or
• involuntary civil commitment pursuant to § 37.2-814 et seq.
then:
1. The Commissioner shall petition the committing court for such.
2. The Commissioner’s duty to file such a petition does not preclude the ability of any other person who meets the requirements defined in §37.2-808 from doing so.
A. The verdict of acquittal by reason of insanity of a misdemeanor offense, and the initial placement of the misdemeanant acquittee in the temporary custody of the Commissioner is based upon the criteria delineated in § 19.2-182.2 of the Code.
B. The revisions to § 19.2-182.5 did not change the statutory basis for the (“forensic”) period of commitment to the custody of the Commissioner. That commitment period continues to be based upon the criteria set forth in § 19.2-182.3. That section of the Code provides for the commitment of the acquittee if he has a mental illness or intellectual disability and is in need of inpatient hospitalization. The court considers the following factors, in rendering its decision:
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1. The extent to which the acquittee has mental illness or intellectual disability;
2. The likelihood that the acquittee will engage in conduct presenting a substantial risk of bodily harm to other persons or to himself in the foreseeable future;
3. The likelihood that the acquittee can be adequately controlled with supervision and treatment on an outpatient basis; and
4. Such other factors as the court deems relevant.
C. The provisions of § 19.2-182.6, pertaining to Commissioner and acquittee petitions for release, and § 19.2-182.7, pertaining to conditional release criteria and plans, are applicable to misdemeanant acquittees during the period of forensic commitment to the custody of the Commissioner.
D. For all misdemeanant acquittees who have been conditionally released from the custody of the Commissioner, those sections of the Code that address revocation from conditional release shall continue to apply.
IV. Specific operational procedures for the management of misdemeanant acquittees
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A. Temporary Custody
1. Pursuant to § 19.2-182.2, misdemeanant acquittees are placed in the temporary custody of the Commissioner for the 45-day evaluation period, in the same manner as those acquitted of felony offenses. All departmental procedures for the evaluation and management of felony insanity acquittees, including initial placement, and the completion of the Analysis of Risk Report, are applicable to misdemeanant acquittees.
2. Verification by the Forensic Coordinator that the offense for which
INTRODUCTION
The individual has been found not guilty by reason of insanity was a misdemeanor offense, and not a felony, and determination of the accurate date of acquittal of the misdemeanant offense by reason of insanity shall be completed as soon as possible following the placement of a misdemeanant acquittee in the temporary custody of the Commissioner.
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a. The Forensic Coordinator, or designee, will contact the committing NGRI court to determine the classification (misdemeanor or felony) for all offenses for which the individual has been acquitted.
b. The Office of Forensic Services will seek proper verification of the actual date of acquittal (date of verdict) for all misdemeanant acquittees. (court orders for temporary custody are typically signed at a later date than the actual date of the verdict.)
c. Each offense for which the acquittee has been found NGRI will be entered into the Forensic Information Management System (FIMS) along with the corresponding offense level (misdemeanor or felony) of each offense.
d. The verified acquittal date shall be recorded in the Forensic Information Management System (FIMS).
e. The verified date of acquittal shall be used to set the termination date for the completion of the one-year commitment period.
B. The privileging process for misdemeanant acquittees
It is the policy of the DBHDS that misdemeanant acquittees who have been committed to the custody of the Commissioner pursuant to § 19.2-182.3 shall remain under forensic status, and shall be subject to the acquittee privilege, risk management and treatment procedures of the DBHDS throughout the portion of their period of forensic hospitalization, until they have been conditionally or unconditionally released from the custody of the Commissioner, or transferred to civil commitment status.
It shall also remain the goal of the DBHDS that the principle of graduated release shall be adhered to with regard to the privileging process for misdemeanant acquittees who are in the custody of the Commissioner.
The limited time parameters within which a misdemeanant may advance through the privileging process shall require that facility treatment teams maintain a proactive and expeditious approach with regard to identifying the readiness of misdemeanant NGRIs for increases in privileges, and with seeking appropriate privilege increases for eligible acquittees.
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The FRP and the IFPC shall continue, as designated and appropriate, to be charged with approval of all:
Requests for increases in privileges, including transfer from the maximum security forensic unit to civil hospital placement;
Requests for conditional release from acquittees and treatment teams
Requests for release without conditions
Requests for approval of conditional release plans
Requests for approval of plans for return to conditional release for acquittees who have been revoked while under forensic commitment status from conditional release.
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Whenever appropriate, during a misdemeanant acquittee’s period of hospitalization, the treatment team should seek IFPC and FRP approval of requests for conditional or unconditional release of the acquittee.
All entities involved in the development of requests for conditional or unconditional release of a misdemeanant acquittee by the committing court shall anticipate the time constraints that apply with misdemeanant acquittees.
There is no provision in § 19.2-182.5(D) for extension of the one-year commitment period for the completion of Commissioner-Appointed Evaluations, or for any other purpose.
In timing the development of requests for release, particular consideration should be given to the likelihood that petitions for release, pursuant to § 19.2-182.6, from the Commissioner to the committing court may require at least an additional 60 days for the completion of independent evaluations, pursuant to § 19.2-182.6(B) following the petition hearing, if such evaluations are ordered by the court.
The facility Forensic Coordinator shall have responsibility for informing the Commonwealth’s Attorney for the jurisdiction of the committing court of the scheduled release of an acquittee not less than 30 days prior to the release date.
C. Placement on and duration of conditional release
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A misdemeanant acquittee who has been placed on conditional release shall remain under that status for an indefinite time period, until and unless the committing court has unconditionally released him, revoked him from conditional release and recommitted him to the custody of the Commissioner, or civilly committed him as a result of a revocation process.
Revocation of Conditional Release
As noted above, the procedures defined in §§ 19.2-182.8, 19.2-182.9, and 19.2-182.10, regarding revocation from conditional release are applicable to misdemeanant acquittees who have been placed on conditional release.
In the event a misdemeanant acquittee is in need of revocation, the CSB shall initiate the revocation process, in accord with the procedures outlined in § 19.2-182.8, or § 19.2-182.9.
Whenever a misdemeanant acquittee has been revoked to a DBHDS hospital, all of the procedures outlined in Chapter 6 of these Guidelines shall be completed, with regard to the preparation of a packet for submission to the FRP within 30 days of the admission of the misdemeanant acquittee.
In the event that the treatment team requests that the acquittee be approved for return to conditional release, and the FRP approves that request, the Panel must notify the court within sixty (60) days of the acquittee’s hospitalization of its recommendation.
If the court approves the conditional release of the acquittee at the scheduled hearing in the matter, then the misdemeanant acquittee shall be returned to the community, following the approval of a proper conditional release plan by the court.
If it is the opinion of the treatment team that the misdemeanant acquittee is not ready for return to conditional release, and shall require continued hospitalization, the team should indicate that viewpoint in the privilege packet that is submitted to the FRP, following the revocation of the acquittee.
If the FRP disapproves a request from a treatment team for approval of conditional release of a revoked misdemeanant acquittee, or if the Panel concurs with the team’s assessment that the misdemeanant acquittee is in need of continuing hospitalization, the Panel shall direct the facility treatment team to seek a civil commitment of the misdemeanant acquittee from the committing court.
D. Procedures for misdemeanant acquittees recommended for civil commitment
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The actions listed below are to be followed for all misdemeanant NGRIs who are considered ineligible for conditional or unconditional release, and who are candidates for civil commitment by the committing NGRI court:
Facilities should not submit privilege request packets to the FRP for civil commitment of misdemeanant NGRIs, unless the acquittee is hospitalized as a result of a revocation from conditional release.
Following review of the individual’s clinical and risk status, facility treatment teams shall notify the facility IFPC of any plans to seek civil commitment for a misdemeanant acquittee who will have been in the custody of the Commissioner for one year from the date of acquittal.
A designated member of the treatment team will notify the acquittee of the treatment team’s intent to petition the court for civil commitment, prior to sending the petition to the court. Notification of the acquittee shall be documented in the acquittee’s medical record.
The facility Forensic Coordinator shall serve as petitioner for the civil commitment of the misdemeanant acquittees at the facility. The Forensic Coordinator shall complete all necessary arrangements for the prescreening and psychiatric evaluation of the acquittee, as well as scheduling of court hearings and other logistical matters in an expeditious and timely manner.
A qualified clinical psychologist or psychiatrist shall complete the physician’s examination for the petition. That evaluator shall also attend the commitment hearing that the court schedules in the matter, in order to provide any requisite expert testimony.
The following documents should be sent to the committing NGRI court of jurisdiction for the misdemeanant acquittee as soon as the petition for civil commitment has been completed:
The completed civil commitment petition;
A cover letter notifying the court of jurisdiction indicating it is the treatment team’s recommendation that the misdemeanant acquittee be civilly committed.
Copies of these documents shall be sent to the Commonwealth’s Attorney in the case, the acquittee’s attorney, the Chair of the FRP, the facility IFPC, and the Director of the Office of Forensic Services at the time that they are sent to the court.
E. Procedures for misdemeanor acquittees who have been found Not Guilty by Reason of Insanity in more than one court
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There are cases in which a misdemeanant acquittee has been acquitted in more than one court.
In those instances in which the misdemeanant acquittee has also been acquitted of a felony in another court, it shall be necessary for the facility to coordinate all activities regarding the case with the court that will retain jurisdiction for the felony NGRI status of the acquittee.
In cases of this type, the Facility Forensic Coordinator shall contact the Office of Forensic Services for consultation on the proper procedures to be followed.
I. The Analysis of Risk Report (ARR)
The ARR is a systematic means to (1) assess the risk(s) of aggression for an individual acquittee and (2) develop means by which to address the risk(s).
A.
The ARR is a psychological evaluation that includes data collected on the acquittee's past aggressive episodes, treatment and social history, and current functioning and is used as a basis for
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1. Treatment interventions and risk management
2. Decision-making regarding the management of privileges and placement for the acquittee
3. Making recommendations to the court regarding conditional release and release without conditions
4. Release planning
5. Community aftercare
B.
The ARR is an anamnestic (Miller & Morris, 1988; Melton, Petrila, Poythress & Slobogin, 1997) approach to risk assessment and management that integrates
[SIZE=36pt]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY INTRODUCTIONThis manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI). It emphasizes risk assessment, treatment planning, and risk management strategies to ensure safety and appropriate care.
TABLE OF CONTENTSThe document is organized into sections covering assessment procedures, risk factors, treatment planning, and updates to risk assessments. Each section provides detailed protocols and considerations for forensic and clinical staff.
[SIZE=21.96pt]I. Risk Assessment and Management StrategiesThe focus of the ARR (Assessment of Risk and Reoffense) is on identifying relevant risk factors for future aggression and planning risk management strategies, rather than predicting aggression with certainty.
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1. The ARR emphasizes a dynamic understanding of the acquittee's history of aggressive behavior, variables influencing that aggression, and suggestions for decreasing and preventing future aggression.
2. The assessment of risk factors is integrated into treatment planning and conditional release planning, with specific risk factors identified and directly addressed to contain future risk.
A thorough review is conducted, not limited to the NGRI offense, including collateral sources and various assessments.
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A. A description of the NGRI offense, using collateral sources of information, mental status at the time of evaluation, police reports, victim/witness statements, and the acquittee’s account (which may be combined or separate to highlight differences). Consider precipitating factors such as mental status, substance use, stress, and destabilizing events.
B. Review all criminal charges, including those associated with the acquittal, noting the frequency, type, and age of onset of aggression and violence.
C. Review records of previous hospitalizations for incidents of aggression and violence in community and treatment settings.
D. Collateral sources such as family members and community treatment providers should also be considered for past aggressive behaviors not resulting in arrest, charges, or hospitalization.
E. Past and current psychiatric, psychological, and social history assessments, along with hospital staff observations and mental status examinations, are sources of information for patterns of aggressive behavior.
F. Past instances when the patient did not become aggressive or violent despite similar circumstances.
G. The ARR evaluator may request additional information not provided in the admission packet.
Once data from multiple sources—collateral sources, self-report, and structured interviews—are collected, analysis is performed as follows:
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A. The relationship of existing or pre-existing mental disorder(s) to past aggressive episodes, including:
The analysis of risk begins at admission to temporary custody. If an initial ARR has not been completed prior to this, it should be done as soon as possible.
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A. Efforts to obtain relevant information should be made immediately upon admission or appointment of evaluators, including requesting all available data, following up systematically, and emphasizing collateral sources.
B. Information gathering is crucial for accurate risk assessment.
C. A suggested format and hypothetical cases are included later in this chapter.
D. The ARR shall be provided as soon as possible to the two evaluators appointed by the Commissioner.
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A. Identifying Information
B. Purpose of Evaluation
C. Statement of Non-Confidentiality
D. Sources of Information
E. Relevant Background Information
F. NGRI Offense
G. Acquittee’s Account of the NGRI Offense
H. Collateral Accounts of the NGRI Offense
I. Behavioral Observations and Mental Status Examination
J. Psychological Testing Results (if completed)
K. Diagnostic Impression and Formulation
L. Patient Strengths Which Mitigate the Probability of Future Aggressions
M. Analysis of Risk Report
1. Narrative description of current risk factors
Any factor related to an increased risk of aggression towards self or others shall be identified as a risk factor (see Current Trends in Assessing Risk in this Appendix).
[SIZE=21.96pt]VII. Updates to the Initial ARRThe treatment team shall update the ARR within 30 days prior to any requests for increased privileges or community access, including transfers, privileges, visits, conditional releases, or unconditional releases.
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A. The initial ARR serves as a baseline. Updates demonstrate progress or lack thereof, maintaining continuity in risk assessment.
B. Risk factors identified initially or later shall not be deleted, even if deemed no longer current or inappropriately applied.
C. The Risk Management Plan and treatment plans should reflect ongoing risk assessment and management strategies.
D. Updates shall include:
This section provides an overview of the guidelines and procedures for managing individuals found not guilty by reason of insanity (NGRI). It emphasizes the importance of risk assessment, treatment planning, and legal considerations to ensure public safety and appropriate care.
TABLE OF CONTENTSI. General Principles and Legal Framework
II. Risk Assessment and Management
III. Treatment Planning and Interventions
IV. Legal and Administrative Procedures
V. Appendices and Resources
[LARGE FONT]VIII. General Risk Factors to be considered in Assessing Risk[/LARGE FONT] A. HISTORY OF VIOLENCE IS THE STRONGEST SINGLE PREDICTOR OF FUTURE VIOLENCE1. Great care should be given to documenting a complete history of violence across the acquittee’s lifespan.
Clinicians should take into account the acquittee's history of violence in the roles of Perpetrator, Victim, and Observer.
2. Acquittee's violent behaviors should be considered to be the most important. Experience as an observer or victim of violence may be important but it should be related to the perpetration of violent behavior if it is relevant.
B. SUBSTANCE ABUSE: RISK IS HEIGHTENED CONSIDERABLY WHEN A DIAGNOSIS OF SERIOUS MENTAL ILLNESS IS COMBINED WITH A DIAGNOSIS OF SUBSTANCE ABUSE152]
[LARGE FONT]IX. Historical Clinical Risk -20 Checklist (HCR -20) (Douglas, Hart, Webster, & Belfrage, 2013)[/LARGE FONT] A. The DBHDS requires the use of the HCR -20 in Initial Analysis of Risk Reports.Currently, the HCR -20 is in its third version (HCR -20:V3). The HCR -20:V3 will be replaced by future versions as published and trainings provided by the DBHDS and/or the University of Virginia, Institute of Law, Psychiatry and Public Policy (ILPPP).
B. The HCR -20 is a Structured Professional Judgement measure which allows for the assessment of risk factors for future violence in a population with mental illness. The identified factors are rated by their presence as well as their relevance to the individual assessed.
C. The HCR -20:V3 requires training and/or supervision to use. Training should be completed through the ILPPP or DBHDS. Forensic Coordinators and/or Psychology Directors may provide supervision, as needed.
D. The HCR -20 includes the following domains and risk factors:
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1. Historical Factors: Historical factors are rated based on any past experiences throughout the individual’s lifespan, up to and including the day of the assessment. The presence of these risk factors may not go away and are typically more static; however, the relevance of each factor can shift and are more dynamic. Factors included in the Historical Factor domain include a history of problems in the following areas:
• Violence
• Other Antisocial Behavior
• Relationships
• Employment
• Substance Use
• Major Mental Disorder
• Personality Disorder
• Traumatic Experiences
• Violent Attitudes
• Treatment or Supervision Response
2. Clinical Factors: Clinical factors are rated based on the individual’s current status. Choose a time frame and note in your assessment the time frame used. Common time frames may be the last six months, the time period since the NGRI offense, time since admission to DBHDS, or time since last privilege level in cases of ARR Updates. Factors included in the Clinical Factors domain include recent problems with:
• Insight
• Violent Ideation or Intent
• Symptoms of Major Mental Disorder
• Instability
• Treatment or Supervision Response
3. Risk Factors: Risk Factors require the clinician to make assumptions about situations the individual may face in the future. The clinician should choose a time frame and note that in the assessment. Six months into the future is a reasonable time frame and anchor point for most individuals, but can be modified based on the person’s acuity (shorter time frame for more symptomatic individuals, longer time frame for more stable patients). For Initial ARR’s, the Risk Factor domain items should be scored “In” (if the acquittee is committed to the hospital) and “Out” (if the acquittee is conditionally released, discharged, or is permitted to remain in the community after outpatient temporary custody). For Updated ARR’s, the clinician should determine if the Risk Factor domain items should be scored “In” or “Out” depending on the privilege level requested. Factors assessed in this domain include future problems with:
• Professional Services and Plans
• Living Situation
• Personal Support
• Treatment or Supervision Response
• Stress or Coping
A. Ideally, clinicians should compare the individual acquittee's risk factors with base rate information describing the national insanity acquittee population.
B. “Failure” on conditional release can occur either with re-arrest for a new crime or violating conditions of release leading to revocation and readmission to a hospital.
C. Following release from hospital to conditional release: there is a re-arrest rate of 5% to 22% when followed over a period of two to five years.
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1. Generally, the closer the NGRI is monitored in the community, the lower the arrest rate, but the higher the re-hospitalization rate.
2. Acquittees who did well on conditional release:
• were employed before the offense;
• were married;
• had committed a less severe offense;
• adjusted well to hospitalization;
• showed a general assessment score on the GAF of less than 50;
• showed fewer than 7 symptoms on the SADS-C.
3. The first six months of conditional release were particularly high risk periods for revocation of conditional release.
4. Following release without conditions, there are significant increases in re-arrest rates (42 to 56%), as compared to re-arrest rates while on conditional release.
D. More information about risk factors and their impact on violent outcomes is available through the MacArthur Research Network's risk data on mental illness and violence. Updates on this major research initiative are provided regularly through the training and conferences offered by the University of Virginia, Institute of Law, Psychiatry and Public Policy.
XI. Treatment teams, Forensic Coordinators, and staff completing the Analysis of Risk must remain current in the research and practice of assessing risk.-
A. The DBHDS contracts with the Institute of Law, Psychiatry and Public Policy to provide:
• A wide range of forensic training programs including: basic forensic evaluation, risk assessment and management of NGRI acquittees;
• Semi-annual Forensic Symposia that bring in nationally recognized experts on related risk assessment topics;
• Annual Mental Health and the Law Symposium which also brings in national experts and covers a broader range of relevant topics; and
• Consultation to facility and CSB staff.
B. Ongoing training and review of the developing risk assessment literature is essential.
Name:
______________________________
Date of Birth:
______________________________
Age:
______________________________
Reg. No.:
______________________________
NGRI Offense:
______________________________
Case #:
______________________________
Court:
______________________________
Judge:
______________________________
Date of NGRI Offense:
______________________________
Date of NGRI Adjudication:
______________________________
Date of Report:
______________________________
PURPOSE OF EVALUATION:[Acquittee] was adjudicated Not Guilty by Reason of Insanity (NGRI) pursuant to section 19.2-182.2 of the Code of Virginia.
[Note if the acquittee was permitted to remain in the community, or was admitted to a hospital and the date of that admission].
This evaluation, the Initial Analysis of Risk Report, is a routine assessment protocol for new NGRI acquittees.
This report will focus on the acquittee’s current psychological functioning, risk factors for aggression, and treatment recommendations in order to inform [his/her] temporary custody evaluations.
LIMITS OF CONFIDENTIALITY:Prior to beginning the interview, the acquittee was informed of the purpose and nature of the evaluation.
He/She was advised that [his/her] disclosures to the examiner and the results of psychological testing would be compiled into a report that would be included in files maintained by DBHDS.
He/She was also told that this report would be reviewed by two Temporary Custody Evaluators, the court, [his/her] local CSB, and by various DBHDS personnel tasked with recommending that [he/she] either be committed to a DBHDS hospital or [allowed to remain in/be discharged to] the community, with or without mandated conditions.
He/She was reminded that the usual doctor-patient confidentiality does not apply in this situation, and that if [he/she] discloses any thoughts of wanting to harm [himself/herself] or others, or reports child or elder abuse, these comments may need to be reported to others.
The acquittee said [he/she] understood these conditions, was given the opportunity to ask questions, and agreed to participate.
SOURCES OF INFORMATION:[List all records reviewed and collateral sources reviewed/consulted. If you requested records and they were not received, then include that information here as well.]
BACKGROUND INFORMATION:This background section is from the sources noted above.
Developmental/Family History:
Trauma history:
Academic History:
Employment History:
Legal History and Other Incidents of Violence:
[Note the source of the criminal history. It may be important to contrast this with the acquittee’s self-report. The acquittee may also be able to provide information about a juvenile delinquency history that may not be available for review or other instances of violence.]
Date Offense Jurisdiction Disposition
Review of past violent behaviors:
Ask the acquittee about acts of violence across the lifespan. Discuss triggers and precipitants to violence, and explore possible patterns of behavior. Also discuss situations in which destabilizers and triggers were present, but the individual did not act violently. Include police reports if available.
Substance Use History:
Medical History:
Psychiatric History:
NGRI Offense:
Remind the reader of the charge and date of offense.
Collateral Accounts of the Instant Offense:
Divide separate collateral accounts if significantly different from one another. Include the account in the MSO report as a collateral source, too.
Acquittee’s Account of the Instant Offense:
Include the acquittee’s current explanation of the NGRI offense. Probe for insight into the role of mental illness played in the offense, as well as the possibility of substance use. Discuss with the acquittee if she/thinks there is anything she could have done to avoid doing the NGRI offense.
RECENT ADJUSTMENT:Include information about behavior in jail and whether the individual was diagnosed with a mental illness and if he/she took prescribed medications.
If the individual remained on bond, it is important to obtain information about the person’s functioning in the community such as treatment adherence, violence, living situation, common stressors, things that may get in the way of following a conditional release plan such as lack of transportation, etc.
If the evaluation is inpatient, include course of hospitalization.
MENTAL STATUS EXAM & BEHAVIORAL OBSERVATIONS:Summary of psychological testing:
[If completed]
Neurocognitive Functioning:
Summarize the results of any neurocognitive testing such as a mental status exam and/or intelligence test. Considering comparing to prior tests if you have the data.
Personality Assessment:
[LARGE FONT]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY[/LARGE FONT]INTRODUCTION
This manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI). It covers assessment procedures, risk evaluation, treatment planning, and legal considerations to ensure appropriate care and supervision.
TABLE OF CONTENTS
I. Diagnostic Impressions (DSM-5)
II. Risk Assessment
III. Historical Risk Factors
IV. Recent Clinical Risk Factors
V. Risk Management Factors
VI. Risk Formulation
VII. Patient Strengths
VIII. Summary and Risk Management Plans/Recommendations
IX. ARR-Update Format
[LARGE FONT]DIAGNOSTIC IMPRESSIONS (DSM-5):[/LARGE FONT]Walk through your diagnostic formulation. Use the DSM-5 codes and names.
-
Code: [Insert DSM-5 code]
Name: [Insert diagnosis name]
The undersigned completed an evaluation of [Name’s] violence risk based on all the information available at the time of the evaluation, including an interview with the acquittee and a review of collateral records.
The purpose of a violence risk assessment is to identify factors which increase an individual’s risk of violent behavior in the future — with consideration to the nature, severity, imminence, frequency, and likelihood of future violence — as well as to identify strategies for minimizing these risks.
For the purpose of this report, violence is defined as actual, attempted, or threatened physical harm of another person, including intimidation or fear-inducing behavior that is nonconsensual.
To evaluate the acquittee’s risk for violence, the undersigned used the HCR-20-V3, which utilizes a Structured Professional Judgement (SPJ) approach.
A SPJ approach considers historical factors that may not change or be slower to change, as well as more dynamic factors that are often the focus of clinical interventions.
The HCR-20-V3 provides a framework to assess risk of future aggression across three dimensions: historical, clinical, and risk management.
Within each dimension, the examiner considers the presence of various specific risk factors, as well as the relevance of each factor to risk management planning.
[LARGE FONT]Risk Factors[/LARGE FONT]Historical Risk Factors
Historical factors are characteristics of an individual’s background which tend to remain relatively stable over time.
Research has identified several aspects of an individual’s history which are useful in predicting risk over a longer period of time and in a broader context.
For the HCR-20-V3, historical risk factors are considered up to the day of the assessment; so the relevance of these historical risk factors may change with interventions.
History of Problems with Violence (H1):
Describe each risk factor as it applies to the individual. At the end, in bold, note if you rate the factor’s presence and relevance.
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Presence: [Yes/No]
Relevance: [High/Moderate/Low]
History of Problems with Other Antisocial Behavior (H2):
History of Problems with Relationships (H3):
History of Problems with Employment (H4):
History of Problems with Substance Abuse (H5):
History of Problems with Major Mental Disorder (H6):
History of Problems with Personality Disorder (H7):
History of Problems with Traumatic Experiences (H8):
History of Problems with Violent Attitudes (H9):
History of Problems with Treatment or Supervision Response (H10):
[LARGE FONT]Recent Clinical Risk Factors[/LARGE FONT]The clinical factors assessed here capture the acquittee’s functioning within the past [note time-frame].
These factors are most relevant to short-term risk for aggression.
Recent Problems with Insight (C1):
Describe each risk factor as it applies to the individual. At the end, in bold, note if you rate the factor’s presence and relevance.
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Presence: [Yes/No]
Relevance: [High/Moderate/Low]
Recent Problems with Violent Ideation or Intent (C2):
Recent Problems with Symptoms of Major Mental Disorder (C3):
Recent Problems with Instability (C4):
Recent Problems with Treatment or Supervision Response (C5):
[LARGE FONT]Risk Management Factors[/LARGE FONT]This risk factor was coded considering the risks [he/she] may face in the next [time frame] in [setting, either inpatient or outpatient].
Future Problems with Professional Services and Plans (R1):
Describe each risk factor as it applies to the individual. At the end, in bold, note if you rate the factor’s presence and relevance.
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Presence: [Yes/No]
Relevance: [High/Moderate/Low]
Future Problems with Living Situations (R2):
Future Problems with Personal Support (R3):
Future Problems with Treatment or Supervision Response (R4):
Future Problems with Stress or Coping (R5):
[LARGE FONT]HCR-20: V3 Summary[/LARGE FONT]HISTORICAL FACTORS:
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History of problems with…
Factor
Initial Assessment
Relevance
H1. Violence
H2. Other Antisocial Behavior
H3. Relationships
H4. Employment
H5. Substance Use
H6. Major Mental Disorder
H7. Personality Disorder
H8. Traumatic Experiences
H9. Violent Attitudes
H10. Treatment or Supervision Response
CLINICAL PROBLEMS:
-
Recent problems with…
Factor
Initial Assessment
Relevance
C1. Insight
C2. Violent Ideation or Intent
C3. Symptoms of Major Mental Disorder
C4. Instability
C5. Treatment or Supervision Response
Risk Management Factors: Future problems with…
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Context: [Insert context and time frame]
Factor
Initial Assessment
Relevance
R1. Professional Services and Plans
R2. Living Situation
R3. Personal Support
R4. Treatment or Supervision Response
R5. Stress or Coping
Provide a narrative (1-2 paragraphs) of why this individual becomes violent. What are the most important risk factors, triggers, destabilizers, etc., that lead to aggressive and violent behavior.
Does this person have one primary pathway towards violence or several that require different interventions and management? This tells the individual’s violence story.
[LARGE FONT]Patient Strengths Which Mitigate the Probability of Future Violence:[/LARGE FONT]Describe if any protective factors are present. They are: intelligence, secure childhood attachment, coping skills, self-control, resilient personality traits, empathy, employment, leisure activities/hobbies, strong commitment to school, motivation for treatment, medication adherence, financial management, positive attitudes towards authority, life goals, having a social network, professional care involvement, prosocial involvement, strong attachment and bonds, appropriate and supportive intimate relationships, and positive living circumstances.
[LARGE FONT]SUMMARY AND RISK MANAGEMENT PLANS/RECOMMENDATIONS:Provide an extremely brief summary of the acquittee’s relevant history and what led to the current assessment.
Given the results of the HCR-20 V3, as well as protective factors, it is my opinion that [Name’s] overall risk for future violence, especially within the next [risk time frame], is [low, moderate or high]. Explain reasoning.
The following risk management plan is offered for consideration:
-
1. [Strategy 1. Make sure you address all relevant risk factors. Some strategies may address multiple risk factors, and some risk factors may be addressed by multiple interventions. Consider the risk scenarios when developing risk management interventions]
The following recommendations are provided for the consideration of the Temporary Custody Evaluators, the court, treatment providers, and the Forensic Review Panel as possible ways to reduce the acquittee’s risk of violence in the future. Conclusions and recommendations are limited by the information received. New information and a different context may change the assessment of risk and recommendations offered.
It is generally not necessary for an ARR-Update to have all the components of the Initial Risk Assessment due to the fact that it is usually part of a more comprehensive report (e.g., submission to the Forensic Review Panel, Annual Confinement or Hearing Report, etc.) which already contains relevant background information, mental status, and other information that would complete the report as "stand alone."
The ARR-Update, when part of another submission/report, should minimally include the following:
Risk Factors for Aggression While Exercising Proposed Privilege Level Using HCR-20 V3.
To evaluate Ms. Doe’s risk for violence, the undersigned used the Historical Clinical Risk Management - 20, Version 3 (HCR-20-V3) and the Female Additional Manual (FAM). Both tools utilize a Structured Professional Judgement (SPJ) approach and consider historical factors that may not change or be slower to change, as well as more dynamic factors, that are often the focus of clinical interventions.
The HCR-20-V3 provides a framework to assess risk of future aggression across three dimensions: historical, clinical, and risk management.
Within each dimension, the examiner considers the presence of various specific risk factors, as well as the relevance of each factor to risk management planning.
The FAM, which is designed to be used in conjunction with the HCR-20-V3, is a complementary measure designed to assess factors specific to female-perpetrated violence.
It is scored in the same manner as the HCR-20-V3 but also includes influencing someone else to commit violence or being an accessory to violence carried out by another individual in the definition of violence.
For the purpose of this report, Ms. Doe’s risk for violence will be explored and conceptualized using these tools.
[LARGE FONT]Historical Factors:[/LARGE FONT]Ms. Doe’s most salient historical risk factors for violence include a history of problems with:
-
serious mental illness (H6),
problems in relationships (H3),
and parenting difficulties (FAM H12).
Ms. Doe is currently diagnosed with Bipolar I Disorder and has been experiencing symptoms since her 20’s.
She has a history of depressive and manic mood episodes, the latter of which presented with psychotic features during the NGRI offense (grandiose delusional beliefs that she was God, the president, or an agent of the CIA).
Documentation indicates there may have been some limited experience of hallucinations.
Ms. Doe has reportedly been hospitalized several times for symptoms consistent with her diagnosis of Bipolar Disorder, and at the time of her NGRI offense, Ms. Doe was experiencing symptoms of mania.
This item is rated Present and of High Relevance for her violence risk (History of Problems with Major Mental Disorder).
Ms. Doe’s history of violence is limited and has almost exclusively been directed at her second ex-husband.
Per her report, her infrequent bouts of violence have occurred in response to distress within a romantic relationship, though the NGRI offense was related to concerns about her youngest child (History of Problems with Relationships and Parenting Difficulties).
Ms. Doe’s descriptions of her prior romantic relationships have been notable for their emotional strain.
Her first marriage was reportedly difficult given her husband’s substance abuse problems and physical abuse towards her.
The early years of her second marriage were reportedly characterized by reciprocal physical and verbal abuse.
In 2003, Ms. Doe reportedly became suspicious that her second husband was having an extramarital affair and when reviewing contents of his computer, became aware of his possession of pornographic images of children.
Ms. Doe noted there was subsequent legal action, following which, their marriage improved and reciprocal abuse stopped for many years.
Ms. Doe incurred a charge of Assault and Battery against her second husband in 2014 and divorced him in 2015, reportedly due to renewed concerns about his possession of child pornography.
Despite allegations made in court by Ms. Doe’s eldest daughter, (the daughter with whom she currently takes passes) that he had sexually molested her during her childhood, he was awarded custody of their two children.
Since her ESH admission, Ms. Doe’s statements about her ex-husband are indicative of persistent distrust and negative emotions.
Ms. Doe has recently allowed the undersigned to communicate with her ex-husband for the purposes of discussing possible visitation with her youngest daughter in the community in the future.
Though she continues to verbalize distrust toward him, this is considered a positive change in her approach to their relationship.
[LARGE FONT]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY[/LARGE FONT]INTRODUCTION
co-parenting relationship. Ms. Doe denies any history of aggression toward her children when asymptomatic. However, during prior periods of symptom resurgence, she has been noted to become verbally threatening toward them.
Per her IAAB, there were “indications that she was accused of assaulting her older daughter and husband in 2014.” However, in the description provided below, it appears the violence was largely directed at her ex-husband.
At the time of the NGRI offense, Ms. Doe reported learning that her youngest daughter was being hit by her older sister (this is the middle of Ms. Doe’s daughters, but the eldest of their union and not the daughter with whom Ms. Doe takes passes). not the sister with whom Ms. Doe currently takes passes). Ms. Doe reported she attempted to address this with her ex-husband, but that he was reportedly dismissive of her.
She described becoming angry and upset with him following this and committed the NGRI offense the same day.
Given the history of relational difficulties, mounting co-parenting tensions at the time of the NGRI offense, and the fact that her ex-husband and youngest daughter were the victims of her NGRI offenses, the risk factors for Relationships and Parenting Difficulties are considered Present and Highly Relevant.
Other less critical risk factors for Ms. Doe’s violence include problems with: previous violence (H1), suicide/self-injurious behavior (FAM 14), medical issues (other), history of traumatic and adverse experiences (H8), employment (H4), and problems with treatment or supervision response (H10).
Ms. Doe’s history of violence has been relatively brief and was largely directed toward her second ex-husband (History of Violence). Ms. Doe described this as sporadic and reciprocal domestic violence prior to the NGRI offense.
In 2014, Ms. Doe reportedly became violent toward him in the context of a “steroid rage” and was charged with Assault and Battery.
She indicated she received a steroid injection as a treatment for pneumonia and approximately one week later, she hit and/or kicked her husband.
She initially noted she was not clear why she was angry, but subsequently mentioned her husband had said something to do with money, following which she hit him.
She denied causing him injury, but her oldest daughter called the police.
Ms. Doe’s only other instance of aggression toward him was the NGRI offense, which involved Ms. Doe driving her car into her ex-husband’s home, making threats of wanting to kill him, and attempting to circle the house looking for him after crashing her car.
Ms. Doe has consistently attributed her behavior to active symptoms of mental illness and frustration with her husband for his lack of concern in response to complaints that their youngest daughter was being assaulted by her older sister.
Records indicate she previously had a protective order from threatening her ex-husband and for her two youngest children, but this has since been lifted.
As noted previously, Ms. Doe denies any history of aggression directed toward her children during periods when she was asymptomatic.
However, records have indicated she has verbally threatened her children when ill and placed her youngest in danger during the NGRI offense when she crashed her car into the home of her ex-husband.
Ms. Doe has consistently reported that her aggressive behavior toward her children has occurred during times of active psychiatric symptoms and when in her “right mind” she vigorously denies any historical bouts of aggression or aggressive ideation toward her children.
Ms. Doe has not exhibited any aggressive behavior or reported any aggressive ideation during her hospitalizations at CSH and ESH.
Taken together, this risk factor is considered Present and of Moderate Relevance.
Ms. Doe has a history of suicidal thinking and behavior to include suicidal ideation as part of her depressive episodes and four suicide attempts (Suicidal thinking and behavior).
Her first attempt occurred at age 20, in approximately 1989, when she attempted suicide by overdosing on her Prozac, which she reports induced some suicidal thinking.
Her next attempt, another overdose, occurred approximately one year prior to the NGRI offense.
She reported a final suicide attempt approximately one week later in which she took several Motrin.
She clarified this attempt, unlike her prior attempt, was unplanned, but was prompted by ongoing relationship difficulties with her ex-husband.
Finally, she attempted suicide on 5/XX/2019 by attempting to jump from her parents’ moving car … due to hopelessness related to persistent pain.
Though her suicidal acts have not historically been connected with acts of violence, her most recent attempt did endanger the lives of her parents and others on the road.
Her history of suicide attempts have occurred during periods of increased stress and are understood to reflect a more pervasive loss of more adaptive coping strategies and impulsivity.
As such, these are indirectly related to her risk for violence.
As such, this is considered Present. However, given the intermittent relationship of her suicide history to her violence, this is considered of Moderate Relevance.
Ms. Doe has a history of multiple medical issues, but has exhibited greatest disruption as a result of chronic gynecological pain (Medical Issues).
While this issue has not played a direct role in her previous violence, it played a role in her most recent suicide attempt, which endangered the lives of her parents while transporting her and others on the road.
This risk factor is considered Present and of Moderate relevance to her risk for violence as when present, it has taxed her coping resources and influences her impulsivity, putting herself and others at risk.
At the time of the attempt, Ms. Doe reported feeling overcome with hopelessness that her pain would continue for the rest of her life and there would be no end to it.
She denies any other precipitating stress and denies any awareness of her level of distress prior to going on pass.
Since this event, Ms. Doe’s medication regimen has been adjusted considerably and she had surgery, which she reports has been quite effective in reducing her pain.
With the resolution of her most acute pain, she exhibited some insight into the relationship between her stress and her pain, which was a critical area of intervention prior to her attempt.
At this time, Ms. Doe reports persistent discomfort but minimal pain (ranging between a 1-2 out of 10) for the last several months.
She denies any anxiety related to this pain along with suicidal ideation and hopelessness.
As noted before, should she experience other physical complaints that tax her coping ability, this may make her more likely to engage in behavior that could endanger herself and those around her, but at this time, her pain appears to be well-managed.
Ms. Doe has a history of sexual assault as a child, being threatened with violence as a teen, and as an adult experiencing domestic violence and learning of her husband’s sexual molestation of her child while under her care (History of Traumatic Experiences).
This history of trauma likely affects Ms. Doe’s difficulty coping with stress and it is possible they play some role in her current chronic gynecological complaints as well.
Though her violence has not been enacted during times of traumatic events or recollection of such, it is likely that her experience of trauma has compromised her ability to cope with certain situations and in the presence of other more salient risk factors, may increase the likelihood of resorting to aggression as a situational response.
As such, this is considered Present and of Moderate relevance.
Though Ms. Doe was reportedly compliant with her medication at the time of the offense, she reported altering her dosing schedule to accommodate her disrupted sleep/work schedule.
Recently, Ms. Doe noted this was approved by a community provider, but this is uncorroborated.
Ms. Doe reported some historical medication noncompliance in the community, but noted this paled in comparison to her longer periods of compliance.
In the hospital, she has remained compliant with all medication and treatment recommendations.
However, she struggles with development of insight into specific domains of risk management. As such, this item (History of Problems with Treatment Supervision and Response) is rated as Partially Present.
As it has been inconsistently related to her violence, this item is considered of Moderate Relevance.
Risk factors that seem to have little, if any, relevance to Ms. Doe’s history of violence include: a history of violent attitudes (H9), problems with other antisocial behavior (H2), having a personality disorder (H7), substance use (H5), employment problems (H4), prostitution (FAMH11), and pregnancy at a young age (FAMH13).
Ms. Doe has consistently denied a history of violent attitudes and while she engaged in reciprocal domestic violence for a period of time with her second ex-husband, the absence of violence in other relationships indicates she likely does not hold pervasive attitudes supportive of violence.
She does not have a history of other antisocial behavior, prostitution, or a personality disorder.
Ms. Doe has a history of alcohol consumption, but it has not been connected to her previous instances of violence and she has remained sober since her incarceration.
While substance use in general increases the risk for violence and it is likely that consumption of alcohol or other substances would likely impair her ability to effectively deal with stress and in the presence of other risk factors, this is not considered of great relevance for her risk of aggression at this time.
Finally, while she became pregnant at a young age, she denied any long-lasting negative impacts from these experiences and they do not seem to have been implicated in her acts of violence.
Ms. Doe has a long history of employment as a nurse and reportedly enjoyed her vocation immensely.
Her history of employment is not stereotypically problematic, but was a source of stress and a precipitating factor prior to her NGRI offenses (History of Problems with Employment).
Due to the nature of Ms. Doe’s work, she was frequently changing her sleep schedule and attempted to alter her medication regimen to fit her needs.
Rather than stop or change her work schedule, Ms. Doe persisted, although there was no reported disruption in her work.
Ms. Doe wants to work and she has mentioned interest in renewing her nursing certification following her release.
While working in general has been helpful for her and is generally a protective factor, Ms. Doe will need to remain mindful how to negotiate her work obligations and resultant distress in ways that protect her recovery.
This risk factor is considered Not Present and of Low Relevance.
Clinical Factor
Time frame: 90 days or since last privilege increase
Over the last 90 days, Ms. Doe’s most salient clinical risk factors include lack of insight (C1), instability (C4), and treatment and supervision response (C5).
Ms. Doe’s insight has been a critical area of intervention for much of her hospitalization (Problems with Insight).
Her level of insight has varied depending on the area of inquiry and the level of distress she is currently experiencing.
By and large, she accepts her psychiatric diagnosis and need for medication to effectively deal with symptoms.
However, she has struggled to appreciate education about her risk factors and the notion that risk requires consistent management rather than some factors just being sufficiently managed because they are in the past.
This has been a consistent observation of Ms. Doe across work with the undersigned and per report of her individual therapist.
For example, Ms. Doe struggled to accept that her chronic pain may have affected her ability to tolerate stress and that this could be a risk
[LARGE FONT]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY[/LARGE FONT]INTRODUCTION
This section provides an overview of the guidelines and the importance of structured management for individuals found not guilty by reason of insanity. It emphasizes the need for comprehensive assessment and tailored interventions to ensure safety and stability.
TABLE OF CONTENTS
1. Risk Factors and Relevance
2. Discharge Planning and Privilege Levels
3. Treatment Interventions and Monitoring
4. Family and Support System Involvement
5. Stress Management and Coping Strategies
6. Special Considerations for Childcare Responsibilities
7. Appendices and References
[LARGE FONT]Risk Factor Assessment and Management[/LARGE FONT] [21.96 pt]1. Violence and Insight DeficitsThe following assessment pertains to Ms. Doe's risk factors related to violence and insight into her condition.
Problems with Insight and Stress Tolerance
Ms. Doe's history indicates a factor for violence in that it compromised her overall ability to tolerate stress and manage impulsive decision-making.
Only following her surgery has she become more receptive to discussing the relationship between her pain and her stress level, recognizing that they may inform one another.
Finally, following her suicide attempt in May 2019, she struggled greatly to even identify the event as a suicide attempt, to develop additional insight surrounding this event, and generally use the experience for proactive relapse prevention.
She has made recent improvements in this domain. Given this, the item is rated Partially present. However, because this deficit in insight has not been functionally related to any episodes of violence in the last 90 days, and months before that, it is considered to be of Moderate Relevance.
Emotional and Cognitive Instability (Problems with Instability)
Ms. Doe is compliant with all treatment interventions and her most acute manic/depressive symptoms are well-managed with medication.
She also reports decreased pain, consistent use of coping resources (i.e., latch hooking, talking with family, attending therapy), and has remained free of violence.
However, she does exhibit some recurrent emotional and cognitive instability, despite her general psychiatric stability.
Specifically, Ms. Doe frequently devolves into tears when distressed and has resorted to all-or-nothing problem-solving/ideation when confronted with difficult or upsetting news.
With intervention and time, she is
There have been several recent examples of this, and once given time to verbalize her frustration and calm down, she exhibited more reasonable thinking about the matter.
She describes herself as a sensitive individual and notes that crying is often a helpful way for her to express her emotions.
This presentation, characterized by emotional and cognitive impulsivity, is rated as Present.
That said, in the presence of these, she has not exhibited any behavioral impulsivity (e.g., aggression toward self or others, disengagement from treatment, refusal to take medication, etc.).
Therefore, this instability is considered to be only moderately relevant to her risk for violence at this time.
Though intermittently tearful and anxious, she has engaged her coping skills effectively.
Finally, while she is a self-admitted worrier who cries often, she is otherwise pleasant and capable.
As her insight and emotional regulation strategies remain points of intervention, due to slow responsiveness, the risk factor Problems with Treatment and Supervision is also rated as Partially present and of moderate relevance.
[21.96 pt]2. Other Risk Factors Over the Last 90 DaysThe following risk factors have not been problematic over the last 90 days:
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Symptoms of active mental illness (C3)
Covert and manipulative behavior (FAM C6)
Low self-esteem (FAM C7)
Medical issues
Ms. Doe denies and has not exhibited any symptoms of mania, depression, or psychosis in the last 90 days.
She has not exhibited manipulative behavior or made statements suggestive of low self-esteem in this period.
While she is frequently emotive, it is not clear that this is related to low self-view, though she may feel shame and guilt about her daughter's involvement in the offenses and the subsequent restrictions on their interaction.
Her medical issues appear to be adequately addressed following her surgery, with persistent low-level pain (1 out of 10), which has decreased from prior levels, and she reports satisfaction with the surgery.
[20 pt]3. Discharge Privilege Level: Next 90 DaysThis privilege level would allow Ms. Doe to take overnight passes at her independent apartment in the community, which is also her proposed discharge placement.
The following risk factors are considered present and relevant, to some degree, for her risk on the next level of privilege:
Management During Passes
-
While on overnight passes, Ms. Doe’s clinical needs will be addressed by therapeutic interventions available at ESH and XXX Day Treatment Center.
While in the hospital, she will continue attending PSR groups and individual therapy.
While on pass, she will attend the XXX Day Treatment Center one to two days per week, and also attend a weekly AA meeting.
Her medications will be administered by ESH staff when she is here, and the XXX Day Treatment Center will administer the majority of medication doses while on passes.
Because she will be living in an independent apartment where PACT services will not be available until discharge, Ms. Doe will be expected to take some of her medications herself.
She will transport her medication to the XXX Day Treatment Center and hand it over to the nurse.
The nurse will dispense medications during the day, and before leaving, Ms. Doe will receive her evening dose and call the treatment team social worker (or designee) to verify she has taken her medication by 8 pm.
The next day, she will take the morning and midday doses at the XXX Day Treatment Center, with the nurse dispensing the evening dose.
Ms. Doe will call the team social worker (or designee) to verify each dose has been taken.
Although she has a remote history of medication noncompliance, the plan ensures monitoring at several points to promote compliance.
She also has a remote history of suicide attempts via overdose, but she will not be given enough medication at any one time to pose a lethal risk, and she will be searched upon return to prevent stockpiling.
This risk factor is considered Not Present and of Low Relevance to her risk for violence (Problems with Professional Services and Plans).
Family and Support System
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Ms. Doe reports having a very close-knit family, including her parents, children, and several friends.
Her parents and eldest daughter have attended requested meetings, visit her weekly, and respond highly when contacted.
Her family is supportive of her treatment, and she has taken between 5-10 family passes since regaining privileges.
She relies on her daughter and father for emotional support and decision-making.
While family support is important, there is concern that Ms. Doe is overly reliant on them and less independent in thinking and emotional resilience.
The team is pursuing an independent apartment rather than discharging her to her parents, as was her preference.
She plans to visit her parents in the evening after treatment, with team approval, using this new privilege.
The family has been amenable to treatment interventions and additional meetings as needed.
This risk factor (Problems with Personal Support) is rated Partially Present and of Moderate relevance.
Stress and Emotional Resilience
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Ms. Doe will be in her own apartment, somewhat distanced from family, but may experience distress related to her ex-husband, though less than with renewed contact.
Given her history of compliance, she is highly likely to remain compliant with her psychiatric medication and treatment while on overnight passes.
Remaining areas of treatment response include her emotional sensitivity and slow insight development, though she has shown some improvement since her suicide attempt.
She has complied with significant medication changes addressing mood dysregulation and impulsivity.
She has demonstrated behavioral stability through gradual privilege resumption and unescorted community passes.
Post-surgery, her pain level has decreased to 1-2 out of 10 and remains stable.
She maintains a daily log of pain, suicidal ideation, and hopefulness, reviewed regularly.
While insight development remains slow, she uses adaptive coping skills to manage distress.
This risk factor is rated Partially Present and of Moderate Relevance.
Stress from External Factors and Family Dynamics
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Ms. Doe anticipates ongoing stress from holidays, family issues, and her ex-husband.
She remains connected to her ex-husband due to shared children, despite no longer being in a relationship.
She holds distrustful beliefs and negative emotions about him, distressed at the idea of renewed communication.
She has agreed to team communication regarding visits with their daughter, pending approval.
She is likely to become tearful when stressed but employs adaptive coping skills such as latch-hooking, coloring, therapy, and social support.
Her medications have been adjusted post-suicide attempt, and she actively engages with providers.
She has remained free of aggression or self-injury.
Ms. Doe is highly motivated to stay stable to reconnect with her children, discharge, and return to her life.
Her current management strategies have been effective over the past six months.
This risk factor (Problems with Stress and Coping) is rated Present and of Moderate Relevance.
Impact on Childcare Responsibilities
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Ms. Doe reports distress over limited contact with her children, especially her youngest daughter, a victim of the offense.
She has an estranged relationship with her adult son.
She is pursuing reconsideration of the FRP bar to visiting her youngest daughter in the community.
This overall assessment indicates ongoing challenges but also progress in managing her responsibilities and emotional state.
NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY
INTRODUCTION
The undersigned to speak with her ex-husband about this following his contact with the Forensic Coordinator and the undersigned. This risk factor is considered Present. At this time, the limited role in her youngest daughter’s life is not new and during the six months since she was restricted from such contact with her daughter, she has remained free of violence and impulsive behaviors.
Though childcare concerns were at the heart of her NGRI offense, she is considerably more stable at this time and additional stress from work and other familial stressors are no longer present. As such, this is considered to be of Moderate Relevance at this time.
Ms. Doe is currently involved in a romantic relationship with a hospital peer. Per her report, this is a healthy and supportive relationship, unlike her prior romantic relationships. There have been no reports of grossly inappropriate interaction between them.
At this time, there is no cause for concern that her current relationship will induce the same kind of destabilization as her prior relationships did, that Ms. Doe would be driven to domestic violence against her partner, or that together they would engage in offending behaviors. Therefore, the risk factor Problematic Intimate Relationships is rated Not Present and of Low Relevance.
Ms. Doe’s will reside predominantly at the hospital during her next pass, but in an independent apartment when in the community. This was decided upon by the team because for several reasons. Primarily, it was reasoned that living independent of family would help in mitigating risk of decompensation posed by living with family in a highly emotive, potentially enabling environment.
Additionally, given her history of functional independence and the daily observation by mental health providers that will be included in her structured activities, the level of supervision and restriction in a group home was thought to be excessive.
Ms. Doe will continue to utilize her coping skills enumerated above while on pass, will be in contact with providers daily, and will be provided with emergency support contact information should she need them in the community.
Despite her protests of this placement, Ms. Doe has exhibited intermittent contentment about going to her own apartment given her reports of frustration on the unit with multiple peers and the quiet and solitude afforded in the apartment.
Additionally, she will be able to maintain contact with her parents. Ms. Doe will be working closely with the KEYs program to find a long-term apartment while on her next pass as she currently only has an interim apartment.
Once identified, she can move into the long-term apartment where she can demonstrate risk management in that setting as well before seeking release.
She reported feeling somewhat unsafe about the surrounding neighborhood of her interim apartment, but that she would likely remain in the apartment rather than travel after certain hours. This is consistent with her behavior in the hospital when faced with a tumultuous unit as well and does not appear to increase her risk for violence.
As such, the risk factor Future Problems with Living Situation is considered Partially Present, given the nature of the neighborhood surrounding her interim environment and her fears, but of Low risk for violence.
Similarly, as her medical condition is currently sufficiently managed, this is considered not present and of low relevance to her risk for violence.
Ms. Doe has no history of arson or escape.
HCR -20 V3 Factor Assessment
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H1. Violence Present — Moderate — Present — High
H2. Other Antisocial Behavior Partial — Low — Partial — Low
H3. Relationships Present — High — Present — High
H4. Employment No — Low — No — Low
H5. Substance Use No — Low — No — Low
H6. Major Mental Disorder Present — High — Present — High
H7. Personality Disorder No — Low — No — Low
H8. Traumatic Experiences Present — Moderate — Present — Low
H9. Violent Attitudes No — Low — No — Low
H10. Treatment or Supervision Response Partial — Moderate — Partial — Moderate
H11. Prostitution No — Low — No — Low
H12. Parenting Difficulties Partial — High — Partial — High
H13. Pregnancy at a young age No — Low — No — Low
H14. Suicidality/Self-Harm Present — Moderate — Present — Low
OC-H Other: Medical Issues Present — Moderate — Present — Moderate
C1. Insight Partial — Moderate — Partial — High
C2. Violent Ideation or Intent No — Low — No — Low
C3. Symptoms of Major Mental Disorder No — Low — No — Low
C4. Instability Partial — Moderate — Partial — Low
C5. Treatment or Supervision Response Partial — Moderate — Partial — Moderate
C6. Covert and Manipulative Behaviors No — Low — No — Low
C7. Low Self-esteem No — Low — No — Low
OC-C Other: Medical Issues Partial — Low — N/A — N/A
R1. Professional Services and Plans No — Low — No — Low
R2. Living Situation No — Low — No — Low
R3. Personal Support Partial — Moderate — Partial — Low
R4. Treatment or Supervision Response Partial — Moderate — Partial — Moderate
R5. Stress or Coping Yes — Moderate — Partial — High
R6. Problematic Child Care Responsibility Yes — Moderate — Partial — Moderate
R7. Problematic Intimate Relationship No — Low — No — Low
OC-R Other: Medical Issues No — Low — N/A — N/A
Risk Formulation
Describe present factors and if they are currently relevant to the risk posed by utilizing the requested privilege:
Ms. Doe has a limited history of violence. The bulk of her historical aggression has been directed toward her second ex-husband, though she has also threatened her daughters and put another at risk of injury in the commission of her NGRI offense.
While Ms. Doe’s history of psychiatric illness was directly involved in her NGRI offenses and the aggression directed towards her daughters, her violent behavior toward her second ex-husband has not consistently been related to her experience of psychiatric symptoms.
Rather, the common factor in most of her instances of violence with him has been an underlying difficult relationship, exacerbated by other attendant risk factors.
As such, her psychiatric illness can be thought of as a risk factor that destabilizes Ms. Doe and generally elevates her risk as it compromises her ability to cope and rationally select nonviolent coping methods.
However, her interpersonal conflicts with romantic partners, parenting difficulties, and difficulties with emotional regulation are also critical to her risk of violence.
With regard to violence directed toward her husband, Ms. Doe described a period of reciprocal domestic violence in the early years of their relationship and noted that after a period of stability, nearly all instances of aggression were preceded by some sort of disagreement, whether about finances, suspicions of infidelity, or disagreements about parenting practices.
Thus it seems the interpersonal strife within this relationship acted as a contributing but steady factor that increased her violence risk.
Ms. Doe, however, denies this and instead, attributed her violent behavior to the effects of steroid medication and need for self-defense during these instances.
At the time of the NGRI offense, Ms. Doe was contending with a number of risk factors. Her problematic relationship with her then-husband was amplified as she was reeling from their bitter divorce in which prior evidence of her husband’s sexual deviance resurfaced.
In an attempt to provide financially, Ms. Doe had been working multiple shifts as a nurse with no consistent pattern of sleep or routine, in which she also rearranged her medications schedule in an attempt to accommodate her inconsistent schedule.
The disruption in sleep and medication, in the presence of increased relational distress, likely contributed to her reemergence of symptoms.
While symptomatic, Ms. Doe reported that her younger daughter told her she was being hit by her older sister.
When Ms. Doe attempted to address it with her ex-husband the same day, she felt he dismissed and disregarded her concerns.
Following this disagreement, Ms. Doe drove to her ex-husband’s house and the NGRI offenses ensued.
Therefore, her parental concerns and more specifically, the disagreement with her husband in an already compromised state appeared to precipitate the events of the NGRI offense.
Ms. Doe’s brief history of aggression directed toward her daughters seem to all have occurred in the context of active psychiatric symptoms compounded by increased stress related to relationship dissolution.
Ms. Doe denied any history of violence toward her children when not actively symptomatic and she noted that both instances were quickly followed by bizarre behavior (e.g., urinating on herself and making odd statements to police officers following her arrest), again supporting the notion that her psychotic thinking in the context of a bitter divorce precipitated her aggressive and uncharacteristic aggression toward her children.
Ms. Doe’s most recent suicide attempt also endangered the lives of her parents and others on the road. While not intentionally violent, it was nevertheless a reckless act that could have caused injury.
As outlined above, Ms. Doe has complied with several treatment interventions since that time and has exhibited behavioral stability.
Further, she is no longer in the excessive pain she was at the time of the attempt and reports great relief in this.
As the identifiable precipitant (i.e., pain) has been alleviated and the associated impulsivity appears to be well controlled at this time with medication and psychosocial intervention/support.
She consistently denies suicidal ideation and verbalizes her motivation to remain stable and leave the hospital so as to carry on with her life.
At present, Ms. Doe’s risk for violence is well-managed with consistent medication adherence and the provision of a structured setting to minimize stressors present at the time of the offense to include parenting difficulties, employment demands, and involvement in unhealthy romantic relationships.
Ms. Doe’s risk for violence is perpetuated by her mental illness, emotional reactivity, struggles with insight development, and co-parenting responsibilities.
However, many of the risk factors present on the day of the NGRI offense have been mitigated.
For instance, she has been consistently compliant with her medication which has resulted in successful management of her psychiatric illness.
She has additionally participated in multiple groups that have focused on appropriate emotional expression and more appropriate relationship functioning.
She participates in individual therapy and is developing more insight into her risk factors.
Though she wants to work, she is not currently employed and will spend much of her time on this privilege engaged in treatment activities.
Risk Management Plan
(add additional strategies as needed)
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Management Strategy #1: As Ms. Doe’s psychiatric stability is critical, her consistent compliance and responsivity to medication will be closely monitored on the next privilege level. She has remained compliant with medication thus far and voices her intention to comply moving forward.
As highlighted above, Ms. Doe will be responsible for some management of her own medication on this privilege level, but will be expected to check in with team members following each independently administered dose.
Her compliance will be monitored with routine lab work. Nursing staff and treatment team members will closely monitor her mental status for changes in mood, sleep, thought disturbances and paranoia as well as suicidal or homicidal ideation prior to exercising new privileges (if approved) and address as needed.
If her mental status worsens, the treatment team will suspend privileges pending further evaluation.
Management Strategy #2: Ms. Doe’s history of violence has been circumscribed to those with whom she shares close relationships, specifically, her former
The introduction section would go here, but the provided text does not include it. Please insert the relevant content as needed.
TABLE OF CONTENTSThe table of contents section would go here, but the provided text does not include it. Please insert the relevant content as needed.
[SIZE=21.96pt]Management Strategies and Risk Assessment [SIZE=20pt]Management Strategy #3Another important area of risk management for Ms. Doe involves her ongoing development of emotional regulation strategies and insight, and for this, her individual therapy will continue.
Additionally, the undersigned will continue to meet with her regularly to discuss her evolving risk management strategies.
She has revised her WRAP plan and will be encouraged to update this as appropriate for the remainder of her hospitalization so that she might share it with family and community providers.
[SIZE=21.96pt]Future Violence/Case Prioritization-
Low
Moderate
High
Serious Physical Harm: Low Moderate High
Imminent Violence: Low Moderate High
Check protective factors and how those factors help mitigate risk at this proposed privilege level.
[SIZE=21.96pt]Protective Factors-
• Intelligent Secure childhood attachment
• Appropriate coping skills
• Self-control
• Resilient personality traits
• Empathy
• Employment
• Leisure activities/hobbies
• Motivation for treatment
• Medication Adherence
• Financial management
• Positive attitudes towards authority
• Future oriented
• Social network/attachments
• Pro-social involvement
• Strong attachment and bonds
• Intimate Relationships
• Other: Ms. Doe has a number of protective factors that mitigate her risk for violence. Specifically, she has a history of advanced educational attainment and long periods of employment, periods of high level functioning in the community while appropriately managing her illness, multiple coping strategies (e.g., coloring, talking to support system, and latch-hooking among others), motivation for treatment, medication adherence, positive attitudes towards treatment providers, and goals for her life after discharge.
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Appelbaum, P. S., Robbins, P. C., Monahan, J. (2000) Violence and delusions: Data from the MacArthur Violence Risk Assessment Study. American Journal of Psychiatry, 157, 566-572.
Bell, C. C. (Ed.) (2000) Psychiatric Aspects of Violence: Issues in Prevention and Treatment. Vossey-Bass, Inc., San Francisco, CA.
Binder, Renee L. (1999) Are the mentally ill dangerous? Journal of the American Academy of Psychiatry and Law, 27, 189-201.
Boer, D. P., Wilson, R. J., Gauthier, C. M. & Hart, S. D. (1997) Assessing risk of sexual violence: Guidelines for clinical practice. In Webster, C. D. & Jackson, M. A. (Eds.) Impulsivity: Theory, Assessment and Treatment (pp. 326-342), the Guilford Press, New York, NY.
Borum, R., Fein, R., Vossekuil, B. & Berglund, J. (1999) Threat assessment: Defining an approach for evaluating risk of targeted violence. Behavioral Sciences and the Law, 17, 323-337.
Dolan, M. & Doyle, M. (2000) Violence risk prediction: Clinical and actuarial measures and the role of the Psychopathy Checklist. British Journal of Psychiatry, 177, 303-311.
Grisso, T., Davis, J., Vesselinov, R., Appelbaum, P. S. & Monahan, J. (2000) Violent thoughts and violent behavior following hospitalization for mental disorder. Journal of Consulting and Clinical Psychology, 68, 388-398.
Hanson, C. K. & Thorton, D. (2000) Improving risk assessment for sex offenders: A comparison of three actuarial scales. Law and Human Behavior, 24, 119-136.
Hare, R. D. (1999) Psychopathy as a risk factor for violence. Psychiatric Quarterly, 70, 181-197.
Hare, R. D. (1998) The Hare PCL-R: Some issues concerning use and misuse. Legal and Criminal Psychology, 3, 99-119.
Hare, R. D., Cooke, D. J., & Hart, S. D. (1999) Psychopathy and sadistic personality disorder. In Millon, T. & Blaney, P. H. (Eds.) Oxford Textbook of Psychopathology (pp. 555-584), Oxford University Press, New York, NY.
Hare, R. D., Forth, A. E. & Strachan, K. E. (1992) Psychopathy and crime across the lifespan. In Peters, R. D., McMahon, et al. (Eds.) Aggression and Violence Throughout the Lifespan (pp. 285-300), Sage Publications, Inc., Thousand Oaks, CA.
Hare, R. D. & Hart, S. D. (1993) Psychopathy, mental disorder and crime. In Hodgins, S. (Ed.) Mental Disorder and Crime (pp. 104-115), Sage Publications, Inc., Thousand Oaks, CA.
Harris, G. T., Rice, M. E., & Quinsey, V. L. (1993) Violent recidivism of mentally disordered offenders: The development of a statistical prediction instrument. Criminal Justice and Behavior, 20, 315-335.
Hart, S. D., Forth, A. E. & Hare, R. D. (1990) Performance of criminal psychopaths on selected neurological tests. Journal of Abnormal Psychology, 99, 374-379.
Heilbrun, K., Hart, S. D., Hare, R. D., Gustafson, D., Nunez, C. & White, A. J. (1998) Inpatient and post discharge aggression in mentally disordered offenders: The role of psychopathy. Journal of Interpersonal Violence, 13, 514-527.
Heilbrun, K. (1997) Prediction versus management models relevant to risk assessment: The importance of legal decision-making context. Law and Human Behavior, 21, 347-359.
Hemphill, J. P., Hare, R. D. & Wong, S. (1998) Psychopathy and recidivism: A review. Legal and Criminal Psychology, 3, 139-170.
Kernberg, O. F. (1992) Aggression in Personality Disorders and Perversions. Yale University Press, New Haven, CT.
Kropp, P. R. & Hart, S. D. (1997) Assessing risk of violence in wife assaulters: The Spousal Assault Risk Assessment Guide. In Webster, C. D. & Jackson, M. A. (Eds.) Impulsivity: Theory, Assessment and Treatment. Guilford Press, New York, NY.
McNeil, D. E. & Binder, R. L. (1994) Relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence. Hospital Community and Psychiatry, 45, 133-137.
Michaud, S. G. & Hazelwood, R. (1998) The Evil that Men Do. St. Martin’s Press, New York, NY.
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INTRODUCTION
This manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI). It covers legal frameworks, court systems, effective communication with courts, and evaluation procedures to assist professionals involved in such cases.
TABLE OF CONTENTS
I. Understanding the Law
II. The Court Systems
III. Working Effectively with the Courts
IV. Commissioner Appointed Evaluations
[LARGE FONT]I. Understanding the Law[/LARGE FONT]A. Constitutional law
Virginia and United States Constitutions establish principles of law.
B. Statutory law
Virginia General Assembly enacts statutes that are collected in the Virginia Code.
C. Administrative law
Government agencies promulgate regulations on authority delegated by legislatures (e.g., Human Rights Regulations).
D. Case law
Appellate courts resolve questions in the law not made clear elsewhere; appellate decisions establish precedent that trial courts within the same jurisdiction must follow.
[LARGE FONT]II. The Court Systems[/LARGE FONT]A. Organization of Virginia courts (see flow chart in this chapter)
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1. District courts
a. General District courts
(1) Civil trials involving relatively small claims
(2) Misdemeanor trials (less serious criminal offenses)
(3) Felony preliminary hearings (more serious criminal offenses)
(4) Civil commitment and emergency revocation of NGRI conditional release
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(1) Delinquency and status offenses
(2) Custody, support of children
(3) Crimes against children or within families (preliminary hearings in felony cases, trials in misdemeanor cases)
(4) Concurrent jurisdiction for commitment of adults with general district court (§16.1-241 B.)
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(a) Civil cases involving large claims
(b) Felony trials
(c) Misdemeanor "appeals" (new trial)
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(a) No trials
(b) Hears appeals on the record from circuit court decisions
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(a) No trials
(b) Hears appeals on the record from trial court decisions and decisions of the Court of Appeals, in some cases
A. Knowing the players
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1. Commonwealth's attorney: prosecutor
2. Defense attorney may be:
a. The public defender in some Virginia county/city jurisdictions
b. A court-appointed attorney
c. Employed by the defendant
B. Communicating with the courts: general rules
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1. Stay relevant
2. Do not give opinions you cannot support with data
3. Do not give opinions outside your area of expertise
4. Be concise
5. Watch for jargon: define, explain, or avoid
a. Diagnostic labels (e.g., schizophrenia)
b. Mental status terminology (e.g., affect, egodytonic)
c. Medication names (e.g., Seroquel, Risperidone)
C. Communicating with the courts: in writing
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1. Address correspondence to the judge as "The Honorable (name of judge)"
2. Organize reports carefully
3. Keep facts separate from opinions and recommendations
4. Provide the source for facts (e.g., "The acquittee's brother reported that.....")
5. Support opinions and recommendations with a clear rationale
D. Communicating with the courts: orally
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1. As a "fact witness"
a. Present just the facts
b. Do not present inferences or opinions
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a. May present inferences and opinions if based on "specialized" clinical knowledge or skills that will add to what the court would be able to discern for itself
b. Requires qualification as an expert
(1) Educational requirements vary according to issues asked to address
(2) Specialized training and experience (such as evaluating/treating defendants, offenders, NGRI acquittees)
(3) Appropriate evaluation procedures
The attached NGRI evaluation emphasizes a broadly based assessment approach. Depending on individual considerations, various sections in the outline may be covered in more or less detail.
For example, evaluations during temporary custody regarding newly admitted acquittees may emphasize background data to inform the court as fully as possible. For longer-term patients and evaluations after petitions for release, the court may be well aware of much background material, and recent adjustment information would be an area of inquiry having greater importance for dispositional considerations.
Psychometric information, as determined by individual cases, may be useful to obtain and include (e.g., MMPI, WAIS, Brief Psychiatric Rating Scale, Psychopathy Checklist, etc.).
A specific section should be devoted to an assessment of risk of future aggression. The outline suggests several factors which should be considered in such an assessment, including identification of risk factors based on the NGRI offense and other aggressive incidents in the acquittee's history.
See Initial Analysis of Risk and ARR-Updates (see Appendix A).
Consideration of the offense for which the NGRI individual was acquitted is important because judicial decisions in Virginia have explicitly upheld different commitment standards for insanity acquittees, in part because they have already been shown beyond a reasonable doubt to have committed at least one dangerous act (i.e., the criminal offense for which they were acquitted).
It is also appropriate to discuss the limitations and imprecision of assessing risk of future aggression, such as the difficulty of generalizing from one environment (e.g., the hospital) to another environment (e.g., the community).
The CSB and other community treatment providers who treated the acquittee in the past should be contacted for information about the acquittee's course of treatment with them, adherence to community treatment, and the CSB's resources for future conditional release.
This is particularly necessary for temporary custody evaluations, and whenever a recommendation for conditional release or release without conditions is being considered.
Based upon background information, clinical data, and risk of future aggression assessments, and taking into consideration the factors outlined in §19.2-182.3, the evaluation should include summary opinions regarding the acquittee's need for inpatient hospitalization.
Provide clear rationales linking background information, assessment, and the §19.2-182.3 factors considered to your summary opinion.
Tables 2.2, 2.3, and 2.4 clearly outline the criteria and supporting information needed to provide opinions regarding an acquittee's need for inpatient hospitalization, eligibility for conditional release, or eligibility for release without conditions.
Consult those tables carefully.
Opinions regarding intellectual disability should be based upon current American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria.
These criteria require deficits in both level of intellectual functioning and adaptive capacity.
See also the definition of intellectual disability specified in Virginia Code section 37.2-100, and the criteria established by the American Association of Intellectual and Developmental Disabilities (AAIDD).
Note that the phrase "maximum benefit of hospitalization" is not included in Virginia's criteria for commitment, conditional release, or release without conditions.
Opinions regarding disposition of acquittees should be based directly upon the criteria outlined in Virginia Code. Therefore, recommendations based on an acquittee reaching "maximum benefit of hospitalization" should be avoided.
The evaluator shall summarize his or her final recommendation regarding court disposition within the criteria set forth in Virginia Code.
The evaluator shall use the language in one of the following three paragraphs to conclude each Commissioner-appointed evaluation:
CONCLUSION AACQUITTEE HAS A MENTAL ILLNESS OR INTELLECTUAL DISABILITY AND IS IN NEED OF INPATIENT HOSPITALIZATION
Based on my evaluation of Mr./Ms. ______________ as discussed in this report, it is my opinion that Mr./Ms. ______________ has a mental illness or intellectual disability and is in need of inpatient hospitalization at the present time.
Taking into account Mr./Ms. _______________'s current mental condition, psychiatric history, risk of aggressive behavior, amenability to outpatient supervision and treatment, and other relevant information, I believe that if Mr./Ms. _______________ is not hospitalized, there would be a significant risk of bodily harm to other persons/himself/herself in the foreseeable future.
I do not believe that Mr./Ms. _______________ can be adequately controlled with supervision and treatment on an outpatient basis at this time.
(Although the symptoms of Mr./Ms. _______________'s mental illness are in/partially in remission, I do not believe outpatient treatment or monitoring would prevent his/her condition from deteriorating to a degree that he/she would need inpatient hospitalization.)
CONCLUSION BACQUITTEE NOT IN NEED OF INPATIENT HOSPITALIZATION BUT A SUITABLE CANDIDATE FOR CONDITIONAL RELEASE
Based on my evaluation of Mr./Ms. ______________ as discussed in this report, it is my opinion that Mr./Ms. ______________ is not in need of inpatient hospitalization at the present time but needs outpatient treatment and monitoring to prevent his/her condition from deteriorating to a degree that he or she would need inpatient hospitalization.
Appropriate outpatient supervision and treatment are reasonably available, as discussed in this report.
There is significant reason to believe that Mr./Ms. ______________, if conditionally released, would comply with a reasonable set of conditions.
Based on my assessment of Mr./Ms. ______________'s risk of future aggressive behavior, I do not believe conditional release would present an undue risk to public safety.
CONCLUSION CACQUITTEE NOT IN NEED OF INPATIENT HOSPITALIZATION NOR IN NEED OF CONDITIONAL RELEASE
Based on my evaluation of Mr./Ms. ______________ as discussed in this report, it is my opinion that Mr./Ms. ______________ is not in need of inpatient hospitalization at the present time nor does he or she need outpatient treatment and monitoring to prevent his/her condition from deteriorating to a degree that he or she would need inpatient hospitalization.
Commissioner appointed evaluations are independent evaluations provided to the courts. As such, they do not require approval from the FRP when recommending conditional release or release without conditions.
Should inpatient hospitalization be recommended, an assessment of the appropriate level of security required during that hospitalization should be made.
Should conditional release be recommended, suggestions regarding appropriate conditions of release are useful for both the court and the staff developing appropriate conditional
[LARGE FONT]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY[/LARGE FONT]INTRODUCTION
This outline is offered as a guide and includes those issues that clinicians should consider or discuss in order to meaningfully inform the court regarding commitment, conditional release, or release without conditions decisions. As noted above, clinicians will choose to emphasize different elements of this outline depending upon the case at hand.
As in any forensic report, it is important to use language that is comprehensible to the lay reader and to avoid excessive psychological/psychiatric jargon. Although it is reasonable to assume that the court may require testimony in order to clarify important issues or points, this does not justify the preparation of reports that are cursory or conclusory in nature.
It is wise to prepare such a report assuming that you may be asked to re-examine an acquittee for the same issues one year hence. In such a case, a prudent clinician should develop the best data base possible in order to do a good job the next time around.
TABLE OF CONTENTS
I. Identifying Information
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A. Name
B. Sex
C. Age
D. Date of birth
E. Level of education completed
F. Judge
G. Court of jurisdiction
H. NGRI court case number
I. NGRI offense(s)
J. Date of NGRI adjudication
K. Date of admission
L. Type of evaluation
1. Temporary custody evaluation, pursuant to §19.2-182.2
2. Evaluation after Commissioner's request for conditional release in an annual continuation of confinement report or acquittee requests release, pursuant to §19.2-182.5 (B)
3. Petition for release evaluation, pursuant to §19.2-182.6 (A)
II. Background Data
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A. Pre-offense history (education, employment, marital/family status, living situation)
B. Mental illness and treatment history
1. Psychiatric (dates, medication, treatment, response)
a. Hospitalizations
b. Community treatment (include any involvement by CSB)
2. Medical (disorders, treatment)
3. Substance abuse (types, frequency, duration, periods of abstinence)
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1. From criminal records
2. From pre-trial evaluations of criminal responsibility
3. From acquittee's self-report
4. From any other collaborating sources
III. Recent Adjustment
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A. Participation in treatment
Include acquittee's perception of mental condition, need for treatment, nature of treatment, and value of treatment
B. Medication regimen
1. Response
2. Compliance
IV. Mental Status Examination
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A. Description of present symptomatology
B. Note level of patient cooperativeness, defensiveness, and insight into condition
C. Diagnostic Impression
1. Summary of past diagnoses and current diagnoses
2. Describe conditions and comment on discrepancies
V. Risk of Future Aggression Assessment
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A. Summary of aggressive episodes and brief description of each, including recent hospital aggression
B. Identification and exploration of any relevant risk factors
C. Description of associated treatment and management for each risk factor
D. Identification and exploration of supports and strengths related to future adjustment
E. Conclusion regarding current risk of future aggression
VI. Summary Opinions/Recommendations
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A. Assessment of mental illness and intellectual disability and need for inpatient hospitalization, based on factors described in §19.2-182.3. court
If recommending conditional release or release without conditions, specifically address the Virginia Code criteria for that disposition.
1. If inpatient hospitalization is needed, suggest level of security required.
2. If inpatient hospitalization is not needed and acquittee meets criteria for conditional release, suggest conditions needed for an appropriate conditional release plan.
3. If inpatient hospitalization is not needed and acquittee does not meet criteria for conditional release, suggest components needed for an appropriate discharge plan.
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A. ACQUITTEE HAS A MENTAL ILLNESS OR INTELLECTUAL DISABILITY AND IS IN NEED OF INPATIENT HOSPITALIZATION
Based on my evaluation of Mr./Ms. ______________ as discussed in this report, it is my opinion that Mr./Ms. ______________ has a mental illness or intellectual disability and is in need of inpatient hospitalization at the present time.
APPENDIX D
Reports to the CourtThis appendix covers treatment team submissions of annual continuation of confinement (Annual) reports to the court and requests for conditional release or unconditional release. These are not independent evaluations as are the Commissioner-appointed evaluations outlined in Appendix C.
No report to the court shall include a recommendation for conditional release, release without conditions, or an opinion that the acquittee no longer needs hospitalization without prior review and approval from the FRP.
The attached outline includes a broad range of background and behavioral data covering treatment and adjustment issues that may be of interest to the court.
The sections regarding identifying information and background data serve to review pertinent historical and background information, and should succinctly convey those circumstances that led to the NGRI adjudication.
This section will necessarily be longer and more detailed for recent insanity acquittees, but can probably be abbreviated considerably for longer term patients with whom the court may be well acquainted.
Do not assume, however, that the court is familiar with a particular individual's background and be sure to review that information of which the court should clearly be aware, such as a notably serious offense or extensive treatment history.
The recent adjustment section should specifically focus on the patient's progress and behavior since the last report to the court.
Note strengths as well as problems, treatment compliance, and medication response.
A specific section should be devoted to an assessment of risk of future aggression and should be based on the Analysis of Risk (see Appendix A).
The outline suggests several factors that should be described in the report, including identification of risk factors based on the NGRI offense and other aggressive incidents in the acquittee's history.
Consideration of the offense for which the NGRI individual was acquitted is important because it has already been shown beyond a reasonable doubt that the individual committed at least one criminal offense for which he or she was acquitted.
It is also appropriate to discuss the limitations and imprecision of assessing risk of future aggression, such as the difficulty of generalizing from one environment (e.g., the hospital) to another environment (e.g., the community).
The mental status and diagnostic impression sections, along with the risk of future aggression section, should serve to describe the acquittee's present condition and prognosis.
Based upon background information, clinical, and risk of future aggression assessments and taking into consideration the factors outlined in Virginia Code § 19.2-182.3, the report should include summary opinions regarding the NGRI individual's need for inpatient hospitalization.
Provide clear rationales linking background information, assessment, and the § 19.2-182.3 factors considered to your summary opinion.
Tables 2.2, 2.3, and 2.4 clearly outline the criteria and supporting information needed in order to provide opinions regarding an acquittee's need for inpatient hospitalization, eligibility for conditional release, or eligibility for release without conditions.
Consult those tables carefully.
Make specific references to the criteria outlined in the law for the disposition you are recommending.
Opinions regarding intellectual disability should be based upon DSM criteria which require deficits in both level of intellectual functioning and adaptive capacity.
See also the definition of intellectual disability specified in Virginia Code §37.2-1, as well as AAMR criteria.
Avoid using "maximum benefit of hospitalization" as a criterion for release from hospitalization.
This factor is not included in the criteria for commitment or release outlined in Virginia Code §19.2-182.2 through 19.2-182.16.
Should inpatient hospitalization be recommended, an assessment of the appropriate level of security (maximum security of Central State Hospital---Forensic Unit vs. civil hospital placement) required during that hospitalization is useful.
Should conditional release be recommended, a complete conditional release plan (see Chapter 5-Planning for Conditional Release) should be attached with a description of the CSB's involvement in the development of the plan.
Recommendations for either conditional release or release without conditions require prior review and approval by the FRP before submission to the committing court.
This outline is offered as a guide and includes those issues that clinicians should consider or discuss in order to meaningfully inform the court regarding commitment, conditional release, or release without conditions decisions.
[LARGE FONT]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY[/LARGE FONT]INTRODUCTION
This manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI). It emphasizes the importance of structured assessment, treatment planning, and legal considerations to ensure appropriate care and public safety.
TABLE OF CONTENTS
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I. Identifying Information
II. Background Data
III. Recent Adjustment
IV. Mental Status Examination
V. Risk of Future Violence Assessment
VI. Summary Opinions/Recommendations
APPENDIX E: Active Treatment Approaches for Insanity Acquittees
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A. Name
B. Sex
C. Age
D. Date of birth
E. Level of education completed
F. Judge
G. Court of jurisdiction
H. NGRI court case number
I. NGRI offense(s)
J. Date of NGRI adjudication
K. Date of admission
L. Date of commitment to DBHDS
M. Date of last annual report to the court
N. Time frame covered by this annual report
O. Type of evaluation
1. Annual continuation of confinement hearing report, pursuant to § 19.2-182.5 (A)
2. Petition for release by the Commissioner report, pursuant to § 19.2-182.6 (A)
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A. Pre-offense history (education, employment, marital/family status, living situation)
B. Mental illness and treatment history
1. Psychiatric (dates, medication, treatment, response)
a. Hospitalizations
b. Community treatment
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1. From criminal records
2. From pre-trial evaluations of criminal responsibility
3. From acquittee's self-report
4. From any other collaborating sources
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A. Participation in treatment: Include acquittee's perception of mental condition, need for treatment, nature of treatment, and value of treatment
B. Medication regimen
1. Response
2. Compliance
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A. Description of present symptomatology
B. Note level of patient cooperativeness, defensiveness, and insight into condition
C. Diagnostic Impression
1. Summary of past diagnoses and current diagnoses
2. Describe conditions and comment on discrepancies
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A. Summary of episodes of violence and brief description of each, including recent hospital violence
B. Identification and exploration of any relevant risk factors
C. Description of associated treatment and management for each risk factor
D. Identification and exploration of supports and strengths related to future adjustment
E. Conclusion regarding current risk of future violence
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A. Assess mental illness and intellectual disability and need for inpatient hospitalization, based on factors described in § 19.2-182.3.
1. If inpatient hospitalization is needed, suggest level of security required.
2. If inpatient hospitalization is not needed and acquittee meets criteria for conditional release, suggest conditions needed for an appropriate conditional release plan.
3. If inpatient hospitalization is not needed and acquittee does not meet criteria for conditional release, suggest components needed for an appropriate discharge plan.
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1. Commitment or recommitment to inpatient hospitalization
2. Conditional release
3. Release without conditions
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A. ACQUITTEE HAS A MENTAL ILLNESS OR INTELLECTUAL DISABILITY AND IS IN NEED OF INPATIENT HOSPITALIZATION
Based on my evaluation of Mr./Ms. ______________, as discussed in this report, it is my opinion that Mr./Ms. ______________ has a mental illness or intellectual disability and is in need of inpatient hospitalization at the present time.
Taking into account Mr./Ms. ______________'s current mental condition, psychiatric history, risk of aggressive behavior, amenability to outpatient supervision and treatment, and other relevant information, I believe that if Mr./Mrs. _________________ is not hospitalized, there would be a significant risk of bodily harm to other persons/himself/herself in the foreseeable future.
I do not believe that Mr./Ms. ____________ can be adequately controlled with supervision and treatment on an outpatient basis at this time.
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Based on my evaluation of Mr./Ms. ______________, as discussed in this report, it is my opinion that Mr./Ms. ______________ is not in need of inpatient hospitalization at the present time but needs outpatient treatment and monitoring to prevent his/her condition from deteriorating to a degree that he or she would need inpatient hospitalization.
Appropriate outpatient supervision and treatment are reasonably available, as discussed in this report.
There is significant reason to believe that Mr./Ms. ____________, if conditionally released, would comply with a reasonable set of conditions.
Based on my assessment of Mr./Ms. ______________'s risk of future aggressive behavior, I do not believe conditional release would present an undue risk to public safety.
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Based on my evaluation of Mr./Ms. ______________, as discussed in this report, it is my opinion that Mr./Ms. ______________ is not in need of inpatient hospitalization at the present time nor does he or she need outpatient treatment and monitoring to prevent his/her condition from deteriorating to a degree that he/she would need inpatient hospitalization.
I. Treatment of Insanity Acquittees in DBHDS Facilities
Treatment addresses both symptom reduction and risk reduction to community safety. Insanity acquittees committed to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services (DBHDS) require care considering their dual status as persons involved with criminal courts and as psychiatric inpatients.
Providing care for individuals with such dual status presents unique challenges. Over the past decade, efforts have increased to deliver appropriate, least restrictive treatment, aligned with the principles of Section 504 of the Vocational Rehabilitation Act and the Americans with Disabilities Act (ADA).
The landmark Supreme Court decision (Olmstead v. L.C., 119 S. Ct. 2176, 2188; ) affirmed that ADA standards apply to civilly confined individuals in state facilities. It emphasizes the need for comprehensive, efficacious treatment plans in least restrictive settings for long-term care.
The legal and human rights mandates, combined with the need for cautious release processes, necessitate a highly active, responsive approach to mental health care for insanity acquittees. This approach promotes symptom reduction and risk management in an efficient manner.
Clinical risk assessment principles are integrated into treatment planning, guiding care for high-risk patients, including insanity acquittees. Heilbrun (1997) advocates ongoing risk assessment combined with treatment planning for such populations.
Insanity acquittees currently committed are involved from admission in active, restorative, and rehabilitative care. The Office of Health and Quality Care, along with the Office of Forensic Services, maintains staff training programs to ensure standards are met.
All DBHDS facilities aim to provide comprehensive, appropriate care within the least restrictive environment.
II. General Guidelines for Provision of Active Treatment for Insanity Acquittees in DBHDS Facilities
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A. In accordance with departmental policy, each insanity acquittee will actively participate in all aspects of treatment planning, reflected in the Comprehensive Treatment Plan.
B. Community reintegration (conditional or unconditional release) shall be a primary treatment goal.
C. Pre-discharge planning shall be ongoing, involving the acquittee’s treatment team representative from the CSB of the jurisdiction to which the acquittee is likely to be discharged.
D. Upon admission, the Comprehensive Treatment Plan shall be developed or revised promptly to include all identified dynamic risk factors as clinical problems needing active treatment, as per Appendix A.
E. The Treatment Plan shall include relevant goals, objectives, interventions, and strategies to address symptoms and risk factors.
F. Revisions shall reflect changes in clinical status and treatment needs, especially regarding risk factors, and conform to facility standards.
INTRODUCTION
This section provides an overview of the guidelines and procedures for managing individuals found not guilty by reason of insanity (NGRI). It emphasizes the importance of individualized treatment plans, risk management, and legal considerations in the care of insanity acquittees.
TABLE OF CONTENTS
The document includes the following sections:
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I. Treatment Approaches and Interventions
II. Legal and Administrative Procedures
III. Special Treatment Needs of Insanity Acquittees
IV. References and Resources
V. Appendices
Insanity acquittees have special needs for treatment as a result of their legal status, history of criminal behavior, and mental illness linked with criminal behavior.
The development of effective psychotherapeutic and psychosocial treatments that reduce an individual’s risk for violent and/or significant disruptive behavior has been the focus of much clinical research.
Treatment programs that focus upon Anger Management, in particular, have been widely applied in correctional and forensic mental health settings.
The results of several major studies of the effects of anger management training upon individuals at high risk for violent behavior have yielded positive outcomes, particularly when used in conjunction with cognitive psychotherapy methods.
A recent study of high-risk, violent offenders, for instance (Serin & Brown, 1997), found that completion of a comprehensive program of anger management therapy, prior to release from incarceration, was associated with a significant reduction in the rate of recidivism in the group that had received such treatment, when compared with controls.
Currently, each of the DBHDS facilities that treat insanity acquittees has a highly structured and active program of individual and psychosocial treatments that is directed at addressing the range of risk factors and treatment needs presented by the insanity acquittees who have been placed in that facility.
Mental health professionals with extensive training and expertise in forensic psychiatric treatment are responsible for conducting these programs.
The treatment programs described below serve only as examples of the range of psychosocial interventions currently available at each DBHDS facility.
These approaches to treatment for insanity acquittees may be useful in providing treatment/interventions in both mental health facilities and community settings.
Not every acquittee will require every treatment modality. Treatment should be individualized based on risk and clinical need.
A. Aggression and Anger Control Therapy-
1. This is treatment focusing specifically on the patterns of thinking, feeling, and behavior associated with an acquittee's aggression.
a. Goal: decrease the risk of future aggression.
b. In contrast to "management of aggression," a facility's method for controlling the immediate impact of an aggressive response and preventing further harm to others or the aggressive individual.
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a. Stage 1 - Mutual Discovery
(1) Acquittee gives a comprehensive history of aggression and the situations in which it is expressed, and learns to identify the triggers, fantasies, and feelings associated with it.
(2) Behavioral repertoire of acquittee is identified and then divided into aggressive and non-aggressive behaviors.
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(1) Focus here is on increasing the number of available options for handling potentially aggression-inducing situations in a nonviolent way.
(2) Possible alternatives include:
• avoidance
• assertiveness
• early warning and recognition
• compliance and cooperation with "helping professionals"
• effective management of symptoms
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(1) Develop plan for handling important risk factors for aggression in a nonaggressive way, based on knowledge gained in first two stages.
(2) Develop written plan.
(3) Acquittee practices plan and discusses it sufficiently often so that he or she has a good working understanding of the plan.
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(1) Unstructured group focused on relapse prevention.
(2) Work with relapse prevention plan developed in Stage 3.
(3) Implementing that plan on a daily basis.
(4) Preparing and fine-tuning plan for use during conditional release.
(5) This group could also include acquittees who have been revoked from their conditional release because of threat of aggression, incident in the community, etc.
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1. Group meetings to provide information and answer questions regarding status as an acquittee.
2. Possible topics include:
a. Rights
b. Legal process
c. Understanding legal status
d. Use whenever moving to new legal status:
• Temporary custody
• Commitment to Commissioner
• Civil transfer
• Conditional release
e. Petitions for release
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1. Ongoing, unstructured group meetings to provide support and opportunity for discussion of specific forensic concerns.
2. Address special concerns of this group, such as:
• Anxiety of moving through the criminal justice system
• Publicity from past criminal offense(s)
• Fear of moving into the community after long hospitalization
• Dealing with less structure in the community
• Difficulty making transitions
• Stress of "doing time" (clinically, but not legally, ready for release)
• Stigma of acquittee status
MRT is an evidence-based practice that aims to change thought processes and decision-making associated with addiction and criminal behavior.
MRT utilizes a combination of psychological practices to assist with egocentric behaviors and improve moral reasoning and positive identity.
Studies suggest it is effective in reducing criminal recidivism after treatment.
[LARGE FONT]IV. Helpful References[/LARGE FONT]-
Bloom, Joseph D. (1993). Management and Treatment of Insanity Acquittees: A Model for the 1990s. Washington, D.C.: American Psychiatric Press.
Bloom, J.D., Williams, M., Rogers, J., & Barbur, P. (1986). Evaluation and treatment of insanity acquittees in the community. Bulletin of the American Academy of Psychiatry & the Law, 14, 231-244.
Carter, D., & Prentky, R. (1993). Massachusetts Treatment Center. International Journal of Law and Psychiatry, 16, 71-81.
Clark, C., Holden, C., Thompson, J., Watson, P., & Wightman, L. (1993). Treatment at Michigan's Forensic Center. International Journal of Law and Psychiatry, 16, 71-81.
Derks, F., Blankstein, J., & Hendricks, J. (1993). Treatment and security: The dual nature of forensic psychiatry. International Journal of Law and Psychiatry, 16, 1/2, 217-240.
Dixon, J., & Rivenbark, W. (1993). Treatment at Alabama's Taylor Hardin Secure Medical Facility. International Journal of Law and Psychiatry, 16, 1/2, 105-116.
Golding, S.L., Eaves, D., & Kowaz, A.M. (1989). The assessment, treatment and community outcome of insanity acquittees: Forensic history and response to treatment. International Journal of Law and Psychiatry, 12, 149-179.
Harris, G., & Rice, G. (1994). The violent patient. In M. Hersen & R.T. Ammerman (Eds.), Handbook of prescriptive treatments for adults (pp. 463-486). New York: Plenum Press.
Heilbrun, K. (1997). Prediction versus management models relevant to risk assessment: The importance of legal decision-making context. Law and Human Behavior, 21, 347-359.
Heilbrun, K., & Griffin, P. (1993). Community-based forensic treatment of insanity acquittees. International Journal of Law and Psychiatry, 16, 1/2, 133-150.
Marques, J., Haynes, R., & Nelson, C. (1993). Forensic treatment at Attascadero State Hospital. International Journal of Law and Psychiatry, 16, 57-70.
Novaco, R. W., Ramm, M., & Black, L. (2000). Anger treatment with offenders. In C. Hollin (Ed.), Handbook of offender assessment and treatment (pp. 281-296). London: John Wiley and Sons.
Poythress, N. (1993). Forensic treatment in the United States: A survey of selected forensic hospitals: Introduction. International Journal of Law and Psychiatry, 16, 53-55.
Psychiatric Security Review Board, State of Oregon (1994). A Model for the Management and Treatment of Insanity Acquittees. Hospital and Community Psychiatry, 45, 1127-1131.
Rice, M.E., & Harris, G.T. (1988). An empirical approach to the classification and treatment of maximum security psychiatric patients. Behavioral Sciences & the Law, 6, 497-514.
Rice, M., & Harris, G. (1993). Ontario's Maximum Security Hospital at Penetanguishene: Past, present, and future. International Journal of Law and Psychiatry, 16, 1/2, 195-215.
Roth, L. (Ed.) (1987). Clinical treatment of the violent person. New York: Guilford.
Serin, R.C. & Brown, S.L. (1997). Treatment programs for offenders with violent histories: A national survey. Forum on Corrections Research, 9, 35-38.
Wack, R. (1993). Treatment services at Kirby Forensic Psychiatric Center. International Journal of Law and Psychiatry, 16, 83-104.
Webster, C.D., Hucker, S.J., & Grossman, M.G. (1993). Clinical programmes for mentally ill offenders. In K. Howells & C.R. Hollin (Eds.), Clinical approaches to the mentally disordered offender (pp. 87-109), New York: John Wiley & Sons, Ltd.
Wexler, D.B. (1991). Health care compliance principles and the insanity acquittee conditional release process. Criminal Law Bulletin, 27, 18-41.
COURT-ORDERED CONDITIONAL RELEASE PLAN FOR
[Enter Name of Acquittee]The signatures at the end of this conditional release plan indicate that I understand that I have been found not guilty by reason of insanity for [insert date], pursuant to Virginia Code Section 19.2-182.2, and I am under the continuing jurisdiction of the court as a result of that finding.
Pursuant to Virginia Code Section 19.2-182.7, the Community Services Board will be responsible for the implementation and monitoring of my conditional release plan.
The undersigned parties and I have reviewed this conditional release plan and agree to follow the terms and conditions.
A. GENERAL CONDITIONS
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1) I agree to abide by all municipal, county, state, and federal laws.
2) I agree not to leave the Commonwealth of Virginia without first obtaining the written permission of the judge maintaining jurisdiction over my case and the Community Services Board (CSB). I further understand that, pursuant to § 19.2-182.15 Code of Virginia, I may be charged with a class 6 Felony if I leave the Commonwealth of Virginia without the permission of the court.
3) I agree not to use alcoholic beverages.
4) I agree not to use or possess any illegal drugs or prescribed medications unless prescribed by a licensed physician for me.
5) I understand that I am under the legal control of the judge maintaining jurisdiction over me and under the supervision of the CSB (and/or CSB designee) implementing my conditional release plan. I agree to follow their directives and treatment plans and to make myself available for supervision at all reasonable times.
6) I agree to follow the conditions of my release and conduct myself in a manner that will maintain my mental health.
7) I understand that, even if it is not my fault or the result of any specific violation of conditions, I may be returned to a state hospital if my mental health deteriorates or if I violate the conditions of my release.
INTRODUCTION
This manual provides guidelines for managing individuals found not guilty by reason of insanity (NGRI). It covers procedures, conditions, and responsibilities of community and facility staff to ensure proper treatment, supervision, and legal compliance.
TABLE OF CONTENTS
The document is organized into sections covering legal framework, conditional release conditions, community services, and coordination responsibilities.
[LARGE FONT]Section I. Conditional Release Conditions[/LARGE FONT]A. General Conditions
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I understand that my health deteriorates if I do not follow prescribed treatment and supervision conditions.
If hospitalized in custody during conditional release, my release is revoked unless I am voluntarily admitted.
I agree to pay for all treatment services according to the fee schedule set by the CSB and other community providers.
I agree not to own, possess, or access firearms or illegal weapons of any kind.
I agree not to associate with persons or places involved with firearms or illegal weapons.
Prior to and after discharge, I consent to release all relevant mental health and compliance information to supervising agencies and parties.
I agree to participate in 30-40 hours of structured activities weekly, approved in advance by the CSB.
B. Special Conditions
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I agree to reside where authorized by the supervising CSB, initially at the following: (Name of family member, placement, type of residential placement, or self) Address Phone
If I choose or am asked to move, the CSB will evaluate and recommend an alternative residence. Any change requires court notification.
I will be financially responsible for my living arrangements.
I will receive approximately $___ per month or earn a salary upon discharge.
I agree to participate in structured daytime activities such as employment, school, volunteer work, or support groups.
My initial plan for daytime activities includes: Type of activity: ________ Frequency: ________
Staff at the CSB will provide case management. I agree to meet with my case manager. Contact details are: Name: ________ Phone: ________ Duration: ________ Frequency of office visits: ________ Frequency of home visits: ________
In case of emergency after hours or on weekends, I can reach CSB at: ________
I agree to ongoing assessments of my mental status and risk factors, conducted by qualified staff, as part of case management or separate meetings.
I agree to participate in individual therapy as scheduled: Duration: ________ Frequency: ________ Location: ________
I agree to take prescribed psychotropic medications, monitored by my psychiatrist. Meetings with psychiatrist: Location: ________ Frequency: ________
I consent to periodic blood or urine tests to monitor medication compliance.
I agree to medical treatment for my current conditions, listed as: Condition: ________ Provider: ________ Location: ________
I will be assessed by a substance abuse counselor and follow treatment recommendations. Assessment details: Location: ________ Date/Time: ________
I agree to random drug and alcohol testing, including full drug panels if indicated, and to pay associated fees. Testing schedule: Frequency: ________ Duration: ________
If applicable, I will be assessed by a vocational counselor and follow recommendations.
If unable to attend scheduled meetings, I will notify the designated contact in advance or contact alternative persons listed below: Alternative contact #1: ________ Phone: ________ Alternative contact #2: ________ Phone: ________
I am responsible for transportation to activities, and lack of transportation is not an excuse for non-attendance.
I agree to additional conditions deemed necessary by the CSB in the future.
C. Acknowledgment and Understanding
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I have read or had read to me and understand the conditions of my conditional release.
I understand that failure to comply may result in court notification, legal action, modification or revocation of release, or hospitalization.
I acknowledge that this plan is part of a court document and may be publicly accessible.
Signature of Acquittee: ____________________________ Date: ____________
Signature of Witness: ____________________________ Date: ____________
Signature of NGRI Coordinator or designee: ____________________________ Date: ____________
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The CSB will coordinate the conditional release plan. The designated case manager is: Name: ________ Title: ________ Address: ________ City, State, Zip: ________ Phone: ________ FAX: ________
The CSB shall provide written reports to the court at least every six months, starting six months from the date of release, addressing progress, compliance, and adjustment.
Copies of these reports will be sent to the Office of Forensic Services, DBHDS, at the specified address.
Monthly reports will be submitted for the first twelve months, addressing progress and compliance, due by the 10th of each month.
Any proposed changes to the release plan require court approval.
The CSB shall immediately forward all court orders and notices related to the acquittee to DBHDS, Office of Forensic Services.
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This plan has been developed and approved by the CSB and hospital staff:
Signature: ____________________________ Date: ____________ Name: ________ Title: ________ Facility: ________
Signature: ____________________________ Date: ____________ Name: ________ Title: ________ Facility: ________
Signature: ____________________________ Date: ____________ Name: ________ Title: ________ Facility: ________
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This section allows CSB staff to provide recommendations and comments to the Forensic Review Panel.
Support or opposition to conditional release should be indicated, along with reasons.
Signature/Print Name: ____________________________ Title/CSB: ________ Date: ____________
Since 1987, the Commissioner has required all DBHDS-operated mental health facilities to designate a Forensic Coordinator.
The primary focus of the Forensic Coordinator is to improve the management of forensic patients within DBHDS facilities.
Given the unique involvement of forensic patients in both mental health and criminal justice systems, they require special management to ensure appropriate treatment, evaluation, and safety.
The system is responsible for providing treatment and evaluation services while being sensitive to court needs, security, and safety concerns of patients, staff, and the public.
Forensic patients often have unique reporting requirements or restrictions that must be addressed.
Each facility's Forensic Coordinator is responsible for ensuring proper management of all forensic patients according to Department policies, court orders, laws of the Commonwealth, and coordination with the Division of Forensic Services, Forensic Services section.
[LARGE FONT]NGRI MANUAL: GUIDELINES FOR THE MANAGEMENT OF INDIVIDUALS FOUND NOT GUILTY BY REASON OF INSANITY[/LARGE FONT] INTRODUCTIONThis manual provides comprehensive guidelines for managing individuals found not guilty by reason of insanity (NGRI). It emphasizes the importance of proper procedures, legal compliance, and coordination among facility staff and external agencies to ensure effective treatment, security, and legal oversight.
TABLE OF CONTENTSThe document is organized into sections covering procedures, responsibilities, monitoring, privileges, training, communication, data management, policy review, and legal documentation related to forensic patients.
[LARGE FONT]I. PROCEDURES AND RESPONSIBILITIES[/LARGE FONT] A. Notification of Forensic PatientsInternal procedures to ensure that the Forensic Coordinator is immediately notified of all forensic patients admitted to the facility. The responsibilities of each Forensic Coordinator include, but are not limited to, the following:
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I. Ensure that all forensic admissions, transfers, and discharges are made in accordance with appropriate policies, court orders, and legal standards.
II. Review each court order for the hospitalization, evaluation, temporary custody, commitment, treatment, or discharge of forensic patients for legal sufficiency. Whenever a court order does not comport with the Code of Virginia or other legal standards, the Forensic Coordinator will work with the courts and attorneys to obtain a revised court order that meets legal standards. If, after documented attempts, assistance is required, he or she shall contact the Director of Forensic Service for support.
III. Monitoring management, progress, conditional release planning, and discharge planning for all forensic patients.
Notify the Director of Forensic Services of all admissions, transfers, discharges, escapes, attempted escapes, serious incidents, or deaths of forensic patients within one working day of the event.
C. Management Decisions and Notification MechanismsConsult with treatment teams and staff regarding management decisions. Ensure mechanisms are in place to identify forensic patients upon admission and notify relevant personnel, including treatment team members, direct care staff, and security staff.
Develop and monitor security measures during off-site hospitalization episodes or transportation to medical appointments.
D. Court and Hearing ManagementWork closely with treatment teams and courts to monitor report due dates and hearing schedules for forensic patients:
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1. Maintain current listings of all scheduled court hearings and report due dates.
2. Notify appropriate persons and entities of hearing dates.
3. Ensure timely submission of reports to courts.
4. Notify the NGRI Coordinator of the appropriate CSB/BHA of all court dates for insanity acquittees in custody.
5. Notify persons requesting victim notification as soon as possible, verify hearing details, and update notifications if scheduling changes occur.
6. Review and personally approve each final signed NGRI annual report before submission to the court.
7. Submit subpoenas for staff testimony regarding insanity acquittees, including statements from subpoena recipients about their plans to testify.
Serve as the primary contact with the FRP regarding insanity acquittees to ensure requests for privileges align with clinical needs and legal parameters:
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1. Review and approve all submissions from the facility to the Panel.
2. Receive and deliver information from the Panel to treatment teams.
3. Ensure timely submission of reports to courts.
Develop and maintain a database summarizing the current forensic status and approved privileges for each forensic patient.
B. Audit and Security MeasuresOversee audits to ensure privileges are properly implemented and that forensic patients are served at appropriate security levels.
C. Case Management Restrictions and Committee ParticipationEnsure clinical teams are aware of any restrictions and participate in the Forensic Review Committee to review privilege levels.
[LARGE FONT]III. TRAINING AND STAFF DEVELOPMENT[/LARGE FONT] A. Forensic Training NeedsMaintain a list of staff qualified to perform evaluations of insanity acquittees. Develop an annual training schedule for staff lacking requisite training, provided by the Institute of Law, Psychiatry and Public Policy.
Provide an annual list of psychologists and psychiatrists responsible for forensic evaluations and treatment, noting those who need additional training and scheduling plans.
[LARGE FONT]IV. COMMUNICATION AND CONSULTATION[/LARGE FONT]Maintain communication with the Office of Forensic Services for case information and consultation. Stay informed on changes in forensic issues, policies, and practices by attending relevant training and symposia.
Attend all facility Forensic Coordinator meetings, distribute pertinent information, and convene staff meetings when necessary.
[LARGE FONT]V. DATA MANAGEMENT AND POLICY REVIEW[/LARGE FONT] A. Patient Data and ReportingMaintain and supervise the currency of patient data in the Forensic Information Management System (FIMS). Provide monthly statistical reports and participate in data collection activities.
B. Policy Review and Legal FilesReview forensic policies annually. Develop and maintain legal and privileging files for each acquittee.
C. Document OversightOversee document production, transmission, and receipt among treatment teams, the IFPC, the FRP, and the Office of Forensic Services regarding privileges granted by the facility IFPC.
Guidance for Managing Insanity Acquittees (6310_FOR 03.pdf)
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Developed by Virginia’s Department of Behavioral Health and Developmental Services Office of Forensic Services January 2016
Individuals that have been found Not Guilty by Reason of Insanity (NGRI) are also referred to as insanity acquittees or acquittees because they have been acquitted of their charges. NGRI(s), acquittees, and insanity acquittees all mean the same thing.
This group of people poses a unique challenge to Virginia’s mental health service system because they require attention for clinical and legal needs as a result of their connection to both the mental health and criminal justice systems.
Since the revisions to the Virginia Code for individuals found Not Guilty by Reason of Insanity on July 1, 1992, the Community Services Boards (CSBs)/Behavioral Health Authorities (BHAs) have been required to participate in conditional release planning and, once discharged, to implement the court’s conditional release orders.
After a period of hospitalization in a Department of Behavioral Health and Developmental Services (DBHDS) facility, Virginia Courts have placed well over a thousand acquittees into the care and supervision of the CSBs/BHAs since that time.
This reference manual is provided to the CSB/BHA staff as a tool for working with acquittees while they are in a DBHDS facility, and while they are on conditional release.
This manual is not intended to be a substitute for the policy manual from the DBHDS, entitled *Guidelines for the Management of Individuals Found Not Guilty by Reason of Insanity, 2003 Edition*.
We encourage you to take advantage of the forensic expertise available at the DBHDS Forensic Services Office and in each of our DBHDS facilities.
A list of these individuals is provided in this reference manual.
The Office of Forensic Services will be offering NGRI Training for CSB/BHA staff in conjunction with the dissemination of this manual.
Please contact Sarah Shrum (804-786-9084 or sarah.shrum@dbhds.virginia.gov) at the DBHDS Forensic Services Office if you are interested in training or a copy of this reference manual.
Section 1: The Insanity Defense & the NGRI Finding
The Definition of Insanity Pg. 1
The Virginia Insanity Test Pg. 4
Sanity vs. Competency Pg. 7
The Insanity Defense Pg. 8
Outcomes for NGRI Acquittees Pg. 11
Virginia NGRI Data Pg. 13
Section 2: The Temporary Custody Period & Outcomes
Temporary Custody Evaluations Pg. 19
Risk Assessment during Temporary Custody: The AAB Pg. 22
The Temporary Custody Hearing and Disposition Pg. 25
Criteria for Commitment Pg. 28
The Role of the CSB/BHA during Temporary Custody Pg. 29
Section 3: Commitment & the Graduated Release Process
Ongoing Court Hearings & Reporting to the Court Pg. 32
Graduated Release Process Pg. 37
The Risk Management Plan Pg. 42
Misdemeanant vs. Felony Acquittees Pg. 44
The Role of the CSB/BHA during the Commitment Period Pg. 45
Section 4: Planning for Conditional Release
Developing a Conditional Release Plan Pg. 46
Sections of a Conditional Release Plan Pg. 50
Tips and Overcoming Barriers Pg. 56
The Role of the CSB/BHA in Developing the CRP Pg. 58
Section 5: Conditional Release
First Steps in Implementing the CRP Pg. 59
The Role of the CSB NGRI Coordinator Pg. 61
The Role of the CSB Case Manager Pg. 63
Required Reports Pg. 65
Modifying the CRP Pg. 69
Ensuring Acquittee Success on Conditional Release Pg. 73
Communicating with the Court Pg. 74
Section 6: Non-Compliance with Conditional Release
Assessing Non-Compliance Pg. 77
Legal Interventions for Non-Compliance Pg. 79
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Modifications of the CRP Pg. 80
Revocations (non-emergency and emergency) Pg. 81
Contempt of Court Pg. 84
The Role of the CSB/BHA in Managing Non-Compliance Pg. 85
Section 7: Unconditional Release
Criteria for Removal of Conditions Pg. 87
Assessing Readiness for Unconditional Release Pg. 88
The Unconditional Release Process Pg. 90
Communicating the CSB’s Rationale for UCR Pg. 91
Requirements for Closing the NGRI Case Pg. 92
Section 8: Case Studies
Case Study #1: “Mr. K” Pg. 93
Case Study #2: “Mr. O” Pg. 95
Case Study #3: “Mr. N” Pg. 97
Case Study #4: “Mr. J” Pg. 99
Case Study #5: “Mr. Q” Pg. 101
Section 9: Appendices
Appendix A: NGRI Process Flow Chart Pg. 103
Appendix B: Sample AAB & Description of AAB Update Format Pg. 106
Appendix C: Sample Risk Management Plans Pg. 117
Appendix D: Conditional Release Plan Template & Samples Pg. 123
Appendix E: Sample Letters to the Court Pg. 151
Appendix F: Monthly Report Instructions & Template Pg. 159
Appendix G: Six-Month Review Instructions & Template Pg. 164
Appendix H: Sample Unconditional Release Plan Pg. 170
Appendix I: Model Court Orders Pg. 173
Appendix J: Relevant Code Sections Pg. 186
Appendix K: Forensic Coordinator & DBHDS Staff Contact List Pg. 197
Section 1: The Insanity Defense & the NGRI Finding
The Definition of Insanity Pg. 1
The Virginia Insanity Test Pg. 4
Sanity vs. Competency Pg. 7
The Insanity Defense Pg. 8
Outcomes for NGRI Acquittees Pg. 11
Virginia NGRI Data Pg. 13
The Definition of Insanity
Takes into consideration the mental state of a defendant when the crime was committed.
It is a legal term, not a clinical term.
The Insanity Defense
Protects morally blameless persons from conviction.
It is not a diagnosis.
Helps ensure the "fairness" of the legal system.
Insanity Definition
A person accused of a crime can acknowledge that they committed the crime, but argue that they are not responsible for it because of a mental illness or a "mental defect."
This term is not used in the fields of psychology or psychiatry. It is purely a legal term.
No one is diagnosed "insane."
A person can enter a plea of insanity when charged with a crime. The court will weigh the evidence and may find them "Not Guilty by Reason of Insanity," or NGRI.
They are acquitted of criminal charges when found NGRI by the court, and then there is typically a court-ordered treatment component.
The insanity plea was developed to protect individuals who are "morally blameless."
The insanity defense is a compromise; it reflects society's belief that the law should not punish defendants who, for reasons beyond their control (as a direct result of mental disease or defect), committed a criminal act.
Throughout the country, there are many different legal definitions of insanity. These have been based upon many historical court cases, and in some states have been put into the code language.
In Virginia, the legal code does not directly define insanity; the current definition of insanity in Virginia was established through case law, or historical court cases.
Each state's definition of insanity has similar core elements: the presence of a mental disease or defect, and a) the inability to control their actions as a result of that defect, and/or b) the inability to differentiate right from wrong as a result of that act.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
The act. Often there is both a cognitive and volitional impairment at the same time. A common example of how this has been conceptualized might be a defendant who understood that they were strangling their friend, understood that this was morally and legally wrong, but whose auditory hallucinations were so compelling that they could not control their behavior and resist the impulse to commit the act.
Required level of impairment
The degree of impairment needed to qualify for the insanity finding is not defined in code. In one Virginia case, the court defined the level of impairment needed for an NGRI finding as a "substantial" impairment of the defendant's capacity to understand the nature or consequences of their actions, appreciate wrong from right, or control their actions.
"Substantial" does not require a total lack of capacity. Evaluators are tasked with gauging the level of impairment and determining whether the level was sufficient or "substantial" enough to justify an NGRI finding.
Competency to Stand Trial vs. Insanity at the Time of the Offense
Competency to Stand Trial
Competency addresses the defendant's current ability to understand legal proceedings and assist the attorney in their defense.
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Can be raised by anyone, including the defense, the prosecutor, or the judge.
The defendant does not have to agree with a request for a competency evaluation or finding.
Must be competent in order to go to trial and must be competent in order to submit an NGRI plea.
Can be raised at any point during the trial process. This could be at the very early stages of arraignment, or even at the point of sentencing.
The bar is very low - to be found competent you do not have to be a legal expert.
A defendant must be able to understand the charges against him and assist in his defense.
The court presumes that a defendant is competent unless the issue is raised and an evaluation finds them incompetent.
Competency is fluid, and can change from day to day.
The issue of competency can be raised more than once during a trial process as the defendant's mental status changes.
Insanity at the Time of the Offense
Sanity addresses the defendant's mental state at the time the crime was committed. Can only be raised by the defense.
The defendant must agree to entering an insanity plea & the defendant voluntarily participates in the evaluation.
Just because a defendant was incompetent does not mean that they were insane at the time of the offense and vice versa.
The defense must make a motion of intent to plead NGRI with the court no less than 21 days prior to trial.
The bar is very high; many conditions must be proved by the defense in order to be successful in presenting this defense to the court.
The prosecution does not have to prove sanity, instead the defense has to prove insanity.
The court presumes that a defendant was legally sane unless the defense can prove otherwise.
Insanity at the time of the offense is fixed, it relates to a person's mental state at a fixed point in time when the offense occurred and does not change.
The Insanity Defense
Initial Request for evaluation; assignment of expert for the defense
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§ 19.2 -169.5(A)
Evaluation is done only at the request of the defense
Expert assigned if defendant is indigent and there is probable cause that insanity will play a role in defense.
Defense gives notice of intention to file an insanity plea
§ 19.2 -168
The defense is required to give advanced notice at least 21 days prior to trial.
Commonwealth's Attorney can then seek a second evaluation if they choose
§19.2 -168.1
The same process applies to the appointment of a second evaluator, if requested by the CWA.
Judge or jury makes final disposition of Not Guilty by Reason of Insanity
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Defendant is presumed sane; burden of proof is on the defendant.
Qualified Evaluators
§19.2 -169.5(a) states that an "expert" shall be: A) A psychiatrist, a clinical psychologist, or an individual with a doctorate degree in Clinical Psychology who has successfully completed forensic evaluation training as approved by the Commissioner of DBHDS; AND B) Is qualified by specialized training and experience to perform forensic evaluations." (When the evaluation is paid for by the state, the defendant is not able to select the evaluator of their choosing.)
Location of the Evaluation
§19.2 -169.5(b) states that evaluations must be performed on an outpatient basis at a mental health facility or in jail unless:
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A) Outpatient evaluation services are unavailable; OR
B) The results of an outpatient evaluation indicate that hospitalization for further evaluation is necessary; OR
C) The defendant is committed for emergency treatment prior to trial and the court orders a sanity evaluation during that hospitalization.
Payment for Evaluations
Indigent defendants who show probable cause to believe that sanity will play a role in their defense are entitled to a state-funded expert evaluation.
Defendants who are not indigent must seek out and pay for their own expert evaluations.
All evaluators who perform these evaluations must be either a psychiatrist or a psychologist who has received the DBHDS required training for forensic evaluation.
Information Provided to Evaluators
§19.2 -169.5(c) states that the court shall require "the party making the motion for the evaluation, and such other parties as the court deems appropriate," to provide "any information relevant to the evaluation," including but not limited to:
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A) Copy of the warrant or indictment;
B) Names and addresses of the CWA, defense attorney, and judge;
C) Information about the alleged offense, including statements made by the defendant to police and transcripts of preliminary hearings, if any;
D) Summary of the reasons for the evaluation request;
E) Any available psychiatric, psychological, medical, or social records deemed relevant;
F) Copy of the defendant's criminal record, to the extent available.
The final reports are sent only to the defense attorney at this stage.
Evaluation Requested by the Commonwealth's Attorney
§19.2 -168.1 states :
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A) The evaluation can be ordered only after the defense has given notice of intent to present the insanity defense.
B) The location of evaluation and qualifications of experts are the same as for the defense evaluation.
C) The required background information provided to the CWA's expert is the same; however, the CWA is required to provide that information.
D) If the defendant refuses to cooperate with the CWA's expert evaluation, the court may decide to exclude the defense's expert testimony.
E) The report is sent to both the defense and the CWA.
Disposition of Not Guilty by Reason of Insanity
Upon an NGRI finding, the trial court retains jurisdiction over the case and makes or modifies any placement decisions from this point forward. However, the case shifts from a criminal to a civil case.
Immediately following acquittal, the acquittee is ordered into the custody of the Commissioner of DBHDS for temporary custody evaluations. Following evaluations, the court will decide either to commit to inpatient treatment, conditionally release, or unconditionally release the acquittee.
Outcomes for NGRI Acquittees
Finding of NGRI and simultaneous order for Temporary Custody Evaluations
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§ 19.2 -182.2
Requires placement in a DBHDS facility or "in the custody" of the Commissioner of DBHDS for evaluation and recommendations regarding next steps.
All proceedings from that point forward are "civil" rather than criminal.
The Temporary Custody Evaluations are due to the court 45 days from admission.
The defendant may wait in jail following the NGRI acquittal and admission to a DBHDS facility.
The start of the 45-day period is the day of admission to the facility.
The acquittee is admitted to a DBHDS facility.
The Commissioner is responsible for determining the hospital of placement and for appointment of the two independent evaluators.
Most often, acquittees are admitted to CSH maximum-security unit.
There are three possible outcomes after the two Temporary Custody Evaluations are done:
The defendant may be committed indefinitely to a DBHDS facility.
The defendant may be released with conditions.
The defendant may be released without conditions.
Disposition of Insanity Acquittees
Upon an NGRI finding, acquittees are not subject to penal sanctions such as jail/prison, probation, parole, or fines for any charges for which they were acquitted.
Acquittees are placed into the temporary custody of the Commissioner of DBHDS, meaning they are admitted to an inpatient psychiatric hospital. The court controls management of an acquittee for an indeterminate and possibly indefinite period of time.
The acquittee may be committed pursuant to commitment laws that are more serious and restrictive than those regulating civil commitment.
Temporary Custody Period
Most often, acquittees are admitted to the maximum-security unit at Central State Hospital. In some cases, they can be admitted directly to a minimum-security hospital, at the discretion of the Commissioner of DBHDS.
The CSH maximum-security unit in many ways resembles a jail setting, however it is a treatment facility and there is a very different philosophy.
Some acquittees mistakenly believe they will be released immediately after temporary custody. This only happens in 25% of NGRI acquittals.
In a majority of cases, they remain hospitalized long beyond the temporary custody period. The average length of stay for NGRI acquittees in DBHDS hospitals is 6.5 years.
What Patients Can Expect While at CSH Maximum-Security Unit
The acquittee will enter and exit through a sally-port and searched thoroughly upon admission.
It is a secure environment with
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
little contact with the outside. The acquittee will have limited access to personal items. They are required to walk in "single file" lines when moving throughout the building/unit. They will be "pat searched" several times a day. It is a non-smoking environment. They can expect to be at the hospital longer than the 45 days. Often there is a delay in scheduling the next court hearing, and sometimes based upon the evaluator recommendations, the court may decide to extend the temporary custody period at CSH while civil transfer/conditional release plans are developed.
Virginia NGRI Statistics
Use of the Insanity Defense
Infrequently used, and even when used the defense is rarely successful. Nationally, it is raised in only about 1% of criminal cases and successful in only 25% of that 1%. In Virginia, the percentage of criminal cases in which the insanity defense is used is harder to track, but it does appear that it is close to the national average. Since 1993, the average number of new NGRIs per year is 49, but there has been a steady rise since 2001. Since 2001, the average new acquittees coming into the system has been 57 per year.
New NGRI Admissions to DBHDS Hospitals Per Year 1993 -2015
NGRI Discharges from Hospital to Community on Conditional Release Per Year 1993 -2015
Percentage of NGRI Acquittees in the Hospital vs. Community on Conditional Release 1993 -2015
Regional Percentage of All New NGRI Acquittals 2003 -2015
Hospital Admission Type 1993 -2015
Hospital NGRI Census 2009 -2015
Hospital Discharge Type 1993 -2015
Reason for Termination of Conditional Release 1993 -2015
Percentage of New NGRI Admissions Felony v. Misdemeanor 2003 -2015
---Section 2: The Temporary Custody Period & Outcomes
Temporary Custody Evaluations Pg. 19
Risk Assessment during Temporary Custody: The AAB Pg. 22
The Temporary Custody Hearing and Disposition Pg. 25
Criteria for Commitment vs. Release Pg. 28
The Role of the CSB/BHA during Temporary Custody Pg. 29
Temporary Custody Evaluations
The defendant is found NGRI and placed in the custody of the Commissioner of DBHDS •§ 19.2 -182.2 •The finding of NGRI and the ordering of the temporary custody evaluations occurs simultaneously. •The order is sent by the clerk to the Commissioner of DBHDS and the defendant is admitted to a DBHDS facility when a bed is available. Upon admission DBHDS appoints two evaluators.
•They send their reports to the members of the court, as well as the DBHDS Office of Forensic Services, and the CSB NGRI Coordinator. There are 3 possible recommendations that they can make to the court:
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Each evaluator will make a recommendation to the court to either commit the acquittee to inpatient treatment, release with conditions, or release without conditions.
Immediately upon receipt, the court will schedule an expedited hearing •§ 19.2 -182.3
The Temporary Custody Hearing takes place upon completion of the evaluations.
The judge ultimately decides which of the three options will be ordered at this hearing.
Role of the Facility in the Temporary Custody Evaluation Process
The facility to which the acquittee is admitted for the temporary custody period will complete an Initial Analysis of Aggressive Behavior within 30 days of admission. The facility is responsible for sending this AAB to the appointed temporary custody evaluators.
Prior to admission, the facility also gathers any available documentation regarding the acquittee, including but not limited to the court order for temporary custody, the contact information for all attorneys and the court, a copy of the warrant or indictment, and criminal incident information/copy of the arrest report.
The facility will also identify and reach out to the appropriate Community Services Board that will be working with the acquittee in the hospital and eventually in the community. This is based on the acquittee's last known address.
The facility will begin discharge planning with the appointed CSB. The process of identifying risk factors, developing risk management plans, and assessing the individual's readiness for discharge all begin during this period.
Role of the Office of Forensic Services in the Temporary Custody Evaluation Process
The Office of Forensic Services at DBHDS is the Commissioner's designee for making the official appointments of the temporary custody evaluators. Upon notice of admission from the facility, Forensic Services staff will confirm two qualified DBHDS evaluators to perform the temporary custody evaluations.
This entails an official appointment letter with copies of the court order and the packet of background information prepared by the facility. The Office of Forensic Services will also send a copy of the appointment information to the Judge, the Commonwealth's Attorney, the defense attorney, and the appropriate CSB's NGRI Coordinator.
This letter serves as notice to all parties of the acquittee's admission and timeframe for completion of the two temporary custody evaluations.
Qualified Temporary Custody Evaluators § 19.2 -182.2
States the evaluations shall:
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Be conducted by one psychiatrist and one clinical psychologist skilled in the diagnosis of mental illness and intellectual disability and qualified by training and experience to perform such evaluations ;
At least one of the two appointed evaluators will not be employed at the same facility where the acquittee is admitted;
Neither evaluator shall have provided previous court evaluation or consultation regarding the acquittee's insanity or mental state at the time of the offense.
The Evaluation
Each evaluation will be conducted separately. The evaluators will prepare separate reports. The evaluators will assess whether the acquittee is currently mentally ill or intellectually disabled, their current condition, and the acquittee's need for hospitalization based upon factors in §19.2 -182.3. The resulting report will include one of three possible recommendations: commitment, release with conditions, or release without conditions, and rationale for the recommendation.
The evaluators will send copies of their reports to the judge, Commonwealth's Attorney, Defense Attorney, the Office of Forensic Services at DBHDS, and the CSB NGRI Coordinator.
Basis for a Recommendation for Commitment to Inpatient Hospitalization (§ 19.2 -182.3)
The acquittee is mentally ill or intellectually disabled and in need of inpatient hospitalization, based on the following factors:
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To what extent the acquittee is mentally ill or intellectually disabled, as defined in § 37.1 -100;
The likelihood that the acquittee will engage in conduct presenting a substantial risk of bodily harm to other persons or to himself in the foreseeable future;
The likelihood that the acquittee can be adequately controlled with supervision and treatment on an outpatient basis; and
Such other factors the court deems relevant.
Basis for a Recommendation for Conditional Release (§ 19.2 -182.7)
Based on consideration of the factors which the court must consider in its commitment decision, the acquittee does not need inpatient hospitalization but does need outpatient treatment or monitoring to prevent his condition from deteriorating to a degree that he or she would need inpatient hospitalization;
Appropriate outpatient supervision and treatment are reasonably available;
There is significant reason to believe that the acquittee, if conditionally released, would comply with the conditions specified; and
Conditional release will not present an undue risk to public safety.
Basis for a Recommendation for Release Without Conditions (§ 19.2 -182.3)
Does not need inpatient hospitalization; AND
Does not meet criteria for conditional release. ---
Section 3: Commitment & the Graduated Release Process
Risk Assessment During Temporary Custody: The Initial Analysis of Aggressive Behavior (AAB)
The Focus of the AAB
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The Analysis of Aggressive Behavior (AAB) is a systematic means to (1) assess the risk(s) of aggression for an individual acquittee and (2) develop means by which to address the risk(s).
The AAB is a psychological evaluation that includes data collected on the acquittee's past aggressive episodes, treatment and social history, and current functioning and is used as a basis for:
Treatment interventions.
Decision-making regarding the management of privileges and placement for the acquittee.
Making recommendations to the court regarding conditional release and release without conditions.
Conditional release planning.
Community aftercare.
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The relationship, if any, of existing or pre-existing mental disorder(s) to past aggressive episodes.
Common characteristics or patterns across aggressive episodes.
Conceptualizing Risk Factors
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Age
Gender
Marital Status
Socioeconomic factors
Demographic Risk Factors
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Criminal history
Juvenile delinquency
Age of onset of aggression
Psychiatric history
Employment history
Historical Risk Factors
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Substance abuse
Psychopathy
Brain injury or disease/medical issues
Active symptoms of mental illness
Impaired insight
Clinical Risk Factors
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Use of weapons
Victim characteristics
Social or community support/lack of support
Contextual Risk Factors
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Static vs. Dynamic Risk Factors
Static Risk Factors Cannot be changed through treatment or monitoring. Include, but not limited to:
• Age
• Gender
• Intelligence
• Psychiatric history
• Previous violence/aggression
• Prior failure on conditional release
Dynamic Risk Factors Can be altered through treatment or monitoring. Include, but not limited to:
• Status of mental illness
• Substance abuse
• Access to weapons
• Access to victims
• Employment
• Denial/lack of insight
The Format of the Initial AAB
1. Identifying information
2. Purpose of the evaluation
3. Statement of nonconfidentiality
4. Sources of information
5. Relevant background information
6. Description of NGRI offense A. Acquittee's account B. Collateral accounts
7. Behavioral observations and mental status exam
8. Psychological testing results
9. Diagnostic impression
10. Patient strengths which mitigate the probability of future aggression
11. Analysis of aggressive behaviors A. Narrative description of current risk factors B. Current status of risk factors C. Means of addressing risk factors
The Initial AAB Completed During Temporary Custody
The Analysis of Aggressive Behavior begins at the time of admission to temporary custody placement. The facility housing an acquittee in temporary custody will obtain the relevant information and complete the Initial AAB within 30 days of admission. The AAB shall be provided as soon as possible to the two evaluators appointed by the Commissioner to perform the temporary custody placement evaluations. This information will be integral in making assessments and recommendations to the court regarding disposition.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
The Initial AAB acts as a baseline for risk factors, establishing the current status of those risk factors at the point of temporary custody and the initial risk management plans. The AAB will be continually updated over the course of hospitalization.
Section 2: The Temporary Custody Period & Outcomes
The Temporary Custody Hearing and Disposition
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Upon receipt of the Temporary Custody Evaluations, the Court will schedule a hearing.
§ 19.2 -182.3
The evaluators have sent copies of their reports to the judge, the Commonwealth's Attorney, defense attorney, DBHDS, and the CSB NGRI Coordinator.
The court shall schedule a hearing on an expedited basis upon receipt of the two evaluations.
If either evaluator recommends release, the court will extend the temporary custody period.
§ 19.2 -182.5 (b)
If one or both plans recommend release, the court will extend the time in the hospital under the temporary custody status to allow for the hospital and CSB to jointly prepare either a Conditional Release Plan (CRP) or discharge plan, depending on the recommendation.
The plans are submitted first to the Forensic Review Panel (FRP) for consideration. The Forensic Review Panel (FRP) will submit a recommendation to the Court.
If one or both of the evaluations recommends release, the FRP will review the CRP or discharge plan and accompanying packet from the facility.
The FRP then prepares a written recommendation to the court.
The CRP or discharge plan is included in the packet to the court, even if the FRP is recommending commitment.
The FRP submits its recommendation on behalf of the Commissioner of DBHDS. Ultimately, the judge makes the final decision.
The Judge can agree or disagree with the recommendations of the evaluators and FRP.
Once a decision is made, an order is issued to release with or without conditions or commit to inpatient treatment.
The Forensic Review Panel (§19.2 -182.13)
The Commissioner of DBHDS is given the authority to delegate any of their duties or powers to an administrative panel composed of persons with demonstrated expertise in such matters. Members of the Panel are not compensated for their work on the Panel and are immune from personal liability except for intentional misconduct.
The Panel is established to ensure that release and privilege decisions for insanity acquittees reflect clinical, safety, and security concerns. The Panel also ensures that standards for conditional release and release planning of insanity acquittees have been met, and provides consultation to the treatment teams working with the acquittees.
The Panel only reviews release/privilege requests for insanity acquittees who are in the custody of the Commissioner (not those on conditional release or unconditionally released).
The FRP is a seven-member group with psychologists, psychiatrists, a community member, and a DBHDS Central Office representative. The Panel meets weekly to review insanity acquittee privileging and release requests from all DBHDS facilities throughout the state. Recommendations to the court regarding privileging and release are made by the FRP on the Commissioner's behalf.
When Both Evaluators Recommend Commitment
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The DBHDS facility will continue to assess and treat the acquittee at the hospital until the court makes a final decision and issues a commitment order.
No decisions related to hospital transfers or increase in privileges are made until the court's decision.
The CSB will collaborate and provide discharge planning services to the acquittee in the hospital.
Often at this time the CSB and hospital are evaluating the individual's risk factors and resources/services that will be needed to manage risk if released to the community.
In a majority of cases, at the temporary custody hearing the judge will issue an order for commitment to the custody of the Commissioner of DBHDS, which begins the graduated release process in the hospital setting.
When One Evaluator Recommends Release and the Other Recommends Commitment
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The judge will issue an order extending the temporary custody period in order for the hospital and CSB to prepare written release plans.
If even one evaluator recommends release (either with or without conditions), the DBHDS facility and the CSB are required to develop a release plan.
In cases where Conditional Release is recommended, a Conditional Release Plan (CRP) is developed.
In cases where release without conditions (Unconditional Release) is recommended, a written discharge plan is developed.
The CRP or discharge plan must be jointly prepared by the hospital and the CSB, according to the Code of Virginia.
DBHDS strongly recommends that the CSB take the lead in drafting the plan, seeking input from the hospital and the acquittee before finalizing.
The CSB should also ask for a copy of the AAB.
The DBHDS hospital will create a packet of information (including risk assessments, treatment records, etc.) and attach a copy of the CRP or discharge plan and send that to the FRP for review.
The FRP will issue an official recommendation on behalf of the Commissioner of DBHDS in writing to the court.
The FRP will attach the written CRP or release plan even if they are recommending commitment.
The judge will review the two evaluations, as well as the recommendation from the FRP and the attached discharge plan, and will make a final decision.
When Both Evaluators Recommend Release
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Regardless of whether the evaluators both recommend release with conditions or release without conditions, the same steps are followed from above.
The court will extend the temporary custody period.
The hospital and CSB will jointly prepare a CRP or discharge plan.
In cases where one evaluator recommends conditional release and the other recommends unconditional release, both a CRP and discharge plan will be developed.
The CSB should also ask for a copy of the AAB.
The FRP will review and make recommendations to the court on the Commissioner's behalf.
The judge will review all available reports, recommendations, and plans and make a final decision.
Factors Considered by the Court
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§19.2 -182.3 addresses the factors that the court considers in reviewing the evaluations:
A) To what extent the acquittee has mental illness or intellectual disability, as those terms are defined in § 37.2 -100;
B) The likelihood that the acquittee will engage in conduct presenting a substantial risk of bodily harm to other persons or to himself in the foreseeable future;
C) The likelihood that the acquittee can be adequately controlled with supervision and treatment on an outpatient basis; and
D) Such other factors as the court deems relevant.
Criteria for Commitment
NGRI Commitment Criteria
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§19.2 -182.3 describes the criteria that the judge must use when making initial commitment decisions at the temporary custody hearing:
1. To what extent the acquittee has mental illness or intellectual disability, as those terms are defined in § 37.2 -100;
2. The likelihood that the acquittee will engage in conduct presenting a substantial risk of bodily harm to other persons or to himself in the foreseeable future;
3. The likelihood that the acquittee can be adequately controlled with supervision and treatment on an outpatient basis; and
4. Such other factors as the court deems relevant.
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The court shall order the acquittee released with conditions pursuant to §§ 19.2 -182.7, 19.2 -182.8, and 19.2 -182.9 if it finds that he is not in need of inpatient hospitalization but the criteria for conditional release set forth in § 19.2 -182.7 are met.
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If the court finds that the acquittee does not need inpatient hospitalization nor does he meet the criteria for conditional release, it shall release him without conditions, provided the court has approved a discharge plan prepared by the appropriate Community Services Board or Behavioral Health Authority in consultation with the appropriate hospital staff.
Role of the CSB/BHA During Temporary Custody
Temporary Custody Admission and First Steps
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The Temporary Custody Appointment letter serves as notice to the court members of the acquittee's admission to the DBHDS hospital and appointment of the two temporary custody evaluators.
DBHDS will also mail a copy of this letter to the CSB NGRI Coordinator.
This may be the first notice to the CSB of a new NGRI finding.
The supervising CSB is determined by the hospital upon admission, based upon the acquittee's last known address prior to incarceration.
An individual may be found NGRI in a court outside of the assigned CSB's catchment area. The reason is because the acquittee committed the offense in one jurisdiction but their residence is in a different jurisdiction.
If there are conflicts about which CSB should be assigned to the case, please contact the Central Office Forensic Services staff.
The NGRI Coordinator and the CSB hospital discharge planner (if they are not the same person) should immediately make contact with the treatment team at the hospital to arrange for a visit or consult with the team and acquittee.
The NGRI Coordinator and the CSB hospital discharge planner should request (if the hospital has not already sent it), a copy of the Initial AAB as soon as it is completed (within 30 days of admission).
Additionally, the CSB should provide any and all prior treatment records to the facility if the acquittee has previously been served at the CSB.
Collaboration and consultation with the treatment team about the acquittee's risk factors and risk management and discharge needs should begin immediately.
All discharge planning protocols should be followed.
To review the Collaborative Discharge Protocols for Community Services Boards and State Hospitals go to: http://dbhds.virginia.gov/professionals -and-service - providers/mental -health -practices -procedures -and-law/protocols - and-procedures.
Upon review of the AAB, conversations with the treatment team, and meetings with the acquittee, the CSB should have a sense of whether this person is able to return safely to the community or if they would benefit from ongoing hospitalization.
The CSB NGRI Coordinator should also establish connections with the acquittee's defense attorney, Commonwealth's Attorney, and the judge.
The CSB NGRI Coordinator is the “face” of the CSB in the NGRI cases and will be the primary point of contact for future court matters related to the acquittee’s case.
The Temporary Custody Appointment letter will have all court officials listed.
Results of the Temporary Custody Evaluations and Next Steps
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The CSB should be aware of the date of the temporary custody hearing.
The CSB can look up the acquittee's court date on the Virginia Supreme Court website (http://www.courts.state.va.us/caseinfo/home.html), or can contact the hospital treatment team or Forensic Coordinator.
The temporary custody evaluations are sent to the CSB NGRI Coordinator when completed by the evaluators.
If both evaluations recommend commitment / need for ongoing inpatient treatment, then you likely will wait for the court hearing and (most often) the judge will make a decision to commit.
During this time the CSB will continue working with the hospital treatment team on identifying risk factors, making decisions about privileging levels, and identifying initial treatment and potential discharge needs.
The judge can decide to release even if both evaluators recommend commitment, however this is rare.
If one or both of the evaluations recommend conditional release, the CSB must begin to develop a Conditional Release Plan (CRP) jointly with the hospital.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
Even if the CSB disagrees with the recommendation for release, the CRP is developed in case the judge decides to release the acquittee. The CSB should take leadership in drafting the plan, as the CSB is the entity that will be responsible for carrying out the services and monitoring the conditions once the acquittee is released.
If one or both of the evaluators recommends release without conditions, or unconditional release, the CSB must begin to develop a discharge plan jointly with the hospital. Even if the CSB disagrees with the recommendation for release, the discharge plan is developed in case the judge decides to release the acquittee. The CSB should again take leadership in developing the plan.
Even if the CSB Disagrees with Recommendations for Release
The CSB is required to develop a release/discharge plan whenever one of the evaluators recommends release; however, there are opportunities to voice disagreement with the recommendation to release:
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Use the Comments section of the CRP or discharge plan to note concerns about availability of services necessary for the individual’s or community’s safety, or to make other comments related to the individual’s appropriateness for release. The CRP will be sent to the court, so the judge will have an opportunity to review the recommendations in the Comments section.
In addition to noting objections/concerns in the Comments section of the release plan, the CSB NGRI Coordinator can choose to write a letter to the court and all parties with comments and recommendations from the CSB perspective. Reasons must be given for any opinions offered, and having first-hand knowledge of the individual’s past and current functioning, risk factors, and progress during the temporary custody period is essential.
Reaching out directly to the Commonwealth’s Attorney to advise them of concerns/opinions on the individual’s readiness for release is another option available to the CSB NGRI Coordinator. Often the Commonwealth's Attorney wants to know if there are any potential risk issues and/or lack of appropriate services and supports to manage those risks.
Finally, the CSB NGRI Coordinator can request that the Commonwealth's Attorney issue a subpoena allowing the NGRI Coordinator to testify at the Temporary Custody hearing.
In all cases, it is essential that the CSB inform the hospital treatment team of any and all concerns related to the individual's appropriateness for release or the availability of necessary services and supports to keep the acquittee and community safe. Feedback from the team is important in making a decision on whether to voice concerns to the court. ---
Section 3: Commitment & the Graduated Release Process
Ongoing Court Hearings & Reporting to the Court Pg. 32
Graduated Release Process Pg. 37
The Risk Management Plan Pg. 42
Misdemeanant vs. Felony Acquittees Pg. 44
The Role of the CSB/BHA during the Commitment Period Pg. 45 ---
Ongoing Court Hearings & Reporting to the Court
The court commits the acquittee following the temporary custody hearing:
•§ 19.2 -182.3
•If the court determines that the acquittee meets commitment criteria, they will commit them to the custody of the Commissioner of DBHDS at the temporary custody hearing.
•The acquittee will remain in the hospital. The hospital will begin working with the acquittee on the privileging process. The Forensic Review Panel will determine the appropriate hospital placement:
•§ 19.2 -182.4
•The FRP is designated by the Commissioner of DBHDS to make decisions about placement and privileging levels.
•Considerations include potential for violence to self/others and potential for escape.
•The acquittee will return to court at regular intervals for decisions about ongoing commitment:
•§ 19.2 -182.5
•The original committing court holds hearings assessing the need for continued inpatient hospitalization for acquittees.
•These hearings are held beginning 12 months after the initial commitment date.
•The court will hold yearly hearings following the initial commitment for the first 5 years, then they can schedule hearings biennially from that point forward if they choose.
•Annual reports are prepared by the hospital and sent to the court with their recommendations about ongoing commitment.
•The hospital will make recommendations annually to either recommit, release with conditions or release without conditions.
•Any recommendations for release go through the FRP. If the FRP concurs with the release recommendation, they will send a letter to the court indicating so, accompanied by the release plan. ---
Initial Commitment and Placement Decisions § 19.2 -182.4
If the court determines that the individual will be committed to the custody of the Commissioner of DBHDS, it will issue an initial commitment order. The Forensic Review Panel, as designated by the Commissioner, shall make a determination of the appropriate placement of each acquittee.
Placement can be in any state-operated facility. Decisions are based on potential for violence and potential for escape.
The acquittee will return from court to the hospital unit where they were placed during the temporary custody period. In most cases, this is the maximum security unit at CSH. If the hospital feels that it is appropriate, they will begin the privileging process by requesting transfer to a less secure unit (aka, civil transfer), if they are not already on a civil unit. The FRP must approve this placement.
The treatment team will work with the acquittee on navigating the graduated release process from that point forward. ---
Continuation of Confinement Hearings § 19.2 -182.5
The committing court will hold hearings on a regular basis to assess the need for continued inpatient hospitalization for insanity acquittees. These hearings will occur every twelve months for the first 5 years following the initial commitment.
Following the first 5 years, the court can schedule the continuation of confinement hearings biennially as allowed by Code. However, most courts continue annual hearings.
At each hearing, the court will decide if the acquittee should remain committed, be released with conditions, or be released without conditions. The same criteria for commitment and release apply at the annual continuation of confinement hearing as in the initial commitment.
If recommitted, the court will issue a recommitment order at the hearing. ---
Annual Reports
The treatment team at the hospital will provide to the court, 30 days prior to the continuation of confinement hearing, a report evaluating the acquittee's condition and recommending treatment.
This report is prepared by either a psychologist or psychiatrist at the facility who is qualified to perform forensic evaluations.
The facility will send a copy of the annual report to the judge, the defense attorney, the Commonwealth's Attorney, the CSB NGRI Coordinator, the FRP, and the Office of Forensic Services.
If this report recommends recommitment, it is sent directly to the court and all parties listed above.
If the report recommends release (either with conditions or without), the team will first send their request/recommendations to the FRP for review and approval.
If conditional release is recommended, the team will work jointly with the CSB to prepare a conditional release plan and submit it to the FRP along with the annual report.
The FRP will make final recommendations to the court in matters of release.
An annual report with recommendations is required, even in years in which no continuation of confinement hearing is held. ---
Second Opinion Evaluations § 19.2 -182.5(b)
The acquitee has the right to request release at each continuation of confinement hearing (no more than once per year). If the acquittee requests release at the annual hearing, the court shall issue an order that a second evaluator perform an evaluation of the acquittee's condition.
The second evaluator shall be a qualified psychiatrist or psychologist. The Commissioner, via the Office of Forensic Services, will appoint a second DBHDS evaluator to complete the report.
In the instance of a second opinion evaluation, recommendations for release do not require approval from the FRP before being sent to the court.
The evaluation will be completed and a report issued within 45 days of issuance of the order.
If the second evaluator recommends release, the CSB and the hospital will work jointly to prepare either a Conditional Release Plan or discharge plan and submit it to the FRP.
The FRP will then review and submit the release plan to the court, along with their own recommendation.
In these cases where a second evaluation is ordered by the court, the court will receive: 1) the original annual report and recommendation; 2) the second opinion evaluation; and 3) in the event either one recommends release, the FRP recommendation. ---
Petitions for Release § 19.2 -182.6
The acquittee may petition the committing court for release only once in each year in which no annual judicial review is required pursuant to § 19.2 -182.5.
The Commissioner may petition the court for the acquittee's release at any time, even if it does not coincide with the annual continuation of confinement hearing.
The party petitioning for release shall transmit a copy of the petition to the Commonwealth's Attorney.
In these cases, the court must respond to the acquittee's petition by ordering evaluations of their condition.
The Office of Forensic Services, acting on behalf of the Commissioner, will appoint two evaluators to assess and report on the acquittee's need for inpatient hospitalization.
In the instance of an acquittee's petition for release, evaluator recommendations for release do not require approval from the FRP before being sent to the court.
Evaluations are to be completed and reports submitted within 45 days of the court order.
If either of the evaluators recommends release, the hospital and CSB must jointly prepare either a Conditional Release Plan or discharge plan and submit to the FRP to review and make recommendations to the court. ---
Escape from Custody § 19.2 -182.14
Any person who is placed in the temporary custody or committed to the custody of the Commissioner following an acquittal by reason of insanity, and escapes from that custody shall be guilty of a Class 6 felony.
If the acquittee is subsequently returned to the custody of the Commissioner, the treatment team will submit a packet to the FRP, including updated risk assessment and Analysis of Aggressive Behavior, mental status exam, and recommendations regarding treatment and privilege levels.
Upon return to the hospital, all privilege levels are considered revoked until reviewed and approved by the FRP. ---
Notification to the Commonwealth's Attorney § 19.2 -182.4
The Attorney for the Commonwealth should be notified in writing of any changes in an acquittee's course of treatment that will involve authorization for the acquittee to leave the grounds of the hospital. Specifically, this includes escorted or unescorted community visits, trial visits (as part of an approved conditional release plan), or transfers from one facility to another. This notice is submitted by the facility's Forensic Coordinator. ---
Role of the Facility's Forensic Coordinator During the Commitment Period
The Forensic Coordinator monitors the progress, management, conditional release planning, and discharge planning for acquittees for the duration of their placement in the custody of the Commissioner.
The Forensic Coordinator serves as a consultant to the facility treatment teams with regard to the hospital's role with the courts in acquittee matters, and the acquittee privileging process.
The Forensic Coordinator ensures that the CSB NGRI Coordinator is notified of all court dates scheduled for acquittees in the custody of the Commissioner.
The Forensic Coordinator maintains communication with the Office of Forensic Services regarding significant events.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
(Content for this section not provided in the raw text)
Section 2: The Temporary Custody Period & Outcomes
(Content for this section not provided in the raw text)
Section 3: Commitment & the Graduated Release Process
involving acquittees in the custody of the Commissioner.
37 | P a g e
Graduated Release Process
Graduated Release is a "Demonstration Model" of clinical risk management. It involves gradual increases in freedom based on successful completion of the previous, more restrictive level of privileges. It is a stepwise approach that includes increased responsibility and decreased structure with demonstrated compliance and stability. The process reflects a thoughtful progression in transitioning from maximum security to reintegration into the community.
Goals of Graduated Release Process
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Provide acquittees with privileges consistent with their level of functioning and need for security.
Ensure adequate risk assessment is conducted before granting increased freedom.
Provide opportunities for acquittees to manifest appropriate functioning at various levels of freedom.
Provide treatment teams with information regarding acquittees' ability to handle additional freedom and to comply with risk management plans.
Minimize risk to public safety.
Privilege Levels Decision-Making Entities
Civil Transfer | Escorted Grounds | Unescorted Grounds | Escorted Community Visits | Unescorted Community Visits, Not Overnight | Unescorted Community Visits, Up to 48 hrs. | Conditional Release | Unconditional Release
The Internal Forensic Privileging Committee (IFPC)
Based on the level of privilege being requested by the treatment team and/or acquittee, there are different levels of approval. All privilege increase requests must be approved by the IFPC before they are sent to the Forensic Review Panel (FRP). There is an IFPC at every state hospital that houses insanity acquittees. It has at least five members from the staff of that facility, including a psychologist and psychiatrist, the facility director or his designee, the facility's Forensic Coordinator, and other professionals. The IFPCs meet weekly.
The support of both the treatment team and IFPC is required before requests are forwarded to the FRP. The only instances when privilege requests do not require IFPC approval before submission to the FRP are when the IFPC is not in support of release but:
-
1) the court has ordered the development of a release plan; or
2) when a Commissioner-appointed evaluator has recommended release.
The IFPC ensures that the treatment team has submitted a complete packet with appropriate justifications for the request. The IFPC reviews and approves the following privilege increases before sending to the FRP: civil transfer, escorted grounds, unescorted grounds, escorted community visits, unescorted community not overnight, unescorted community visits up to 48 hours, conditional release, unconditional release.
Permission Required for Privilege Increases
The Forensic Review Panel (FRP)
The FRP is an administrative board established by the Commissioner to ensure that release and privilege decisions for acquittees appropriately reflect clinical, safety, and security concerns. The FRP reviews requests that have already been approved by the IFPC, unless the court has ordered the development of a release plan or an independent evaluator has recommended release, in which case the IFPC does not have to review and the request goes directly to the FRP.
The FRP is a seven-member group with psychologists, psychiatrists, a community member, and a Central Office representative. The FRP meets weekly.
The privilege levels that the FRP must review include: civil transfer, escorted grounds (only if this was submitted at the same time as civil transfer), unescorted community not overnight, conditional release, and unconditional release.
Although the FRP reviews the requests, in the instances where the treatment team, IFPC, and FRP have all agreed to recommend unescorted community passes greater than 48 hours (trial passes at the approved residence), conditional release, or unconditional release, only the NGRI judge can give final approval to move forward.
Once an acquittee is released to the community, the monitoring of compliance with the Conditional Release Plan (CRP) and changes to the CRP is between the acquittee, the CSB, and the court. Neither the hospital IFPC, treatment team, nor the FRP play any role once the acquittee is in the community on conditional release.
The Process for IFPC-Only Privilege Requests
The Process for Requests Requiring FRP Review
41 | P a g e
So, how quickly does this process move? Acquittees do not have to be on any one privilege level for a prescribed period of time. It is individualized to reflect the acquittee’s adjustment to the increased level of freedom. Most acquittees do not request privilege increases every thirty days. While they have the right to request privilege increases at that frequency, most acquittees do not move through the process that quickly. The current average length of stay in the hospital for NGRI acquittees is 6.5 years.
Many factors influence the speed with which acquittees move through this process, including response to treatment, compliance with treatment, insight into the need for treatment, violations of rules, decompensation or changes in symptoms, court process, etc.
The Risk Management Plan
The FRP and Internal Forensic Privileging Committees base their evaluations of privilege and release explicitly on the following risk assessment criteria:
-
Has the treatment team identified and articulated the factors that increase or decrease risk?
Has the treatment team developed a risk management plan that adequately manages these factors?
Is the requested increased freedom justified by the treatment team's assessment of risk and the risk management plan?
The Risk Management Plan
At each level of privilege, the treatment team completes an update to the Analysis of Aggressive Behavior (AAB). In order for the packet to be submitted to the IFPC and FRP, a Risk Management Plan (RMP) must also be developed that describes the scope of the privilege, the conditions required before the privilege can be exercised, the expectations of the acquittee/staff, and the procedures for monitoring risk.
The items of the RMP must address the management of all the risk factors of the AAB. There are basic components of an RMP that document the procedures that any treatment team would take in granting privileges to any hospital patient of any legal status. Then there are “extra” things, such as drug/alcohol screens and prohibition against possessing weapons or materials fashioned into weapons.
Since many of the NGRI acquittees have similar risk factors, there are standard formats of RMPs, which will cover the risk management issues for most acquittees. Special conditions are added to tailor the RMP to the specific acquittee as needed. Examples include supervised contact with children or spouses who were victims of the NGRI offense, probation/parole notification, etc.
The Acquittee's Role
Acquittees are expected to be partners in risk management. The NGRI defense in Virginia means that the acquittee has acknowledged to the court that they committed the act, but should not be held legally responsible for their behavior because of active symptoms of mental illness at the time of the offense.
So how do we hold them responsible for it? We say you may not be legally responsible for that offense, but you are responsible for preventing re-offense. The “responsibility” is acceptance of the fact that they did break the law and must now be responsible for doing everything possible so that it doesn’t happen again.
That means accepting the seriousness of the offense and potential seriousness of future problems. The acquittee must agree to all of the components of the Risk Management Plan and is required to sign the RMP before its submission to the IFPC/FRP.
The RMP spells out the actions that the acquittee will take to manage their own risk at a given privilege level.
The CSBs Role in the RMP Development and Implementation
The facility treatment team or facility Forensic Coordinator will send the CSB a copy of the Risk Management Plan, along with the AAB update. The CSB is required to review and sign any Risk Management Plan for Escorted Community, Unescorted Community (8 hr and 48 hr), unescorted trial visits greater than 48 hours, conditional release, and unconditional release levels.
The plan will outline not only the steps that the acquittee will take to manage their risk but also the role of treatment providers in helping the acquittee manage their risk. It is very important that the CSB take an active role in reviewing and providing feedback on the RMP.
Misdemeanant vs. Felony Insanity Acquittees
NGRI Findings for Misdemeanor Charges
§ 19.2-182.5(c) The Code of Virginia was amended in 2002 to allow for the use of the insanity plea in cases involving misdemeanor charges. Since that time, approximately 15% of all new insanity findings have been for misdemeanor charges.
If an individual has been found NGRI for misdemeanor(s) only, they will still go through the process that we describe in this manual, including the temporary custody evaluations and recommendations either to release with conditions, release without conditions, or commit to DBHDS.
The NGRI court will still make a determination based upon the temporary custody evaluations to commit, release with conditions, or release without conditions.
The only major difference is that the Code limits the amount of time that these Misdemeanant NGRI acquittees can remain committed to DBHDS. If they are committed after the Temporary Custody period, they will go through the Graduated Release process like any other acquittee. However, they cannot remain in the hospital longer than 12 months after the date of their acquittal.
Time in jail following their acquittal, prior to hospital admission, will count towards those twelve months. If the acquittee remains in custody the entire 12 months, at the end of that time the treatment team will assess the need for ongoing inpatient treatment, make recommendations to the FRP, and the FRP will send a letter to the court with one of three recommendations:
-
1. Conditionally Release
2. Unconditionally Release
3. Civilly Commit
If civilly committed at this point in the process, the acquittee’s NGRI case is closed, and they are converted to a civil status at the hospital. Eventually, when discharged, they will have no further obligations to the court.
If the individual is Unconditionally Released, they too will have no further obligations to the court. If the individual is conditionally released, they will be discharged with a release plan like any other acquittee, and there is no limit to the time they can be on conditional release.
At that point, they are treated the same as a felony acquittee on conditional release. If they do not require the full 12 months of treatment during their first hospitalization, they can be conditionally released. However, if revocation is needed later, they can only remain hospitalized under the NGRI status for the remaining balance of the 12 months, then the three options again apply: conditional release, unconditional release, or civil commitment.
Role of the CSB/BHA During the Commitment Period
The CSB is a part of the treatment team. Even if the individual is not likely to be conditionally released for a very long time, it is necessary to begin working closely with the acquittee and the treatment team from the beginning.
Begin discharge planning upon the acquittee’s admission to the hospital. This starts with reviewing the individual’s current risk factors and ways that those factors should be managed in the hospital and eventually in the community.
Follow all discharge planning protocols. To review the Collaborative Discharge Protocols for Community Services Boards and State Hospitals, go to: http://dbhds.virginia.gov/professionals-and-service-providers/mental
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
Health practices, procedures, and law/protocols. Develop a rapport with the acquittee, help them understand your role and the role of other CSB staff (i.e., discharge planner/liaison) with whom they will interact at the hospital.
Educate the acquittee on services available in the community. Have representation at all treatment team meetings. This includes the CSB discharge planner and/or the NGRI Coordinator.
If the NGRI Coordinator is not able to attend treatment team meetings, there should be an internal CSB process established for them to receive information from those who do attend. The NGRI Coordinator must be aware of the components of the Analysis of Aggressive Behavior, Risk Management Plan, and current level of functioning.
The NGRI Coordinator must also review and sign the Risk Management Plan before it is sent to the IFPC or FRP for any level starting with escorted community visits and higher. This means that the NGRI Coordinator should provide input to the team on whether the CSB has the resources to manage the individual’s particular risk factors at each level.
Review and provide feedback and sign all necessary paperwork sent to the CSB as quickly as possible. Delays in responding result in unnecessary delays to the acquittee's progress.
The work of the CSB should always be focused on the acquittee's risk factors and management of those factors. Any concerns about the CSB's ability to manage those factors throughout each step of the graduated release process should be voiced to the treatment team and/or Forensic Coordinator as soon as possible so that a plan can be developed to overcome barriers to release.
Section 2: The Temporary Custody Period & Outcomes
Section 3: Commitment & the Graduated Release Process
Section 4: Planning for Conditional Release
• Developing a Conditional Release Plan Pg. 46
• Sections of a Conditional Release Plan Pg. 50
• Tips and Overcoming Barriers Pg. 56
• The Role of the CSB/BHA in Developing the CRP Pg. 58
Developing a Conditional Release Plan
The Conditional Release Plan contains conditions that the acquittee and CSB must follow.
The "ultimate" risk management plan. It becomes a court-ordered treatment plan. It is a treatment plan but addresses public safety.
Jointly developed by the CSB and hospital. Requests for release can be made by the Commissioner or the acquittee.
-
If the treatment team, IFPC, and FRP all concur that release is appropriate, the FRP will petition the court for the acquittee's release on behalf of the Commissioner.
The acquittee has the right to petition the court for release only once in each year in which no annual review hearing is set.
Evaluations will be ordered and based on recommendations, the FRP will make its own recommendations.
All requests for conditional release must be reviewed and approved by the FRP.
The FRP looks at successful progression through the graduated release process, acquittee compliance and collaborative involvement, stability of the acquittee, and successful management of risk factors.
All Conditional Release Plans are drafted jointly between the CSB and the facility.
§§ 19.2-182.2, 19.2-182.5(c), and 19.2-182.6(c).
The Code explicitly states that the CRP is to be developed jointly between the hospital and the CSB where the acquittee will reside upon release.
The CRP is finalized and signed, sent to the FRP and then to the Court for final approval.
The NGRI court has final say in the approval of the CRP.
Once approved by the court, it becomes a court-ordered treatment plan.
Legal Parameters of the Conditional Release Planning Process § 19.2-182.7
The Code of Virginia stipulates that at any time the court considers the acquittee's need for inpatient hospitalization, it shall place the acquittee on conditional release if:
-
The acquittee no longer needs inpatient hospitalization but needs outpatient treatment or monitoring to prevent deterioration of his condition to the point that inpatient hospitalization is necessary;
Appropriate outpatient supervision and treatment are reasonably available;
There is reason to believe the acquittee would comply with conditions; and
Conditional release will not present undue risk to public safety.
The court shall subject a conditionally released acquittee to such orders and conditions it deems will best meet their need for treatment and supervision and best serve the interests of justice and society.
Only the original NGRI court has the authority to conditionally release the acquittee.
Components of Successful Conditional Release Planning
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Close working relationships early in the process;
Trusting in each other's judgment and perspectives;
Fully considering community concerns; and
Mutual work toward the goal of a timely, comprehensive, and safe release outcome for the acquittee.
CSB and Non-CSB Provider Involvement in Conditional Release Plans
The CSB is a member of the treatment team for the acquittee. It is important for the CSB staff to meet with the acquittee as often as possible, and to routinely participate in treatment planning meetings.
Other providers may contribute to the plan, but the CSB must provide oversight and is held responsible for the overall implementation of the plan.
Non-CSB providers may be asked by the CSB to contribute written confirmation of their willingness to provide specific components of the plan, regular updates to the CSB, and shared information. This is best done prior to submission of the CRP to the court.
Cross-Jurisdictional Conditional Release Placements
In some cases, acquittees may be conditionally released to CSB catchment areas that are different from the jurisdictions of the committing courts. This can occur when:
-
The acquittee committed the offense outside of his original CSB catchment area,
The acquittee chooses to change residences,
The family lives in a different area and is willing to accept the placement of the acquittee upon discharge,
Change of residence comports with clinical and legal recommendations.
Acquittees may take up residence in any area of the state of their choosing. They are not required to return to the area where they were originally acquitted.
The CSB where the acquittee will be released is typically responsible for implementing the plan and coordinating services. The CSB from the original jurisdiction may provide consultation and collaboration, if appropriate.
The CSB that implements the plan is responsible for supervision, monitoring, and reporting to the court. When CSBs change prior to conditional release, the original CSB must remain involved until the new CSB has accepted the transfer and the responsibilities for release planning/case management.
When is a Conditional Release Plan Developed?
A CRP could be required early during the acquittee’s temporary custody. During the temporary custody period, if either of the evaluators recommends conditional release, then a CRP must be written.
A CRP could be required later after the acquittee progresses through the graduated release process and the treatment team recommends conditional release.
A CRP could be required when an independent evaluation is ordered anytime during the acquittee’s hospitalization (as in the case of an acquittee's petition for release) and the evaluator recommends conditional release.
Who Writes the CRP?
In most boards, the CSB is the originator of the written plan, and sends it to the hospital for input from the treatment team and the acquittee.
It is the recommendation of DBHDS that the CSB take the lead role in drafting the CRP, as it bears the responsibility of following through with the outlined services upon release and because the hospital will have no involvement in the implementation of the plan once the acquittee is discharged.
Regardless of who actually writes the first draft of the CRP, input from the CSB is crucial since the CSB is the expert on what services are available in the community and how these services can best be offered.
The CSB, hospital, acquittee, family members, non-CSB providers can all have input into the plan and will all sign the final draft before sending the plan to the FRP for approval.
Sections of a Conditional Release Plan (See Appendix D for a CRP Template)
General Conditions - Generally included in all CRPs; rarely, if ever, are these modified.
• Examples:
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Agreement to abide by all municipal, county, state, and federal laws
Agreement not to leave the Commonwealth of Virginia without obtaining written permission of the judge and CSB
Agreement not to use alcoholic beverages
Agreement not to possess any illegal drugs or medication not prescribed to the acquittee
Agreement not to possess or use weapons
Special Conditions - Modified based on the acquittee's specific risk factors and management of those risk factors; all services and supports, including residential and daytime activities, are outlined in detail.
• Examples:
-
Substance abuse counseling and testing
AA/NA Groups
Anger and aggression control groups
Group or individual therapy
Vocational programming
Residential placement and support services
Frequency of case management and psychiatric visits
List of medications and bloodwork required
Consequences of Non-Compliance - Language in the CRP that describes the consequences of noncompliance and the Code sections that address noncompliance. This is included in all plans and does not require modification.
CSB Information and Requirements - Case Manager name and contact information and outline of specific court-ordered requirements for the CSB.
Signatures - All parties involved in the development of the CRP, all parties who will be responsible for the provision of services, as well as the acquittee and family members (if appropriate), will sign the final plan.
CSB Comments - The CSB can provide written comment on the plan; opportunity to comment on risk factors and readiness for release; also an opportunity to express concerns, if any.
Introductory Paragraph
The first page of the Conditional Release Plan template contains two sections that require completion - the page header and the first paragraph.
The acquittee's name should be listed at the top of the plan in the page header section - this will result in the name automatically appearing at the top of each subsequent page.
The first paragraph then contains a statement about the NGRI finding and that the undersigned parties have read and agree to follow all conditions outlined within the plan.
In the blanks provided, the CSB should list the acquittee's full name, list all of the charges for which the acquittee was found NGRI, and the court of jurisdiction over the case.
Sample Language:
COURT-ORDERED CONDITIONAL RELEASE PLAN FOR John Doe
The signatures at the end of this conditional release plan indicate that I understand that I have been found not guilty by reason of insanity for Malicious Wounding and Petit Larceny, pursuant to Virginia Code Section 19.2-182.2, and I am under the continuing jurisdiction of the Alexandria Circuit Court as a result of that finding.
Pursuant to Virginia Code Section 19.2-182.7, the Alexandria Community Services Board will be responsible for the implementation and monitoring of my conditional release plan.
The undersigned parties and I have reviewed this conditional release plan and agree to follow the terms and conditions.
General Conditions
The first section of the plan, Section A, is the General Conditions section. This section, as the name implies, includes conditions that are general and apply to all acquittees.
There is little to no modification of this section, apart from completing the blanks with the name of the supervising CSB, where indicated, or indicating the amount and type of income the acquittee expects to receive.
There are eleven General Conditions. The CSB and facility should not add any conditions to this section beyond what is included in the template. The following is a list of the General
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
Conditions: 1. Abide by all municipal, county, state, and federal laws.
2. Agreement not to leave the Commonwealth without the judge's and CSB's permission.
3. Agreement not to use alcoholic beverages.
4. Agreement not to use or possess any illegal drugs or non-prescribed medications.
5. Agreement to follow the directives of the judge and CSB and be available for supervision at all times.
6. Agreement to follow all conditions and conduct themselves in a manner that will maintain their mental health.
7. Understands that they may be returned to the hospital if their mental health deteriorates.
8. Agreement to pay for mental health and substance abuse services.
9. Agreement not to own, possess, or have access to firearms or associate with those who do.
10. Agreement to release all information and records.
11. Agree to participate in 30-40 hours of activities per week.
Special Conditions
The next section of the plan, Section B, is the Special Conditions section. This section, as the name implies, includes conditions that have been developed specific to the acquittee.
The plan should be well thought out and developed in collaboration with the facility treatment team, non-CSB providers who are listed in the plan, and the acquittee and his/her family if applicable.
The plan should directly address all specific risk factors that have been identified for the acquittee.
All providers, including case managers, residential providers, support services staff, day program staff, vocational training staff, etc., should have an opportunity to review the plan and be made aware of the components before it is submitted to the FRP.
There is a lot of variability from acquittee to acquittee on the types of special conditions listed in this section of the CRP.
Generally, however, the plan should include information on the following:
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list of psychiatric/case management/therapeutic services and frequency;
substance abuse services and drug testing if necessary, list of medications/conditions and stipulations about taking them as prescribed.
The place of residence, description of type of residential placement (group home, independent apartment, etc.), and supports available at the residential placement.
Name and location of case manager, frequency of case management visits, any stipulations about decreasing/modifying this condition in the future.
List of all daytime activities, including work, day program, volunteer work, etc., based on the specific plan for the acquittee. Description of any vocational training or assistance if appropriate.
Name and location of any individual therapist and/or type and frequency of group therapy (i.e., anger management).
Name and location of psychiatrist and frequency of visits.
List of medical and psychiatric diagnoses and all medications. Stipulations about modifying medications can be included.
Substance abuse assessment and treatment services if necessary. Includes AA/NA, group sessions, and drug testing.
Transportation plans, if necessary.
Any other special conditions identified based on the acquittee's specific risk factors.
Consequences of Non-Compliance
This section outlines the consequences of non-compliance with court-ordered Conditional Release Plan and the relevant Code sections that address non-compliance.
This section is not modified, and remains the same for every acquittee.
From the Plan: I have read or have had read to me and understand and accept the conditions under which the Court will release me from the hospital.
I fully understand that failure to conform to the conditions may result in one or more of the following:
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Notification to the court of jurisdiction;
Notification of the proper legal authorities;
Modification of the conditional release plan pursuant to § 19.2-182.11;
Revocation of conditional release and hospitalization pursuant to § 19.2-182.8;
Emergency custody and hospitalization pursuant to § 19.2-182.9;
Charged with contempt of court pursuant to § 19.2-182.7; or
Arrest and prosecution
I understand that my conditional release plan is part of a court document and could potentially be accessed by the public.
CSB Information and Requirements
This section lists the court-ordered requirements for the designated Community Services Board.
Not only is the CRP a court-ordered treatment plan for the acquittee to follow, but the CSB is also court ordered to monitor, coordinate services, and report to the court and DBHDS.
List case manager name and contact information in the blanks provided.
This section further stipulates the monthly and six-month written reporting requirements that the CSB must follow and to whom the reports should be sent.
This section indicates that the CSB cannot make changes to the court-ordered CRP without permission from the court.
Finally, it requires that any and all updates (including copies of court orders) regarding the acquittee's status should be reported to the Office of Forensic Services at DBHDS.
Signatures
All CSB and non-CSB service providers listed in the plan, including the CSB NGRI Coordinator, CSB Case Manager, providers of residential services, therapeutic services, psychiatric services, etc., may be asked to sign the plan.
The hospital treatment team, such as the social worker, psychologist, and psychiatrist, will sign the plan.
The acquittee's family members, if mentioned in the plan as having a role in the conditions of release (such as residential, transportation, etc.), should sign the plan.
The acquittee must sign the plan.
Once reviewed and approved by the IFPC and FRP, the FRP will send the plan to the court and the court will determine if the plan is acceptable and whether the acquittee shall be released.
If approved, the plan becomes a part of the court record and the acquittee and CSB are ordered to comply with the conditions therein.
CSB Comments
This is an opportunity for the supervising Community Services Board staff to provide recommendations and comments to the Forensic Review Panel.
The CSB is advised to always include comments in every CRP, as this is one of few opportunities to communicate directly with the FRP about the CSB’s support for or against conditional release and an explanation for the CSB’s position.
The CSB is encouraged to use this section to include any information that it feels the FRP and court should be aware of that is not apparent in the written plan up to that point.
If the acquittee has done well and the CSB feels the plan will adequately address their risk and needs, it should be indicated here.
If there have been challenges and the CSB suspects the FRP or court may be uncertain about release, the CSB can address the reasons for supporting the acquittees release under this plan.
If the CSB has concerns that the acquittee may not be ready or that the supports in the community may not be sufficient to manage risk, this is the place where the CSB will list those concerns.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
Details about the insanity defense and the Not Guilty by Reason of Insanity (NGRI) process are discussed in this section. ---
Section 2: The Temporary Custody Period & Outcomes
This section covers procedures and expectations during the temporary custody period, including planning and communication strategies. ---
Section 3: Commitment & the Graduated Release Process
This section provides guidance on the commitment process and the steps involved in graduated community release. ---
The Role of the CSB/BHA in Developing the CRP
Providers should facilitate smooth transitions by arranging meetings between providers and the acquittee at the CSB, especially while on pass, to foster familiarity and reduce anxiety.
Relationships are key to ensuring a successful transition. The CSB should take the lead in drafting the Conditional Release Plan (CRP). Once the initial draft is complete, all treatment team members, providers, and the acquittee should review and provide feedback.
The CSB should take "ownership" of the plan, as it is not only a court order for the acquittee but also for the CSB. The CSB is the expert in community services and supports. If the plan does not accurately reflect available services, it risks setting the acquittee and CSB up for failure.
Participate regularly in treatment planning meetings and meetings with the acquittee to understand relevant risk factors and management techniques in the community. Communicate regularly with the facility's Forensic Coordinator or the Office of Forensic Services staff regarding the AAB and Risk Management Plan, obtain copies if not already provided, and ensure the plan addresses all risk factors.
Consult with the facility's Forensic Coordinator or staff if there are concerns or disagreements about necessary components of the plan. Complete the plan promptly once notice is received that the facility is preparing a packet. After finalization, obtain all necessary CSB provider signatures and return the signed plan quickly to avoid delays. Everyone should communicate and ask questions—collaboration is essential! ---
Section 5: Conditional Release
First Steps in Implementing the CRP (Pg. 59)
Questions to consider include whether the acquittee fully understands the CRP components, whether treatment providers have copies, and understanding the roles of the NGRI Coordinator and reporting requirements.
Code Requirements §19.2-182.7
The CSB is required by law to:
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Implement the court's conditional release orders.
Submit written reports to the court at least every six months.
The CRP itself is a court order. Any changes to conditions must be pre-approved by the court. ---
First Steps Upon Release
Ensure all treatment team members, including CSB and non-CSB providers, have a copy of the CRP before discharge and understand their obligations. Establish communication loops to monitor implementation and the acquittee’s status.
Some acquittees may experience anxiety, drug use temptations, or resistance to the CRP. Most will succeed with proper supports. Set clear expectations early, ideally before discharge, and review the CRP with the acquittee upon release. The acquittee should have a copy of the CRP, and the case manager and NGRI Coordinator should review it together to build rapport and clarify conditions. ---
The Role of the CSB NGRI Coordinator
CSB NGRI Coordinator Responsibilities
The Executive Director must designate a staff member as the NGRI Coordinator. The role's structure varies: it may be the same as the case manager, a separate assignment, or an administrative role with distributed case management.
Key functions include:
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Overseeing compliance with court orders for Conditional Release.
Coordinating submission of required reports.
Maintaining necessary training and expertise.
The NGRI Coordinator is the primary contact and accountability point for all NGRI cases, facilitating communication with judges, attorneys, hospital forensic staff, and DBHDS. Familiarity with the “Guidelines for the Management of Individuals Found NGRI” is essential (available on the Department website).]
It is recommended that the NGRI Coordinator personally sign all court correspondence. If delegating, ensure staff understand their roles, the compliance requirements, and review all correspondence before submission. ---
The Role of the CSB Case Manager
CSB Case Manager Duties Related to NGRI Acquittees
Sometimes the NGRI Coordinator also serves as the case manager; often, these are separate roles. The case manager must understand the CRP and conditions, stay in close contact with service providers, and communicate significant information to the NGRI Coordinator.
They should participate in treatment planning meetings, maintain detailed notes, and monitor the acquittee’s progress, especially for major decisions like revocation or condition removal. If the case manager does not prepare reports, they should send monthly and 6-month court reports to the NGRI Coordinator for review and co-signature.
The case manager should be available to accompany the acquittee to court and discuss potential modifications to conditions. They serve as the link between treatment providers, the acquittee, and the CRP, fostering ongoing communication and collaboration. ---
Required Reports
Monthly Reports
Required by the Performance Contract between DBHDS and the CSBs, following an approved template (see Appendix F). Due monthly for the first 12 months post-release, with the first due by the 10th of the month after the first full calendar month.
Subsequent reports are due by the 10th of each following month. Only full calendar months are reviewed. The six-month report is separate and does not replace the monthly report. Always include comments and signatures, and submit reports to the Office of Forensic Services at DBHDS via fax or mail.
Six-Month Reports
Required by Virginia Code §19.2-182.7, following an approved template (see Appendix G). Due every six months during the conditional release period, starting six months after the initial release. The subsequent report is due six months after the previous one. Attach a cover letter summarizing progress and recommendations. Send original signed reports to the judge, with copies to DBHDS, the defense attorney, and the Commonwealth's Attorney. ---
The Monthly Report (see Appendix F)
The Office of Forensic Services will send a letter outlining reporting requirements and due dates after the acquittee’s release. The first report covers the period from release to the end of the first full calendar month. Future reports are due by the 10th of the following month, e.g., March reports due by April 10th, etc.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
by June 10th, etc. If completing a monthly report in a month that the 6-month report to the court is due, the CSB should complete both. They are separate reports and the six-month report does not replace the monthly report.
Before completing the monthly report, the author of the report should review all progress notes, gather feedback from treatment team members, and gather results of any urinalysis or blood work required by the CRP.
Section 2: The Temporary Custody Period & Outcomes
1. Enter the name of the acquittee and the court with jurisdiction over the case. Then enter the date the report was written. Below, under Time Period in Review, enter the month and year that the report is reviewing.
2. The next section that many people overlook has to do with new charges and new convictions. These are different but both important. If the acquittee has been arrested and charged with a new offense, list the offense and date in the first line. If they have then been convicted of a new offense, it goes in the second line. Make sure to list the offense and the date. Do not leave blank, enter N/A or None if there is nothing to report.
3. The next part of the form is the part where the acquittee's compliance and progress with all conditions is reviewed. First, enter all of the General Conditions in the column on the left, then indicate whether they Always, Sometimes, or Never comply with that condition by putting a check mark in the appropriate box, then enter a brief description of their progress/challenges for that condition that month. This is important not to leave blank. If they have been fully compliant, one sentence indicating that is sufficient. If they have had compliance issues, briefly describe in the right-hand column and provide a detailed description at the end of the report. The same should be done for the special conditions. If the condition is very lengthy, it may be shortened as long as the meaning is still clear on the report.
4. In the next section, the CSB should indicate the last face-to-face with the acquittee, any and all urinalysis drug screens that month (along with the date and result of each screen).
5. A narrative summary of the month should be included at the end of the report. This should never be blank. Indicate if the acquittee has been compliant or non-compliant, if there was progress or setbacks that month, and any other relevant details…particularly if there have been challenges.
6. Finally, the author of the report should sign it, indicate their title, CSB, contact info, and put the date it was signed. If the person writing the report is not the NGRI Coordinator, the NGRI Coordinator should review and co-sign all reports. ---
Section 3: Commitment & the Graduated Release Process
67 | P a g e The Six-Month Report to the Court (see Appendix G) § 19.2-182.7 states that the CSB “shall submit written reports to the court on the acquittee’s progress and adjustment in the community no less frequently than every six months.” However, it is important that all violations of conditional release be reported to the court immediately, and should not wait until the next monthly report or six-month report is due.
DBHDS Office of Forensic Services, in their letter to the NGRI Coordinator following the acquittee's release, will indicate the due date of the first six-month report. It is based on the acquittee's actual release date. The report does not require listing the "period being reviewed," so the date listed on the six-month report should be the date the report was actually written.
The report should always be accompanied by a cover letter. Samples are included in Appendix E. The cover letter should include the acquittee's name, case number, explanation of the author's role and purpose of the report, and brief description of progress/challenges and recommendations. Without the cover letter, these reports may get lost in the system and the judge may not know why they have been sent or what to do with the information.
This report is to be completed by the NGRI Coordinator or other staff designated by the CSB. If the author of the report is not the NGRI Coordinator, the NGRI Coordinator should co-sign the report before it is sent to the court.
DBHDS strongly recommends that the NGRI Coordinator be the person to write the cover letter to the Judge, attach the report, and mail it to all parties. At the very least, the NGRI Coordinator should co-sign the report and review the cover letter before it is sent.
The original letter and report should be mailed to the Judge with jurisdiction over the case. Copies can be either mailed or faxed to the Defense Attorney, Commonwealth's Attorney, and the DBHDS Office of Forensic Services.
All relevant information on the acquittee's progress needs to be collected for the previous 6 months, which is why good monthly reports and regular documentation are critical. It is imperative that the writer contact all service providers and relevant family or friends to gather this information. The goal is to provide a comprehensive assessment of the client’s progress and adjustment in the community.
This report resembles the monthly report in format, but it requires specific recommendations to the court with the rationale for the recommendation.
Through an agreement with the CSBs, DBHDS issues payments in installments for every acquittee returning to the community onto conditional release. These payments are issued based on the submission of the monthly and six-month reports. ($500 after initial release, $1000 after receipt of 6 monthly reports and 1 six-month report, and $2000 after receipt of 12 monthly reports and 2 six-month reports). ---
Section 4: The Six-Month Report to the Court (Cont'd)
In the narrative section of this report, the author of the report will again want to make sure to explain:
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The types of services that the acquittee has received (rather than local program names that the average reader won't understand).
Level of compliance, challenges, and steps taken to resolve them, and any other relevant information.
Also indicate any other important changes to treatment/services that occurred during the reporting period that did not require the court to approve — such as change of address, increase in service frequency or intensity, or voluntary or community-based hospitalizations.
Changes allowable without court approval are limited, so the CRP should be reviewed carefully and if in doubt, contact the Office of Forensic Services for consultation.
The final section of the report requires the CSB to make a recommendation to either: continue conditional release without changes, modify current conditional release order, revoke conditional release, or remove conditions.
This is very important and should be taken seriously, as the court will carefully consider the recommendations.
If requesting any change to the conditional release (modification, revocation, or unconditional release), then the CSB must include a narrative description of the changes proposed, reference the section of the CRP that is impacted, and give a rationale for those changes.
If the CSB is modifying the conditions, changes should also be made to the written CRP itself and the plan should be resubmitted along with the report to the court for final approval from the judge before changes go into effect.
Significant changes to the conditions of release will require a new order from the Judge approving the new plan. The CSB may have to request a new hearing to obtain formal approval, or may be able to request that the court indicate their approval in writing and return it to the CSB.
Either way, follow-up with the Clerk's office, Commonwealth's Attorney, and Defense Attorney may be necessary to move the process along.
Again, if there have been significant problems with the acquittee's compliance with conditions over the reporting period, the CSB should not wait to report this in the six-month report, but should instead notify the court and all parties immediately, with recommendations for next steps.
If this report is done later than the original deadline, the next 6-month period starts from the date it was written, and the due date schedule adjusts accordingly.
DBHDS tracks the timeliness of reports, and will issue reminders for late reports. ---
Section 5: Modifying the Conditional Release Plan
Possible Reasons for Modifying the CRP
The individual is progressing in the community, doing well, and ready for less restrictions.
The acquittee begins to decompensate and increased supports are needed to prevent return to inpatient hospitalization.
The acquittee is struggling with non-compliance and intervention is necessary to avoid incarceration or hospitalization.
Modification of the CRP
If the assigned CSB determines that the CRP needs to be modified, it is incumbent on them to recommend that the court of jurisdiction approve the modified CRP.
Only the court of jurisdiction has the authority to actually approve the modified CRP, and any of the general or specific conditions, unless the plan contains language that allows the CSB to alter the CRP.
Examples of when the CSB should recommend that the CRP be modified include:
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When the service needs identified in the plan change.
The acquittee has improved and no longer needs services described in one of the conditions.
The acquittee's compliance and the adjustment in the community is poor and additional conditions need to be added before revocation is needed.
Generally, the plan can and should be modified whenever the acquittee has demonstrated success or setbacks, always keeping in mind the management of identified risk factors and the safety of the acquittee and the community.
Procedures for Modifications
The court of jurisdiction may modify conditions of release whenever it deems it necessary, based on reports from the supervising CSB or upon petition from the Commonwealth's Attorney or acquittee (the acquittee can petition for modification only once annually, commencing 6-months post-release).
In cases where the CSB is requesting modifications to the plan:
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The petition should be accompanied by a report explaining the request and providing clear rationale in support of the request.
Provide any other evidence in support of the request, such as letters from collateral sources such as family or service providers.
Copies of any correspondence should be sent to the Judge, as well as the Commonwealth's Attorney, Defense Attorney, and the Office of Forensic Services at DBHDS.
There are two possible means of modifying the conditions:
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In cases involving minor modifications that have been built into the written CRP, the CSB should notify the court in writing that they plan to modify the conditions in some way, and request notification of any objections. For instance, if the CRP indicates that after the initial 6 months of conditional release, the frequency of case management visits can be reduced to every other week with approval of the treatment team and NGRI coordinator. In this case, the CSB can make the modification and simply inform the court in writing that it has done so based upon the plan’s stipulations.
For changes that are more significant, the CSB would request formal written approval of a modified CRP from the court, and a) request that the judge order compliance with the new version of the CRP via a new court order, or b) request a court hearing to present the request to the Judge directly. This will depend on how the court typically prefers to handle these changes, and the CSB and Defense Attorney’s agreement with proposed changes. Often, if everyone agrees, no formal hearing is necessary. If there are objections from one party or another, it may be best to have a hearing to discuss it.
Plans should be modified, regardless of time frame, as long as the individual is ready for the change to the plan. CSBs should not keep to a strict time frame if it is not appropriate for the individual.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
mind. This is a live and dynamic process! Whenever changes to the conditions of the CRP are approved, remember to update the monthly and six-month reports to reflect the modification. ---
Section 2: The Temporary Custody Period & Outcomes
Out-of-State Travel Permission §19.2-182.15 Virginia Code makes it a Class 6 felony for an acquittee who has been placed on conditional release to leave the Commonwealth of Virginia without permission from the court with jurisdiction over the case.
In some geographic regions where an individual may need to work or attend appointments or activities across state lines, the CSB may consider incorporating a special condition related to out-of-state travel into the CRP.
The circumstances and limits to travel should be clearly spelled out in the plan. If not already incorporated into the CRP, the CSB will have to seek written permission from the court to allow the acquittee to travel out of state.
The following issues should be considered in any decision for such a request:
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Length of time on conditional release.
Degree of compliance with conditions.
Degree of compliance with psychotropic medications.
Risk factors identified in the AAB.
The acquittee's understanding of the criminal penalty for escape.
The availability of support systems should the acquittee begin to experience difficulties.
The availability of a trusted person to accompany the acquittee.
Any request for a modification of the conditional release order should specify the dates, locations, purpose, notifications/permissions, and other details necessary to demonstrate that risk factors will be managed appropriately. ---
Section 3: Commitment & the Graduated Release Process
Transfer of Monitoring Responsibilities from One CSB to Another on Conditional Release
In some cases, acquittees may request relocation to another CSB's catchment area. In other cases, the services and supports needed to manage the acquittee's risk do not exist in the current CSB's catchment area.
In these instances, the supervising CSB may decide to pursue transfer of the CRP to a different CSB. In all cases in which transfer is considered, the original supervising CSB must ensure that the change comports with clinical and legal recommendations.
Risk should always be considered when proposing this type of modification. Acquittees may take up residence in any area of the state of their choosing. The original CSB must evaluate the availability of appropriate services and supports to mitigate the acquittee's risk factors.
If the original CSB does not agree that the move would be in the best interest of the acquittee or the community at large, they should not proceed with transfer. In this case, the acquittee may request modification of their plan by working with their attorney, and the court will make the final decision.
If the current CSB supports the transfer, the current NGRI Coordinator should reach out to the receiving CSB's NGRI Coordinator to discuss the move, services available, etc. If the receiving CSB agrees to accept the transfer, the CSBs should work collaboratively to modify the existing CRP and should agree on all changes made. Both CSBs must feel comfortable with the new plan before moving ahead.
Once this has been done, the NGRI Coordinator of the current CSB should take steps to seek approval from the court before moving forward with transfer. As with other CRP modifications, this change would require approval of the Judge.
No changes in supervising CSB should occur until the modified conditional release plan (listing the new CSB) is submitted in writing, with justification for the change, and upon receipt of a written approval or modified court order from the Judge.
The original CSB should remain involved in monitoring the acquittee's release until the court has issued written approval, and until the new CSB has accepted the transfer and the CRP.
The current CSB should ensure that there is a clear plan for transition in the revised CRP and clarity on the timeframe when the receiving CSB will begin full supervision, monitoring, and reporting to the court.
All modifications to the supervising CSB should be reported immediately to the Office of Forensic Services at DBHDS with written court approval and a copy of the updated Conditional Release Plan. ---
Ensuring Acquittee Success on Conditional Release
Tips for Ensuring Success on Conditional Release
The AAB is a very useful, comprehensive document. Regular review of the risk factors will ensure better community integration and longer tenure in the community.
It is important to gather information from all treatment providers, including “outside” treatment providers, in order to have a comprehensive view of the acquittee.
Acquittees may present differently to different providers. It is important for the acquittee to understand that all providers are communicating and coordinating their treatment.
The CSB manages risk in an ongoing manner with regular monitoring and review. There are lots of eyes on the acquittee!
The acquittee should be conducting him/herself in such a way that his mental health is valued and priority is given to maintaining stability.
Continued clinical wellness and safety should be the foundation and driving force behind any CRP and in making any modification.
Almost all acquittees are subject to random or periodic breathalyzer, blood, or urine analysis to monitor for the use of alcohol or illicit drugs.
Detection of any drugs or alcohol or refusal to be tested constitutes non-compliance with the CRP.
There is a good reason that these tests are included in the CRP. Substance abuse is a major area to review both with providers and NGRI acquittees.
This is the biggest risk area that leads to relapse and decompensation and, potentially, to re-offending.
Communicate, communicate, communicate! All members of the acquittee's treatment team, especially the NGRI Coordinator, should be made aware of any problems as they arise.
The DBHDS Forensic Office staff are available to assist the CSB with creative problem-solving to get the acquittee back on track, and can solicit help from the hospital Forensic Coordinator when necessary for their clinical input.
Provide opportunities for the acquittee to achieve greater autonomy as they demonstrate success.
Failing to acknowledge progress may result in discouragement and future non-compliance if the acquittee feels that future independence is impossible. ---
Communicating with the Court
The individual at the CSB who communicates with the court is representing the entire CSB. This CSB staff person should make sure that they are authorized to “speak for” the CSB and to make recommendations to the court.
DBHDS recommends that this always be the same person, and that this be the NGRI Coordinator.
Good Communication Coordination:
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Keep others informed of what they need to know, without overburdening them with unnecessary information.
Information: Who needs to know what.
Confirmation: Make sure the right people have the information they need.
Timeliness: A message delivered too early or too late may lead to confusion.
Accuracy: The wrong message may be worse than none at all.
Written Communication (see Appendix E and Appendix I)
Put your communication with the court in writing if at all possible. This ensures that the communication becomes a part of the court record, and that the message sent to all parties involved is consistent.
Letters should be addressed to the Judge, and originals should be signed and mailed to the Judge. Copies should be mailed to the Defense Attorney, Commonwealth's Attorney, and the Office of Forensic Services at DBHDS.
All correspondence should include the following elements:
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The acquittee’s name in the subject line with the court case number(s).
Introduction that the subject of your letter is an insanity acquittee and, if the acquittee is on conditional release, reference the appropriate Code section (§19.2-182.7) for conditional release and the date of release.
Make sure that the purpose for your letter about the acquittee and any requests are clearly stated.
Do not use clinical jargon or acronyms, and use program descriptions rather than names (such as a "supervised group home" vs. "New Beginnings").
Make it easy for the Judge to understand and respond to your request for modifications - reference all relevant Code sections and provide model court orders if needed.
Verbal Communication
Any time that you communicate with the court and you need an immediate response, a follow-up phone call may be needed even if your written communication was very clear.
The courts are very busy entities. It may be necessary to call the court and ask to speak with the Judge’s secretary or clerk for assistance with your request.
Depending on the nature of the request, it may be necessary to call the Commonwealth's Attorney or the Defense Attorney. ---
Tips for Testifying
It is recommended you request a subpoena or court order before testifying. Most times, you are considered a fact witness.
When you are required to testify, remember Sgt. Joe Friday: “Just the facts, Ma'am.” Facts are: he said, she did, the lab reports show, etc.
Also keep in mind that the Judge can qualify you as an expert witness. Check with your agency HIPAA coordinators on the limits to what information you can provide in your testimony.
Be prepared; bring a copy of CRP but don’t bring any records unless you’ve been served a subpoena duces tecum - again check with your agency's HIPAA experts or attorney if necessary.
Don’t volunteer information - only present the facts and only answer the question being asked.
Don’t take your cell phone, even if the court permits this. It will look very unprofessional if it goes off in court.
Don’t let the attorneys rattle you. Slow down by taking a breath or pause as if thinking about your response. Look at the attorney and direct your remarks to them.
Usually the attorneys won’t spend a whole lot of time with you. They’re busy folks too and want to move on.
Occasionally an attorney will challenge you with something like “that’s just an educated guess, isn’t it?” A good response is “No. That’s my best professional assessment.”
Look the part of the professional. Dress as well if not better than you would every day for work; no jeans, T-shirts, knit shirts, shorts. Dressing professionally helps your credibility.
Be honest. Be believable. Be professional. ---
Section 6: Non-Compliance with Conditional Release
Assessing Non-Compliance Pg. 77
Legal Interventions for Non-Compliance Pg. 79
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Modifications of the CRP Pg. 80
Revocations (non-emergency and emergency) Pg. 81
Contempt of Court Pg. 84
The Role of the CSB/BHA in Managing Non-Compliance Pg. 85
Assessing Non-Compliance
Compliance
Non-Compliance
The Nature and Causes of Non-Compliance
There is careful planning and scrutiny before the acquittee is placed on conditional release. As a result, the vast majority of acquittees do extremely well when discharged on conditional release and placed in the community.
There are exceptions, however, and some acquittees will struggle to follow their Conditional Release Plan. Anticipate there will be “ups” and “downs” with compliance.
Some will do quite well initially, then become frustrated when their conditions are not modified in the timeframe they expected. Others will immediately experience difficulties upon release, with the new sense of freedom and return to the places, people, and habits that once got them into trouble.
The first year on conditional release may be the most critical in the conditional release process.
In anticipation of potential unrealistic expectations on the acquittee's part, it may be helpful to tell them the average amount of time other acquittees spend on conditional release, the factors that the CSB will use in considering modifications/reductions to the conditions, and be honest with them about the areas that you are not likely to budge.
The NGRI Coordinator needs to keep a close
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
---Section 2: The Temporary Custody Period & Outcomes
---Section 3: Commitment & the Graduated Release Process
---eye on newly released acquittees as well as those on conditional release for an extended period of time. The newly released may want to "test the waters" or may experience stressors and decompensate with the lack of structure previously provided in the hospital.
The other group who have been on conditional release longer may also become frustrated or complacent about their treatment. In other cases, non-compliance will result from the nature of the illness, not due to intentional behavior from the acquittee.
In each case the CSB will need to carefully examine the root cause of the non-compliance to determine appropriate steps to get the acquittee back on track.
Assessing Non-Compliance
First, assess the seriousness of the non-compliance. Is there a potential for harm to the acquittee or others? Is there a potential for re-incarceration? Is the individual receptive to the CSB's interventions? Is the non-compliance related to the symptoms of their mental illness? Or is the non-compliance a result of general non-compliance, including substance use?
By virtue of their mental illness, the acquittee may need inpatient hospitalization or crisis stabilization from time to time. This may be handled very differently than with an acquittee who willfully violates their conditions.
Based upon the CSB's experience with the acquittee and the results of the CSB’s risk assessment, there are several options for dealing with the non-compliance. Always consider the least restrictive alternative . . .
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Could they benefit from short term crisis stabilization, detox, or temporarily increasing support services and office/home visits?
Could they benefit from PACT team services?
Are medication adjustments necessary?
Hospitalization is another option - an acquittee can be admitted voluntarily to a community hospital and return to conditional release without formal revocation, and in fact an acquittee can be TDO’d to a community hospital and remain in the community on conditional release, if they are able to benefit from their time in the hospital and are still appropriate for conditional release.
The court must always be notified of the hospitalization, but it does not mean they will be revoked to the state hospital starting from square one again.
If the non-compliance is more willful and deliberate, not from mental illness, should the CSB seek penal sanctions or reprimands from the court? The CSB will have to decide the best course of action based on clinical judgment and the likelihood of improvement from one course of action over another.
Legal Interventions for Non-Compliance
Addressing Non-Compliance
In order to determine what to do, the CSB must first assess the type of non-compliance. Is the acquittee experiencing psychiatric difficulty or is the acquittee failing to comply with psychotropic medications? Is it an issue of substance abuse where the acquittee has submitted a positive drug screen? Is it other issues of non-compliance such as missed appointments, termination from specialized housing, or not signing releases?
Identifying the type of non-compliance will assist the CSB in selecting the appropriate response. The CSB must work with the acquittee and all of the treatment providers closely to try to address the issue sooner rather than later.
The CSB should always attempt to resolve the issue using the least restrictive alternative, but should be aware of legal intervention if they become necessary.
Non-Legal Interventions
Voluntary hospitalization or civil TDO to a local (non-state) hospital: Based on a risk assessment by the CSB, an acquittee can be admitted to a local psychiatric hospital as a voluntary admission, or even on a temporary detention order.
Hospitalization does not automatically mean that the person will be formally revoked by the court. In some cases, the individual may get treated and return to the community quickly without the need for admission to the state hospital and formal revocation.
The CSB should notify the court of any signs of decompensation or non-compliance and should notify the court of any hospitalizations, even voluntary.
In its letter to the court, the CSB should advise the court if they feel revocation is unnecessary and should update the court upon the individual's discharge to the community.
However, if the acquittee requires involuntary hospitalization and needs to be committed, the acquittee should be admitted to a state hospital and to the custody of the Commissioner and it should be considered a revocation, with the appropriate steps to seek formal revocation from the court.
Legal Interventions for Non-Compliance - Code Sections
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§ 19.2-182.11 Modification of Conditional Release Orders/Plans
§§ 19.2-182.8, 19.2-182.9 Revocation of Conditional Release
§ 19.2-182.7 Contempt of Court
Modification of the Conditional Release Plan
§ 19.2-182.11 Modification of the CRP has been reviewed to some extent earlier in the manual in the context of when the acquittee has improved and the CSB recommends to the court that certain conditions be reduced or removed thereby giving the acquittee more freedom and more responsibility.
Conversely, use of this Code section can be employed when the acquittee is non-compliant.
EXAMPLE: The acquittee who is abusing substances or failing other conditions of release may need more conditions added. These might include additions such as SA residential treatment programs, increased AA/NA meetings, or more frequent urine drug screens.
EXAMPLE: An acquittee who was evicted from their apartment for failing to clean, leading to insect infestation and threats of eviction. This could require a change in level of residential care, such as a new apartment with the requirement that the individual agree to in-home skill building services or even PACT services if available.
There is a condition at the end of the CRP template that states “I agree to additional special conditions that may be deemed necessary by the supervising CSB in the future.” This essentially allows the CSB to add services to the plan based upon their assessment of the situation.
The NGRI coordinator should modify the written plan, attach a letter describing the noncompliance and the changes made to the plan, and request court approval of those changes.
The CSB has the flexibility given the language of the plan to add services and interventions based on their assessment, however the court should always be notified of the non-compliance and reasons for the adjustment and formal requests for modifications to the plan should always be made in writing.
Revocation of Conditional Release §§ 19.2-182.8, 19.2-182.9
There are two types of revocations that can occur by Code: "non-emergency" and "emergency" revocations. Revocations (regardless of type), mean return to inpatient hospitalization at the state hospital.
In all cases where the NGRI Coordinator is considering the need for revocation, it is recommended that they or the case manager discuss the situation with the DBHDS Office of Forensic Services.
If necessary, the Office of Forensic Services will contact the Forensic Coordinator at the hospital, who may provide clinical guidance if needed and who can alert the hospital admissions staff of the potential admission.
Once the acquittee is revoked, the NGRI Coordinator should ensure that the hospital receives all relevant information about the reasons for the revocation and establish ongoing communication with the facility's treatment team.
Reasons for revocation of conditional release must always include the need for inpatient psychiatric hospitalization.
If the individual does not need inpatient hospitalization, the CSB and the court have different options available. Revocation is not considered a failure; it is an appropriate use of a tool to prevent bad consequences from happening to the acquittee or to others, i.e., re-offending, etc.
Regular (Non-Emergency) Revocation of Conditional Release § 19.2-182.8
This is used in non-emergency situations, however this is rarely used. The “regular” or “non-emergency” revocation process continues at a slower pace than the emergency revocation process.
Utilization of the “regular” or “non-emergency” revocation process is extremely rare but can be useful under certain circumstances. An example might include an individual demonstrating a resurgence of low-risk factors, but is noncompliant with many of the conditions of the CRP and likely to experience decompensation if not addressed.
CSB must petition the court for the revocation by issuing a letter to the court (a format for a petition for revocation is included in Appendix E). This letter should reference the revocation Code section and outline the rationale for the request in detail.
Typically, this letter also requests a court date to hear the matter. The court will appoint an independent evaluator, who will be a psychologist or psychiatrist who is qualified by training or experience to perform forensic evaluations.
After the evaluation is completed, the Judge will determine if revocation is warranted. The criteria for revocation is that the acquittee:
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a. Has violated the conditions of release, or is no longer a proper subject for conditional release based on application of the conditional release criteria, and
b. Is mentally ill or intellectually disabled and requires inpatient hospitalization.
Emergency Revocation of Conditional Release § 19.2-182.9
This Code section was developed to respond to emergency situations, or for situations when the NGRI judge may not be available to hold an expedited revocation hearing.
The process mimics the civil ECO and TDO process but the criteria are different for insanity acquittees.
The revocation criteria is purposefully less restrictive than the civil commitment criteria, to allow for individuals on conditional release to be returned to the hospital as soon as possible, before any potential future violations of their release can occur and to prevent harm to the individual or the community.
There are many examples when emergency revocation is an appropriate alternative and consequence. This option is appropriate when the acquittee's non-compliance is due to mental illness and they require immediate hospitalization to address the issue to prevent re-offending, harm to the acquittee or others, or absconding.
Another example of appropriate emergency revocation may include an escalating pattern of non-compliance due to mental illness (such as missed psychiatrist and case management appointments, being terminated from approved residential services, refusal to participate in 30-40 weekly hours of structured activities, etc.), when this pattern has historically led to significant decompensation.
The reasons for emergency revocation are the same as the "regular" or "non-emergency revocation" criteria. The acquittee:
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a. Has violated the conditions of his release or is no longer a proper subject for conditional release, and
b. Is mentally ill or intellectually disabled and requires inpatient hospitalization.
Typically this process would begin with an ECO and an evaluation by the CSB's Emergency Services staff. The NGRI Coordinator should be involved throughout the entire process, communicating with the case manager and the Emergency Services staff.
The NGRI Coordinator may have to provide education to Emergency Services about the revocation criteria and the differences between revocation and the civil ECO/TDO criteria.
The Code simply states "requires inpatient hospitalization" and does not reference the civil TDO criteria of substantial likelihood of dangerousness to self or others.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
Magistrate or Judge should be using. There is a special section for revocation that is separate from the civil TDO criteria on the form (see Appendix I).
Emergency Revocation (Cont'd)
The acquittee can be TDO'd to a state facility or a private local facility for a period not to exceed 72 hours. Following the TDO period, the acquittee is entitled to a hearing to determine whether he/she will be revoked. The committing court or any General District court Judge or Special Justice (defined in § 37.1-1) can hear the matter. This means that the acquittee can go before the Special Justice holding commitment hearings, or he/she can return before the Judge of jurisdiction.
Because this is difficult to schedule on short notice, often acquittees go before the Special Justice at the scheduled commitment hearing. Before the hearing, the acquittee will be examined by a psychiatrist or a clinical psychologist to certify whether the acquittee needs hospitalization. The court shall revoke the acquittee's conditional release if the revocation criteria is met. Again, the civil commitment criteria does not apply.
Throughout this process, the NGRI Coordinator should notify the Defense Attorney, Commonwealth's Attorney, and the Judge of the need for revocation and the process followed to secure revocation. In cases of revocation, the acquittee will always transfer to a state-operated psychiatric facility following the hearing. The acquittee usually returns to the civil hospital from which they were discharged.
Next Steps & The Impact of Revocation on the Acquittee
Revocation is a very serious step and can have very serious implications for the acquittee. It should only be used after other, less restrictive options have been explored. Return to the state hospital does not guarantee a long-term hospitalization but it might.
If not appropriate to resume conditional release within 60 days, they will start the graduated release process all over again. The CSB and the facility treatment team will develop a recommendation regarding continued hospitalization or resuming conditional release. Given the short time frame, the joint recommendation will be submitted to the FRP by the hospital within 21 days of revocation.
If the recommendation from the team and FRP is to resume conditional release, the Conditional Release Plan should be updated. The acquittee will go before the NGRI Judge and the Judge will have to approve Conditional Release and issue a new order.
If the recommendation is to continue hospitalization, the NGRI judge will likely issue a new revocation/commitment order for continued inpatient hospitalization. Again, if the acquittee is not ready to resume conditional release within that very short window, they will be committed to the custody of the Commissioner and begin the privileging process from the beginning. This might result in another lengthy hospitalization.
Contempt of Court § 19.2-182.7
The Code of Virginia allows the court of jurisdiction to find an acquittee in contempt of court as a result of the acquittee's violation of the Conditional Release Plan if they do not need inpatient hospitalization. This Code section was expressly written for the acquittee who has violated their CRP but does NOT need inpatient hospitalization.
In these situations, therapeutic interventions may not be the most appropriate action and the acquittee needs to be held accountable for the violation of the court-ordered CRP. The CSB may request that the court find the acquittee in contempt of court for failure to follow their court-ordered CRP.
If the Judge finds the acquittee in contempt of court, consequences could include a warning, paying a fine, or even some jail time. Reasons for contempt of court recommendations to the court could include a series of positive drug tests, leaving the state without permission, or new criminal activity.
Going to the hospital is not always effective. In some cases, inappropriate hospitalization can be counter-therapeutic (such as attention-seekers or antisocial individuals). The CSB should use their clinical judgment, as well as consultation with the Forensic Services staff at DBHDS if necessary, to determine the most appropriate course of action.
The Role of the CSB in Managing Non-Compliance
The CSB and the Revocation Process
The CSB NGRI Coordinator should be involved from the moment revocation is considered. The NGRI Coordinator should take the lead on the revocation process, including:
The CSB and the Contempt of Court Process
First, it is important to do a thorough assessment of the acquittee's non-compliance and potential interventions. If the decision is made that the acquittee does not need inpatient hospitalization, but that the non-compliance warrants court intervention for a contempt of court option, then the NGRI Coordinator should initiate steps to request this option.
This will include writing a letter to the court outlining the nature of the violations and the rationale for the request. It may be necessary to educate the court about the distinction between meeting revocation criteria and contempt of court criteria (willful violations of the CRP that are not going to respond to hospitalization). Be clear with the court what the CSB would like to see happen.
Hopefully, the CSB has communicated all previous violations and non-compliance to the court. CSBs must react to violations of the CRP immediately by informing the court as soon as they have occurred. In the notification, the CSB can request a formal hearing to address the CSB's concerns and discuss sanctions.
Building Relationships and Communication
As with all matters concerning acquittees on conditional release, COMMUNICATION is the key. Decisions regarding non-compliance involve making informed judgment calls and the CSB is not alone. Utilize the resources available.
Often when thinking about the "team," we think about the team of CSB staff and other community providers who work with the acquittee. The CSB also needs to think of the Commonwealth's Attorney and the Defense Attorney as part of the team.
The NGRI Coordinator and, in some cases, the case manager should introduce themselves to the Commonwealth's Attorney and the Defense Attorney and enlist their help in resolving compliance issues. Both were participants in the conditional release process and want the acquittee to be safely managed in the community.
Most importantly, don't forget to utilize the DBHDS Forensic Services Office. They have the "advantage" of information about all acquittees on conditional release statewide and can provide assistance with what has and has not worked in other communities around the state.
The Office of Forensic Services at DBHDS can help the CSB determine if it is necessary to include the hospital Forensic Coordinator in the conversation. Even though they will not be directly involved with the acquittee in the community, in many cases, the Forensic Coordinator has worked with the NGRI acquittee for a number of years and has seen them in good times and bad. They can let you know what medications or strategies worked (or didn't) in the past. They can also be helpful in identifying signs of decompensation or relapse in its earliest stages.
Section 7: Unconditional Release
Criteria for Removal of Conditions
[Pg]87[/Pg]Assessing Readiness for Unconditional Release
[Pg]88[/Pg]The Unconditional Release Process
[Pg]90[/Pg]Communicating the CSB’s Rationale for UCR
[Pg]91[/Pg]Requirements for Closing the NGRI Case
[Pg]92[/Pg]Criteria for Removal of Conditions (Unconditional Release)
§ 19.2-182.11 Criteria For Removal of Conditions:
The criteria leaves a lot of room for interpretation and flexibility. This gives the CSB and the court the ability to make decisions about removal of conditions based upon the unique characteristics of the individual acquittee.
If the criteria for inpatient hospitalization is not met, nor does the individual meet criteria for conditional release that is outlined in § 19.2-182.7, then the court should issue an order for removal of all conditions.
Assessing Readiness for Unconditional Release
Factors Leading to Failure on Conditional Release:
Factors Leading to Success on Conditional Release:
What is Unconditional Release?
While the acquittee is on conditional release, the acquittee may be very interested in having their conditions of release removed and their NGRI status formally terminated by the court. This process is technically called removal of conditions. Another term that is frequently used is “unconditional release”.
The acquittee may want you to tell them “when is it over?” There is no set answer or magic formula. An acquittee can be on conditional release for an indeterminate time, including acquittees with misdemeanant offenses. The time an acquittee should be on conditional release is very individualized. The average time an acquittee remains on conditional release is 3 years.
The CSB staff wants to have credibility with the courts when they make a recommendation for removal of conditions. It is very important for the CSB staff to check with their supervisor and CSB NGRI Coordinator to find out the CSB policy before initiating the unconditional release process with the court.
Remember that acquittees that are released without conditions are no longer under the jurisdiction of the court. Sometimes, the leverage of a court-ordered Conditional Release Plan and remaining under the jurisdiction of the court is necessary for compliance.
Release without conditions and the termination of court jurisdiction occurs only at the committing NGRI court’s discretion. Sometimes there are multiple courts of NGRI jurisdiction. In this case, all the courts involved must remove the conditions of release before it is final.
Knowing When It's Over
The CSB wants the acquittee to be successful after the removal of conditions, not to re-offend and to take responsibility for their mental health and/or substance abuse treatment.
Since release without conditions is the final step in the graduated release process for an insanity acquittee, careful consideration should be given to whether the acquittee is now ready and able to manage his/her mental illness and potential for violence without the court-ordered monitoring of the CSB.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Consideration of the risk factors, the acquittee’s compliance with treatment and medications, adjustment to community living, and the NGRI offense(s) should all be taken into account by the CSB before requesting removal of conditions from the court.
Is the acquittee ready for this step? Does he want his conditions removed? Has the CSB given the acquittee the opportunity to demonstrate more responsibility for their MH/SA treatment through modifications of their CRP? The demonstration model should work in the community too! Always look back to the risk factors identified in the AAB. Examine each carefully, and consider the acquittee's progress in each area, management needs, and whether they are capable of managing each factor without the influence of the court to compel them.
Unconditional release is a huge accomplishment, both for the acquittee and the supervising CSB. A lot of work and time go into working on NGRI cases, and all should celebrate when an acquittee is successful!
The Unconditional Release Process
Who can request it?
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The court of jurisdiction may remove conditions of release upon its own motion or based upon reports from:
1. Supervising CSB/BH
2. Attorney for the Commonwealth
3. The acquittee (may petition only once annually, commencing 6 months after the conditional release is ordered)
What is the CSB's Role?
Typically the CSB is the entity petitioning the court for unconditional release. The CSB may recommend removal of conditions to the court through the six-month report; however, the CSB will need to attach a letter with rationale and to request a hearing date to initiate the process.
What is the Rationale?
Recommendation for removal of conditions should be accompanied with documented reasons for the recommendation. The rationale for the recommendation should address the following areas as appropriate:
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Treatment compliance
No re-offenses – at least none in a very long time
No re-hospitalization episodes or seeks hospitalization when needed
Medication compliant
Strong community support
Acquittee has taken responsibility for and accepts their mental illness/substance abuse
The Order
The court must issue a written order for the NGRI case to be officially closed. The CSB should always obtain a copy of that order and send a copy to the Office of Forensic Services to officially conclude the CSB's reporting responsibilities.
Communicating the CSB’s Rationale for Unconditional Release
Recommendation for removal of conditions should be accompanied with documented reasons for the recommendation. The rationale for the recommendation should address the following areas as appropriate:
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Level of treatment compliance.
The number of re-offenses and the last time a re-offense occurred.
Number of re-hospitalization episodes and last hospitalization.
Whether the acquittee seeks treatment or hospitalization when needed.
Level of medication compliance.
Level of community support.
Whether the acquittee has taken responsibility for and accepts their mental illness/substance abuse.
Make your case to the court when the CSB recommends removal of conditions. Any previous violations should be addressed and reasons the CSB feels the person is still ready for this step despite previous challenges. Write a letter to the court when you feel the time has come to make the recommendation (see sample letters in Appendix E). If the request is being made in the 6-month report, attach a cover letter with a specific request, and include a model order for the judge to sign. The CSB can also request a court hearing to discuss the recommendations.
Requirements for Closing the NGRI Case
This is a collaborative process, so always ask for help if you need it! There will always be situations that arise that are unique or complicated! Plan for the end from the beginning - focus on gradual reduction of supervision as the individual demonstrates readiness for more independence! Good luck!
The court will issue an order removing the conditions of release. Acquittees that are released without conditions by the court of jurisdiction are no longer under the jurisdiction of the court as of the issuance of the order. However, the CSB’s court-ordered responsibility for monitoring the acquittee and for reporting to the court and DBHDS ceases only upon receipt of the signed unconditional release order. Send DBHDS a copy of the order - it’s not over until this happens! You will receive confirmation from the Office of Forensic Services once the order is received.
Section 8: Case Studies
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Case Study #1: “Mr. K” Pg. 93
Case Study #2: “Mr. O” Pg. 95
Case Study #3: “Mr. N” Pg. 97
Case Study #4: “Mr. J” Pg. 99
Case Study #5: “Mr. Q” Pg. 101
Case Study #1
Page 1 of 2
Mr. K is a 38-year-old single (never married, no children) male who experienced his first symptoms of mental illness in 2005, 11 years ago. He was living out of state at the time and sought treatment at his local hospital.
At this time he reported having feelings of déjà vu experiences off and on for the past two years and these experiences were intensifying. He received some medications (unknown) in the emergency room but was not admitted.
He had completed college and had worked full-time ever since. At the time of the NGRI offense, Mr. K was employed full-time in an occupation that required him to travel from state to state.
Mr. K reported that he smoked marijuana once per week and drank alcohol occasionally.
In June of 2007, at the age of 29, Mr. K was hospitalized for 6 days in his hometown. At this time he was experiencing delusions, paranoia, and isolation. Examples of his delusions included the following: beliefs that the television was sending him messages; belief that mythological creatures were trying to entice him to battle; belief that a celebrity on TV wanted to marry him; misinterpretation of numbers to indicate that he was GOD.
Again he received medication but stopped the medication once he felt better. Mr. K contends that he was never instructed to get the medication refilled once he left the hospital.
Mr. K was again hospitalized for one week in January of 2008. Records indicate that upon admission Mr. K reported feeling down, depressed, and crying a lot and that he believed he was not himself. He also expressed beliefs that he had been in the military but that he was not sure.
In actuality, he had been in the Navy for approximately 4 months but was discharged due to reported feelings of suicide. At the hospital he reported that his thoughts seemed jumbled. Records indicate that he was treated with Risperdal and diagnosed with Psychotic Disorder, NOS.
Again, he took the medication until the prescription ended but did not seek a renewal.
In April 2008, at the age of 30, Mr. K was traveling through Virginia and had stopped to get some dinner at a restaurant. He reported feeling very paranoid as if someone was going to harm him. He stated that he believed some of the people in the restaurant looked like devils and were possessed by demons.
Mr. K went back to his vehicle and secured a knife for protection. He reentered the restaurant and sat down to have dinner. Another patron approached him and began a casual conversation. At this time Mr. K responded by pulling the knife and stabbing the bystander to death.
Mr. K left the restaurant but stopped to talk to the cashier on his way out the door as if nothing out of the ordinary had transpired. He was arrested a short time later driving on Interstate-95.
After Mr. K’s arrest he spent time at Central State Hospital for restoration to competency. After receiving medications, he was able to be restored and he was also evaluated for a second opinion sanity evaluation requested by the Commonwealth’s Attorney.
In December 2009 he was found Not Guilty by Reason of Insanity and subsequently committed to the custody of the commissioner to begin the privileging process.
Mr. K’s initial progress in the hospital was slow and was laden with numerous medication changes in order to maximize his treatment efficacy. Psychiatric treatment was complicated with the medical problem of brittle diabetes. Additionally, once Mr. K was stabilized and was able to fully appreciate the gravity of the fact that he had committed murder, he was despondent, isolated, and overwhelmingly remorseful thus requiring further medication adjustments.
He began to work with a therapist to address the guilt and shame that he felt due to his actions. Slowly, Mr. K began to make progress and by November 2011 he was able to receive approval from the Forensic Review Panel for Unescorted Community Visits (up to 8 hours) to a day program.
Although Mr. K’s psychiatric stability remained constant, his insulin levels were unpredictable and often dangerous. At one point his passes for unescorted community were held for two months in order to regain control of his medications for his diabetes.
However, by March 2012 Mr. K was ready to request 48-hour overnight passes. Until that time, he had continued to do well psychiatrically and was especially vigilant of his blood sugar levels and has learned to administer his own insulin and other medications.
After several months, he was able to begin 48-hour passes to a local crisis stabilization facility (because his housing was not yet available). Mr. K has never experienced any aggression or loss of privileges during his hospitalization. He has been totally compliant with all aspects of treatment.
At this time the treatment team and CSB are preparing for conditional release to a shared apartment (with a roommate who is also NGRI).
Page 2 of 2
Case Study #2
Page 1 of 2
Mr. O is a 55-year-old Caucasian male who was adjudicated NGRI for felony arson. He grew up in a rural part of Virginia, dropping out of high school prior to completion due to attendance problems and challenges learning due to an intellectual disability.
He has a limited work history, only maintaining consistent employment for a brief time while enrolled in a supervised work program.
The onset of his illness occurred when he was 21 years old, at which time he started experiencing command auditory hallucinations and suicidal ideation.
Since that time he has been hospitalized on multiple occasions, each the result of treatment non-adherence and rapid psychiatric decompensation.
Over the years, Mr. O engaged in dangerous behavior while psychiatrically unstable. He has a lengthy history of arson and assaulting family members in response to paranoia and command auditory hallucinations, thus his relationship with his mother and siblings is strained.
Despite this, his mother does allow him to live in her home for periods at a time, before kicking him out when he becomes psychotic and then allowing him to return after stabilization at the hospital.
Mr. O has had a long history of treatment with his local CSB. He has a case manager; however, he has not achieved stability, and most of his interactions with the CSB have been through Emergency Services and Acute Care.
His most recent diagnosis is Schizoaffective Disorder, Bipolar Type.
In the months leading up to the NGRI offense, Mr. O stopped taking his medications reportedly because he could not afford them. He did not report this to his case manager at that time, nor did he contact Emergency Services.
He started to experience auditory hallucinations and paranoia that others were laughing at him. He set fire to his mother’s home in an attempt to get rid of the “demons and voices.”
Mr. O was found Not Guilty by Reason of Insanity in 2013 for arson. He has been hospitalized for three years.
During the course of his hospitalization he has been adherent to his medications and he has not had any residual symptoms of his illness. There have been no episodes of aggression. While he attended treatment programming both in the hospital and the...
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
Community on escorted and unescorted 8-hour passes, his participation has been minimal. While he has acknowledged having a mental illness that requires continued treatment, he has limited insight with regard to benefits of medication and/or consequences for stopping the medication.
He has struggled with identifying structured activities that are meaningful to him, and thus chooses to attend day treatment five days per week. Mr. O has completed 48-hour passes successfully to an assisted living facility, although he has difficulty accepting that he needs this level of residential care and often speaks about his eventual discharge to an apartment.
However, his passes have been uneventful and staff at the ALF report that he is doing well and interacting with his peers. At this time, the treatment team and CSB are preparing for conditional release.
Section 2: The Temporary Custody Period & Outcomes
Mr. N is a 37-year-old single (never married, no children) male who experienced his first symptoms of mental illness at the age of 16 and subsequently was hospitalized on three occasions and received medication.
Mr. N was in special education throughout his primary and secondary education. He was diagnosed with borderline intellectual functioning and doctors believed he was experiencing symptoms of Schizophrenia. Precursors to hospitalizations included feelings of paranoia and impulsiveness regarding thoughts of harm to self or others.
On one occasion, Mr. N attempted suicide by cutting his wrists because the voices told him to do so. Mr. N was always compliant with his medications but at times his mother had difficulty refilling prescriptions due to lack of funding.
At the time of his NGRI offense in 1997, Mr. N, then 18, reported feelings of isolation as his older sister had left home for college and his dog had recently died. He was unable to get his medication refilled. He began to experience sounds and visions that he could not understand (auditory and visual hallucinations).
He was frustrated that his sister had abandoned him and could not stand living in his mother’s home another day. He expressed that the house was closing in on him so he believed that if he burned down the house he would be free. He set the house on fire and then went next door to a neighbor and called 911. A few days prior to this offense, he had also set fire to a neighbor’s porch but no charges were filed.
Mr. N was found Not Guilty by Reason of Insanity and was committed to DBHDS in November 1997 and subsequently admitted to Central State Hospital under temporary custody. He was eventually transferred to a civil hospital where he remained hospitalized for the next 19 years.
Mr. N’s initial progress in the hospital was very slow. He often engaged in attention-seeking behaviors highlighted by increasing somatic complaints and threats of suicide. Due to his cognitive impairment, his understanding of his symptoms and the NGRI process is also limited.
Mr. N has had several altercations with staff during his hospitalization. One such altercation resulted in charges being filed for assault and a sentence of 120 days in jail, all of which was suspended.
His lengthy hospitalization coupled with his cognitive impairment has created an environment of dependency and fear of leaving the hospital. When he begins to near the point of conditional release, he will begin acting out and threatening suicide, which has slowed the process of release.
As a result of this, he also requires frequent prompting and reassurance in order to gain full compliance and participation with treatment. He has been medication adherent and enjoys attending groups and activities. He has no history of substance use.
After a lengthy process, he achieved the privilege level of Unescorted Community - 8 hour passes, which he used to attend a psychosocial day program operated by the CSB 4 days per week (and by all accounts has been very active there).
Mr. N is notorious for giving away his money to peers. Although Mr. N has made progress in understanding his mental illness, the need for medication adherence, and some living skills such as personal hygiene, he continues to demonstrate poor interpersonal skills which make him vulnerable to exploitation.
He also has a very low frustration tolerance and higher levels of anxiety that require frequent reassurances from staff. Over the course of his hospitalization, his diagnoses were modified to Schizophrenia, Disorganized Type, Borderline Intellectual Functioning, and Personality Disorder, Dependent Type.
At this time, he has begun 48-hour passes to a local supervised group home, where he will ultimately be conditionally released. It appears that he is excited about this placement (he reports that he will be living with friends that he knows from the day program) and he has not demonstrated any of the previous attention-seeking behaviors that have stalled his progress in the past.
The team and CSB have begun to draft the conditional release plan and will move forward with that request after two more 48-hour passes to the group home.
Section 3: Commitment & the Graduated Release Process
Mr. J is a 41-year-old married male who experienced his first symptoms of mental illness in 1997, at the age of 22. He spent most of the early years of his illness untreated, experiencing episodes of anger, mood changes, and some psychotic symptoms.
He was living with his parents at that time, and eventually was hospitalized and treated with medications. During that hospitalization, he was diagnosed with bipolar disorder. Upon discharge, he continued his medications; however, in the years following, he would often stop medications and resume after an incident that prompted police intervention.
He also struggled with substance use, which led to several arrests for possession of controlled substances or driving while intoxicated. He eventually married, and resided in an apartment with his wife for several years prior to the NGRI offense in 2013.
He has a spotty employment record, mostly part-time employment and often of short duration. Eight months prior to the NGRI offense, he reportedly went on a 7-day amphetamine binge, subsequently becoming paranoid and possibly experiencing auditory hallucinations.
He was boarding up his apartment, plastering holes in the ceilings, and claiming cameras were watching him. His NGRI offense occurred when he assaulted his wife and the responding police officer, for which he was charged with one count of misdemeanor assault and battery and one count of felony assault on a law enforcement officer.
He was first admitted in 2013 to the state hospital from jail for competency restoration prior to his trial. On admission, he was suspicious and guarded. He refused to answer questions, was isolative, and his behavior was bizarre. Upon admission, he was detoxing from benzodiazepines. He had limited insight, and reported that he was arrested for no reason.
He was initially diagnosed with Amphetamine Induced Psychotic Disorder. According to the psychiatrist, his history was consistent with substance abuse problems and personality disorder.
Mr. J also had a history of some mood disturbance that included impulsive outbursts of aggression, some depressive symptoms, and reported psychotic symptoms. At the time of discharge back to the jail following his restoration to competency, he was diagnosed with Schizoaffective Disorder, Bipolar Type.
Mr. J was later found NGRI and committed to the custody of DBHDS in January 2014.
Upon his current admission, Mr. J complained of nicotine addiction as he was smoking several packs of cigarettes a day prior to incarceration and state hospital admission. He was prescribed nicotine chewing gum, a nicotine patch, and was requesting additional nicotine withdrawal support.
He initially demonstrated some denial of mental illness and denial of substance abuse, and often refused to participate in group activities and treatment team meetings. His privileges were often suspended due to rule violations, such as bringing cigarettes into the facility after passes.
Although his mental illness was well managed with medications, he continued to deny substance abuse problems and tended to minimize his need for treatment. He has been prescribed mood-stabilizing medications, which appear to have had positive results on his mood swings and angry outbursts, and he has been adherent to his medications.
Upon approval of his unescorted community visits, he was able to obtain part-time employment as a mail clerk at a local engineering firm and began to work on GED courses.
Mr. J has maintained a relationship with his wife, who appears to be supportive and willing to have him return home upon discharge. He was eventually able to successfully use his 8-hour and then 48-hour passes.
Despite his ongoing minimization of his substance abuse issues, he reports that he will comply with all conditions and has been able to manage at greater levels of independence through the privileging process.
At this time, the treatment team and CSB are preparing a conditional release plan and will submit a request to the FRP.
Section 4: Additional Case Studies and Outcomes
Mr. Q is a 28-year-old single, separated male with three children from two separate relationships. Mr. Q has no established history of major mental illness, and had never struggled with psychiatric illness in the past.
The sanity evaluation conducted prior to his acquittal indicated that a late-onset mental health condition was likely and that it directly resulted in the NGRI offense.
In the events leading to his arrest and subsequent NGRI finding, he experienced several incidents of substance-induced domestic assault on his partner and his mother-in-law; these were the most recent in a series of domestic assaults, all primarily occurring during times of intoxication, but have occurred in the absence of substance abuse as well.
At the time of his NGRI offense, Mr. Q reported “hearing voices” and feeling that he was “commanded” to assault his family members, as they were “going to hurt my children.” Mr. Q was found Not Guilty by Reason of Insanity in 2002 and subsequently committed to DBHDS.
Later, while hospitalized, it was determined that, while possibly predisposed to psychiatric symptoms under certain situations, the symptoms he experienced were likely due solely to substance abuse at the time of the offense.
Mr. Q was transferred between three state facilities over the course of his hospitalization due to ongoing issues with violence toward staff and peers, and general non-compliance.
During his current civil hospital placement, a more pro-social approach to treatment was taken, expressly based on forming therapeutic alliances, and he began to establish the first therapeutic relationships since his NGRI commitment.
He was entrusted with more freedoms and he seemed to do better with a collaborative approach than with a corrections approach of consistent negative consequence for maladaptive behavior.
He remained psychiatrically stable and over a period of several years, achieved the Unescorted Community - 8 hour pass level and began working full time in the community. He reestablished relationships with family members, and adhered to hospital rules.
He engaged in individual therapy to address antisocial behavior, specifically domestic violence, and through prosocial treatment, began to understand the benefits of sobriety and prosocial living.
He took pride in his AA/NA participation and built a very healthy support system through the AA/NA community. Previously noted as having a weak self-concept, he gravitated to AA/NA principles and appeared to integrate them into a stable identity.
He progressed to the point of initiating...
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
and then facilitating his own AA group in the community.
During times of stress in particular he continued to push boundaries in the hospital and act against his treatment providers, but a flexible approach that highlighted support was typically successful in preventing these periods from escalating into patterns.
His treatment team and CSB were able to locate a housing placement at an adult foster home, where he was able to complete his 48-hour passes.
The team is now preparing to submit a request for Conditional release.
Section 9: Appendices
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Appendix A: NGRI Process Flow Chart Pg. 103
Appendix B: Sample AAB & AAB Update Format Pg. 106
Appendix C: Sample Risk Management Plans Pg. 117
Appendix D: Conditional Release Plan Template/Samples Pg. 123
Appendix E: Sample Letters to the Court Pg. 151
Appendix F: Monthly Report Instructions & Template Pg. 159
Appendix G: Six-Month Review Instructions & Template Pg. 164
Appendix H: Sample Unconditional Release Plan Pg. 170
Appendix I: Model Court Orders Pg. 173
Appendix J: Relevant Code Sections Pg. 186
Appendix J: Facility/DBHDS Forensic Services Contact List Pg. 197
Appendix B: Format for Initial AAB
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1. Identifying Information
2. Purpose of Evaluation
3. Statement of Non-confidentiality
4. Sources of Information
5. Relevant Background Information
6. NGRI Offense
a. Acquittee’s Account of the NGRI Offense
b. Collateral Accounts of the NGRI Offense
Recent Adjustment Behavioral Observations and Mental Status Examination Psychological Testing Results/Personality Dynamics Diagnostic Impression 7. Patient Strengths Which Mitigate the Probability of Future Aggression 8. Analysis of Aggressive Behaviors
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a. Description and Current Status of Risk Factors
b. Means of Addressing Risk Factors
Sample Initial Psychological Evaluation and Analysis of Aggressive Behavior
Name: Mr. N. Sanity
Acquittee SS#: XXX-XX-XXXX
Date of Birth: 3/17/56
Age: 43
Sex: Male
Reg. #: XXXXXX.003
Marital Status: Divorced
Education: High School Grad
NGRI Offense: Murder
Case No.: 99-XXX
Date of NGRI Adjudication: 11/12/1999
Date of Admission: 11/17/1999
Court: Circuit Court, City of Smalltown
Judge: Honorable He B. DeJudge
Date of Report: 12/17/1999
Purpose of Evaluation: Mr. Acquittee was adjudicated Not Guilty by Reason of Insanity (NGRI) pursuant to Virginia Code Section 19.2-182.2 on 11/12/99, having been charged with murder.
This is the report of a routine assessment protocol for newly admitted patients who have been found NGRI. This report will focus on the patient’s current psychological functioning, the risk of aggression, and recommendations for the management of risk.
Mr. Acquittee was informed concerning the purpose of this evaluation and the limits of confidentiality. He indicated that he understood these limits and agreed to proceed under these conditions.
Sources of Information:
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1. Clinical interviews conducted in the Maximum Security Unit of CSH.
2. Review of the patient’s current CSH medical and legal records.
3. Consultation with the patient’s current CSH treatment team.
4. Review of Forensic Evaluation of Mr. Acquittee’s Mental State at the Time of the Offense completed by Dr. Knowitall and dated 11/10/99.
5. Review of Evaluation of Legal Sanity conducted by Ms. Snickers, and Drs. Bruce Good and Gary Plenty, dated 10/20/99.
6. Review of records from the Marion Correctional Treatment Center.
7. Review of records from two admissions to the Smalltown Regional Medical Center (SRMC).
8. Results of psychological testing with the WAIS-III, MMPI-2, MCMI-III, the RRASOR, and the PCL-R, Thematic Apperception Test (TAT).
Statement of Non-confidentiality:
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The purpose of the evaluation was explained to Mr. Acquittee.
He was told that a report would be developed concerning his psychological functioning to include analysis for possible aggressive behavior and that this report would be utilized in treatment planning as well as by individuals reviewing his situation for increasing privileges.
He was also told that this report could be seen by court officials.
He indicated that he understood and agreed to continue with the evaluation.
Relevant Background:
Mr. Acquittee was born as the younger of two boys into a middle class family. He was born with jaundice and several allergies, and has been described by his mother as a “sick baby.” The family relocated several times in the Southeast United States during Mr. Acquittee's childhood due to his father’s job. When he was five months old, Mr. Acquittee was left with his aunt as the family moved to Louisiana, reportedly due to his mother’s concern about the child’s ability to tolerate the climate. Mr. Acquittee was reunited with his family at some point, and they spent the greatest amount of time living in the Maryland area. Mr. Acquittee suffered an allergic reaction to penicillin at age ten which caused his body to swell, and he then contracted typhoid fever at age 14 and mononucleosis at age 18. Mr. Acquittee has reported that he made average to above-average grades and had little conflict with teachers or peers. Mr. Acquittee reported that he was suspended once in 8th or 9th grade for skipping school. He graduated in 1975 and enrolled in the University of Maryland but instead of attending college, he began working and subsequently got married. Mr. Acquittee has worked a number of different jobs, including construction work, stocking supplies, delivering office equipment, selling life insurance, carrying U.S. mail, doing factory work, and delivering pizzas. He has had frequent financial difficulties with credit problems that he attributed to “living beyond my means.” Mr. Acquittee has abused alcohol and marijuana on occasion, but has not shown symptoms of dependence. His pattern of abuse appears to include occasional weekend binges during young adulthood with declining substance abuse as he has grown older. He was reportedly drinking the night of the NGRI offense, but was not considered intoxicated by arresting officers. The patient and his wife had significant marital problems, resulting in a legal separation in the summer of 1988 after approximately 13 years of marriage. Reports indicate that the defendant was using alcohol extensively and was physically abusive to his wife. The marital conflict culminated in an incident that Mr. Acquittee refers to as a “misguided attempt at reconciliation.” Mr. Acquittee was convicted of rape and served four and a half years in the Virginia Department of Correction (DOC), primarily at the Bland Correctional Center. Mr. Acquittee's adjustment to the DOC was poor. He was engaged in several fights, one involving a knife. He admitted to instigating some of these fights. He participated in a sex offender treatment program for a time until he was requested to sign a “contract” committing to the principles of the program. He became suspicious of the contract, refused to sign, and was returned to general population. At this time, Mr. Acquittee became increasingly paranoid and began to search his environment for signs and signals of any impending danger. He also began to believe that God was sending him messages through the television and radio. Records of psychiatric treatment (during and after his incarceration) support the patient’s claim that he did not hear voices. Mr. Acquittee has subsequently described obsessional and delusional thinking about the meaning of signals, scriptures from the Bible, and whether the food or water was being poisoned. Some delusions were of a sexual nature, like his belief that he saw a “naked woman” on television, and when he sent a signal to her, she somehow returned his signal. His behavior became more bizarre and uncooperative with correctional officers, and on 10/27/94 he drank some cleanser and rubbed his face and eyes with the cleanser. Mr. Acquittee has reported that this was in response to obsessions, self-harm, and delusions about his sinfulness and need for “cleansing” rather than an attempt at self-harm. On 10/31/99 he attempted to grab a nurse’s crotch. Mr. Acquittee was admitted to the Marion Correctional Treatment Center (MTCT), the psychiatric inpatient setting for DOC inmates, on 11/8/94. He was described as extremely paranoid and was once considered “too regressed” to speak with his parents when they came from Florida for a visit. He was also described as masturbating compulsively and attempted, in separate incidents, to grab two more female nurses in the crotch and, on 11/15/94, he grabbed the crotch of a female officer. During his incarceration, he reported that he grabbed at female crotches in order to allay rumors that he was homosexual. More recently, Mr. Acquittee has attributed these actions to psychotic experiences (e.g., believing he was receiving messages or signals from the females). Mr. Acquittee also engaged in an incident described as “inappropriate touching” of a female laboratory assistant’s breast during an admission to the Riverside Liberty Forensic Unit. Mr. Acquittee reported that he took medication offered to him at the MTCT, though records indicate that he may have been “cheeking” his medication some of the time. His mental status improved, but he remained in the MTCT until his mandatory parole date of 9/30/95 when he was released to the community. His diagnoses were Axis I: Dysthymia and Axis II: Borderline Personality Disorder. Mr. Acquittee was next hospitalized at the Smalltown Regional Medical Center (SRMC) on 1/13/97 after he became agitated and was banging his head in his rented room. He’d been living in Smalltown, VA, and working at the Skinny River Mills factory since his release from prison. He has described being religiously obsessed and delusional concerning the identity of people around him and concerning persecution by the devil. Records indicate that he did not express delusions and he was discharged with a diagnosis of Depressive Disorder, not otherwise specified. Neurological studies (EEG) found no evidence of a seizure disorder. In April of 1999, Mr. Acquittee experienced several days in which the radio and television appeared to be sending messages to him. He again became religiously obsessed and “broke down” emotionally at work, crying and trembling and pleading for help. He was readmitted to SRMC on 4/19/99 where he was initially tremulous, mute, and “catatonic.” He was treated with Ativan and discharged on 4/22/99, the day of the NGRI offense. Mr. Acquittee apparently did not reveal any delusional or confused thinking prior to discharge, though his later accounts report that he was experiencing delusions concerning how his posture (e.g., not crossing his legs) affected his relationship to Christ and that he was listening to the radio for messages from Christ.NGRI Offense:
Mr. Acquittee was charged with Murder for the stabbing death of his father. From the reports of the patient’s mother and the arresting officer (as detailed in the Sanity at the Time of the Offense evaluation completed by staff of the Institute of Law, Psychiatry and Public Policy, dated 10/20/99), the patient was eating dinner with his mother and father when he began to look “like a caged animal” to his mother. He appeared menacing and held the steak knife he’d been eating with. After his father told him to put the knife down, Mr. Acquittee lunged at his father and began stabbing him in the crotch. Mrs. Acquittee called the police and the patient lay on the floor and began to cry. His father got on top of him and attempted to take the knife away from him, but the patient just slung his father off of him and continued to hold the knife. At this point, Mrs. Acquittee went outside the apartment to get help and neighbors entered the scene to find Mr. Acquittee stabbing his father in the chest area several times and saying, “You better not do this again.” As noted in theNot Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
During the sanity evaluation, the patient “appeared unresponsive to calls for his attention and soon after the stabbing he was witnessed standing over his father shaking.” The police soon arrived and reported hearing neighbors say “Hurry up, he’s killing him,” and then entered the apartment.
The patient was noted to be standing over his father with a knife. The victim was bleeding from the groin area. The officer instructed Mr. Acquittee to drop the knife, and Mr. Acquittee began to walk toward him. He was again instructed to drop the knife, and this time he did drop the weapon and was placed under arrest.
At the police station, the patient was observed rocking back and forth in a chair with his eyes closed, and he had urinated in his pants. Mr. Acquittee has reported difficulty remembering exactly what happened to trigger his attack on his father.
In a written account of his memory of the relevant events, which he prepared at the suggestion of his attorney, Mr. Acquittee described believing his father was the devil who’d taken on human form, and wondering if his “father” had always been the devil in disguise.
He reported trying to remember how the devil had managed to appear in the Garden of Eden and how the devil had entered Judas Iscariot at the Last Supper. Then Mr. Acquittee described his father as standing “too close” and striking out at him with the knife.
He recalled thinking, as he stabbed his father, that the devil had made himself vulnerable by taking on human form. Mr. Acquittee indicated that he felt like Jesus being crucified when he was arrested.
He recalled the story of Jesus being offered vinegar while on the cross and felt that he should experience a similar humiliation and urinated on himself. Mr. Acquittee reported that he had been drinking “heavily” that day.
Course of Hospitalization
At Central State Hospital, he has been diagnosed with Psychotic Disorder, NOS, Rule Out Schizophrenia, Paranoid Type/Delusional Disorder. He has also had diagnoses in the past including Dysthymia, Depressive Disorder, and Borderline Personality Disorder with paranoid and antisocial features.
Mr. Acquittee has been generally calm and cooperative during this hospitalization. He has taken medication as prescribed, despite some doubts about how necessary this was or whether this was the correct medication or not.
He has shown great concern that potential “errors” in his record be corrected; specifically, he expressed concern that he would be inaccurately diagnosed as having a substance abuse disorder, and that “malingering” was mentioned in some of his initial evaluations, despite the ultimate finding that he was Not Guilty by Reason of Insanity.
Although he has expressed remorse for “what happened,” the patient has shown a great deal of concern about how he is perceived by others.
Mr. Acquittee has attended all treatment groups that were recommended and has filled other time by playing cards and reading.
Current Mental Status
Mr. Acquittee was generally well-groomed and healthy-looking Caucasian male with a moustache and “salt-and-pepper” graying dark hair. He was fully alert and oriented throughout the evaluation and showed no impairment in memory or concentration.
His speech was coherent and goal-directed, though he had a distinctive “roundabout” way of speaking (his word) which seemed at times evasive but more often appeared circumstantial.
He usually hesitated before responding to a question and did not offer a great deal of detail about the circumstances of any given event, and found it difficult to briefly summarize his memories of past events.
On an occasion in which he did respond quickly and to the point, he then commented, “I regret having answered so quickly,” and proceeded to offer additional details which clouded the picture somewhat.
It was frankly difficult to determine whether Mr. Acquittee was offering numerous details to minimize the seriousness of past events, to avoid responsibility, or because he was showing mild symptoms of a thought disorder marked by tangential and circumstantial speech.
He did acknowledge that this has been his style for his entire adult life, and that his ex-wife used to complain about not being able to “nail him down” on anything.
Mr. Acquittee did not show any signs of delusional thinking, and was able to identify and describe past delusions.
He denied that he was currently hearing voices or that he had ever heard voices. He denied ever seeing things and did not appear to be actively hallucinating during the interview.
His mood was calm and he showed a full range of affect during the interview. Mr. Acquittee's affect was generally appropriate except that he seemed unusually confident and calm, given the circumstances.
He denied and showed no evidence of suicidal thinking.
Mr. Acquittee described having bouts of depression throughout his life. He indicated he had experienced vague suicidal thoughts in the past, but had never developed a plan and never really considered actually completing the act.
He indicated that his reason for drinking some cleanser and rubbing the cleanser in his eyes while incarcerated was his delusional belief that he could protect himself from the devil if he “washed his mouth out,” rather than an attempt at self-harm.
He denied having any homicidal thoughts at present.
The patient showed some insight into and understanding of his mental illness, though this would best be described as incomplete.
When asked to describe the warning signs of a psychotic episode for him, Mr. Acquittee said “An insidiously increasing change in perception as to the relevance of things in the environment.”
This is a reasonable description of the gradual onset of paranoid and delusional thinking which Mr. Acquittee appears to have experienced on three separate occasions (10/94 while incarcerated, 1/98 and 4/99).
He then went on to describe an example of, for instance, hearing staff jangle keys and not being able to tell whether a) it was just a coincidence that a number of people were doing it at once or b) it was an intentional experiment to see how he would react or c) he notices them more because he’s looking for signals and special messages in his environment.
He indicated that at present he was not experiencing the problem with alternative c), but he was unable to recognize the paranoid quality of alternative b).
Mr. Acquittee also indicated that he was concerned that he could not know for certain that his symptoms were currently under control because he was not taking the right medicine for him, and he believed that he could help control his symptoms through the use of cognitive rational-emotive self-treatment.
The patient indicated that he believes that he was receiving inspiration from God in committing the NGRI incident.
He currently exhibits little insight. He believes the incident "should be considered a religious experience" and he then stated he intended to read the Bible this whole year so that he would know better.
His memory appeared intact as indicated by his capacity to recall the will of God, his immediate, recent, or remote events. There was no indication of cognitive impairments.
Results of Psychological Testing
The defendant was given the WAIS-III, an individually administered test of intelligence. On this instrument, he scored a verbal IQ of 117, a performance IQ of 106, and a full-scale IQ of 111. This places him in the High-Average Range of intelligence.
On the reading component of a screening test of academic achievement, he scored on a high school level.
Results of previous testing conducted at the MTCT during his incarceration and then at the Riverside Liberty Forensic Unit during his pre-trial evaluation period have shown a consistent pattern of attempting to present himself in the best light while minimizing any problems or shortcomings he might have.
He completed the MMPI-2 at the MTCT which, in addition to the minimizing of his problems, showed a pattern consistent with individuals who are rebellious toward authority and often have stormy or conflictual relationships with family and friends.
Individuals with similar scores are often impulsive and act without adequate planning or consideration of the consequences of their actions.
The patient completed the MMPI-2 and the MCMI-III for his 10/20/99 evaluation at the Riverside Unit and showed a guarded response pattern, and unwillingness to admit common shortcomings.
The MMPI-2 showed some tendency toward tightly controlling and inhibiting socially unacceptable responses, especially hostility and aggression, in direct contrast to his recent behavior.
The acquittee, also on the MMPI, scored similar to those individuals experiencing paranoid symptomatology and who have a need to blame others for their problems, denying and minimizing their role in their difficulties.
Such individuals have also been shown to exhibit loss of reality contact and psychotic symptomatology.
On the Thematic Apperception Test, the acquittee exhibited signs of underlying depression and feelings of inadequacy and hostility.
Mr. Acquittee again completed the MMCI-III for the current evaluation. The results indicated a distinct tendency toward avoiding self-disclosure which could be a characterological evasiveness or a general unwillingness to avoid disclosure of a personal nature.
It is noted that the patient has been described as vague and evasive throughout his adult life.
The Psychopathy Checklist-Revised (PCL-R) was completed using a combination of clinical interview and collateral information. This test reflects the relative degree of psychopathy or antisocial tendencies reflected in an individual’s behavior and history.
Mr. Acquittee's overall score of 12 is greater than 16% of adult male forensic patients, and is in the low range.
His score on Factor 1 of the PCL-R, which reflects a selfish, callous, and remorseless use of others, is greater than 55% of male forensic patients, which is in the moderate range and suggests that this pattern of interpersonal relationships may be clinically significant.
The patient’s Factor 2 score, which reflects a chronically unstable and antisocial lifestyle, was in the 9% range, which is a low score.
This pattern of scores does not reflect the presence of significant psychopathy but may be associated with individuals who show features of other personality disorders such as Narcissistic or Borderline personality traits.
The Rapid Risk Assessment for Sexual Offense Recidivism (RRASOR) was completed, which is a screening instrument used as an actuarial method for assessing future risk for sexual re-offending.
Mr. Acquittee's score is associated with a 4.4% rate of recidivism in a five-year period, which is considered a low score.
Diagnostic Impressions
The evaluation indicates that Mr. Acquittee has experienced a Psychotic Disorder, NOS, with paranoid features, e.g., delusions.
He also has signs of Depression and exhibits features of Narcissistic, Paranoid, Antisocial, and Borderline Personality Disorders.
The acquittee has also had significant problems with alcohol.
Features of (Strengths) which Mitigate the Probability of Future Aggression:
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Mr. Acquittee has several characteristics which could contribute to a decrease in the probability of future aggression.
He is a high school graduate with some college, and on a test of intelligence, he scored within the High-Average Range.
When stable, he exhibits no indications of neurological/cognitive impairment.
In addition, Mr. Acquittee has the capacity to exhibit good social skills. He is articulate and can express himself well when stable.
These positive factors could be integrated into treatment and in the development of vocational/training for Mr. Acquittee.
Analysis of Aggressive Behavior/Risk Factors
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1. Mental Illness (FIMS - Major Mental Illness)
[a.] Description of Risk Factor
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
and Current Status : Mr. Acquittee shows a highly atypical pattern of symptoms of mental illness. This pattern includes paranoid and delusional thinking, sometimes associated with bizarre and ritualistic behavior.
He first experienced these symptoms when incarcerated at the age of 39. He denies ever having experienced auditory hallucinations, but reports experiencing delusions that he was receiving messages from the television and radio and beliefs that he could protect himself from persecution by the devil through certain ritualistic behaviors.
These symptoms include Threat/Control Override symptoms in which Mr. Acquittee believes he is threatened by the devil, delusions that were related directly to the NGRI offense. Mr. Acquittee has exhibited symptoms of a Psychotic Disorder, NOS with paranoid features.
Mr. Acquittee also shows features of Narcissistic, Borderline, Paranoid, and Antisocial Personality disorders, including consistent irresponsibility, impaired empathy for others, careless disregard for others' safety, impulsivity, an exaggerated concern for how he is perceived by others, and the perception of threat or attack in benign remarks or events.
B. Means of Addressing Risk Factor
Mr. Acquittee should continue to receive antipsychotic medication and participate in group therapies designed to help him identify and understand the symptoms of his mental illness.
Individual psychotherapy in the context of external limits on behavior is considered the treatment of choice for long-standing personality disorders.
Differential diagnosis will be important to determine whether or not the defendant has an actual schizophrenic process or if his behavior is more of a function of severe personality dysfunction with possible psychotic features.
At this time, it appears the defendant is in need of inpatient hospitalization given that he continues to exhibit signs of psychosis.
2. History of Physically Aggressive Behavior: (FIMS - Aggression/Dangerousness to Others)
A. Description of Risk Factor and Current Status
Mr. Acquittee has exhibited significant acts of aggression in the past. He reportedly was physically abusive to his wife and had gotten in fights in prison.
In addition, his inappropriate sexual behavior appears to have an aggressive component to it.
The NGRI act itself involved the stabbing of his father multiple times in the crotch and chest.
Psychological assessment indicates that he experiences significant hostility. His paranoia and emotional instability contribute to an increased probability of aggression.
This history of aggression and psychological functioning places Mr. Acquittee at risk for future aggression.
B. Means of Addressing Risk Factors
Mr. Acquittee's aggression appears to be, at least partially, related to significant personality disturbance and can be exacerbated by periods of psychosis.
It is imperative that Mr. Acquittee remain on his medication to control emotional instability and distorted thinking.
Mr. Acquittee should participate in Anger Management group in which he would identify the triggers to aggression and alternative behaviors.
Assumption of responsibility for acts of aggression and for preventing future acts of aggression should be addressed directly with Mr. Acquittee.
Individual therapy could assist in helping Mr. Acquittee explore the source(s) of his anger and vent his hostilities in a controlled environment.
It should be made clear to Mr. Acquittee that inappropriate aggressive behavior can result in negative outcomes for him, including possible legal ramifications.
Issues related to sexual aggression are discussed below.
3. History of Sexually Aggressive Behavior: (FIMS - Sexual Assault)
A. Description of Risk Factor and Current Status
The acquittee has a history of inappropriate and aggressive sexual behavior towards females. He reportedly raped his wife and has on four different occasions attempted to grab female staff in the crotch.
He has also been described as having approached females aggressively as possible compensation for issues of sexual identity.
Past reports indicate that he has exhibited excessive masturbation.
This pattern suggests a tendency towards sexually preoccupied aggression that is sometimes in the presence of psychosis.
B. Means of Addressing Risk Factor
Mr. Acquittee should participate in a complete Sexual Offender Evaluation despite his low score on the RRASOR.
Given his past history of aggressive sexual behavior, intervention directed towards assisting the acquittee in more effectively dealing with hostile feelings and aggression, as indicated above, may also prove beneficial relevant to his sexual activity.
Adherence to his medication regimen is also important.
Group work directed towards appropriate sexual conduct in relating to the opposite sex is also recommended, as well as individual psychotherapy to assess, and if appropriate, to intervene relevant to sexual concerns.
4. Denial of Mental Illness: (FIMS - Denial/Lack of Insight)
A. Description of Risk Factor and Current Status
The acquittee reportedly tends to minimize and deny his role in his difficulties.
Psychological testing indicates he tends to project blame onto others, not accepting responsibility for his actions.
He evades questions through becoming circumstantial.
He also doubts the necessity of his medication and believes that his behavior during the NGRI incident was justified, e.g., he was acting for God.
Therefore, the defendant at this time seems to have little insight into his illness.
This represents a risk factor in that he may, under similar circumstances as those surrounding the NGRI incident, react in the same manner as he did during the NGRI offense, exhibiting inappropriate aggressive behavior.
B. Means of Addressing Risk Factor
It is recommended that the defendant be maintained on his medication and participate in individual and group therapy to address his denial and minimization of his symptoms.
It is important that he develop some insight into the fact that his symptoms can be destructive and are a component of his mental illness.
5. Non-Compliance with Treatment: (FIMS - Noncompliance with Treatment and/or Medication)
A. Description of Risk Factor and Current Status
Mr. Acquittee did not participate in follow-up treatment for mental illness following his discharge from either the MTCT while incarcerated or from the SRMC.
When asked about his legal history during his last admission at the SRMC, he refused to discuss his incarceration and did not reveal that he was treated for psychosis or that he was experiencing psychotic symptoms.
During the present evaluation, Mr. Acquittee questioned how, in fact, he could be sure that he needed medication or if he was on the right medication.
He has been suspected of "cheeking" his medication in the past.
Given this, it is likely that, particularly under stress, Mr. Acquittee would be at risk for not taking his medication.
B. Means of Addressing Risk Factor
Mr. Acquittee should participate in Symptom Management and Understanding Mental Illness groups in which the importance of accepting the need for psychiatric treatment is addressed.
Mr. Acquittee would also learn to identify his symptoms, warning signs of relapse, and appropriate interventions for relapse prevention.
It is also important that he maintain his medication compliance, and this compliance should be monitored.
6. Substance Abuse: (FIMS - Substance Abuse)
A. Description of Risk Factor and Current Status
Mr. Acquittee has used alcohol in the past and has been aggressive under the influence of alcohol.
He has also reportedly used marijuana in the past.
He was drinking alcohol at the time of the NGRI offense.
Although he currently does not appear to be experiencing alcohol or substance dependence, any substance use, however, increases the risk of future aggression.
Alcohol can disinhibit emotional control and places one in contact with other individuals who are likely involved with alcohol or drugs and illegal activity.
In addition, substance use can impede psychological growth and can cause neurological damage.
Given the defendant's history of substance involvement, especially alcohol, and the fact that he was using at the time of the NGRI incident, alcohol use represents a particular risk factor for Mr. Acquittee.
B. Means of Addressing Risk Factor
It is recommended that Mr. Acquittee participate in a Substance Abuse Education and Relapse Prevention group to gain information about the importance of remaining drug and alcohol free, despite the likelihood that he does not suffer from a dependence on alcohol or drugs at this time.
When the defendant is no longer in a controlled environment, it is particularly imperative that he is not involved with alcohol/substance abuse.
At that time, random drug screens may be necessary, as well as continued intensive programming for substance abuse depending upon clinical need.
Clare Quilty, Ph.D. Licensed Clinical Psychologist
Forensic Unit, Central State Hospital
12/17/1999
Format for Updated AAB
It is generally not necessary for an Updated AAB to have all the components of the Initial AAB due to the fact that it is usually part of a more comprehensive report (e.g., submission to the Forensic Review Panel, Annual Confinement of Hearing Report, etc.) which already contains relevant background information, mental status, and other information that would complete the report as "stand alone."
The Updated AAB, when part of another submission/report, should minimally include the following:
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1. Identifying Information
3. Risk Factor Updates
a. Description of Risk Factor
b. Update and Status of Risk Factor
c. Means of Addressing Risk Factors
117 | P a g e
Appendix C SAMPLE RISK MANAGEMENT PLAN - ESCORTED COMMUNITY VISITS
Acquittee, , will be provided escorted community visits to attend the following activities: (PROGRAM/ACTIVITY) (DURATION) (FREQUENCY)
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A. The acquittee agrees to abide by all municipal, county, state, and federal laws while on escorted community visits.
B. The acquittee understands that he/she remains an acquittee of Western State Hospital and under the legal control of the judge maintaining legal jurisdiction over him/her.
C. The acquittee agrees not to leave the Commonwealth of Virginia while on escorted community visits.
D. The acquittee understands that any person placed in the temporary custody of the Commissioner pursuant to 19.2-182.2 or committed to the custody of the Commissioner pursuant to 19.2-182.3 who escapes from such custody is guilty of a Class 6 felony. Thus, if there is an escape, the acquittee will face criminal charges.
E. Prior to permitting the acquittee to leave the ward on escorted community visits:
[a.] Physician will provide order for escorted community visits.[/a.]
[a.] RN will ensure acquittee is screened for the presence of any inappropriate thoughts and/or behavior which might place either the acquittee or someone else at risk for harm. This decision will be based on visual observation, acquittee interaction, recent documentation, and shift reports. If there is a question about the acquittee's appropriateness, the acquittee will not be granted escorted community visits until evaluated by a psychiatrist.[/a.]
[a.] Acquittee must have taken all daily-prescribed medications for the previous 30 days, including the day of the visit, in order to be eligible for the visit.[/a.]
[a.] Staff will verify that a recent photograph is available to facilitate identification of the acquittee if needed.[/a.]
[a.] Acquittee's schedule of activities in the community is posted in the ward nursing office.[/a.]
F. Acquittee is required to sign-out of the ward when leaving for an escorted community visit. Staff will note the clothing being worn by the acquittee when leaving.
G. The acquittee will be escorted by staff and will be expected to keep within arm's length of staff unless given permission by
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
Staff to do otherwise. When the acquittee is escorted in a group, there will be an appropriate staff to acquittee ratio. At other times, the acquittee will be escorted 1:1. ---
Section 2: The Temporary Custody Period & Outcomes
H. The acquittee understands that if he/she leaves the sight of escort staff without permission, such an act will be interpreted as an escape.
I. Whenever staff is unable to locate an acquittee on escorted community visits, Hospital Instruction No. 4020 regarding response to acquittee escape will be immediately implemented. Communication will be via cell phone/telephone.
J. The acquittee will provide a cell phone number (if the acquittee has a cell phone) to ward staff members. The number will be included in this RMP and in the acquittee record. The number is ______. The acquittee must answer the phone if called by the hospital. The acquittee cannot utilize the cell phone while on UGP.
K. The acquittee has agreed that no efforts will be made to use or obtain any type of unauthorized substance such as alcohol or street drugs. The acquittee has agreed to submit to drug/alcohol screenings upon return to the ward whenever requested. Drug/alcohol screenings will be conducted at random.
L. Acquittee agrees not to purchase or otherwise obtain items of any kind for other persons/patients while on escorted privilege.
M. Acquittee is allowed to have a maximum of $50 cash in his/her possession. Exceptions to this involve situations in which the acquittee requests to make a purchase larger than $50, at which time the team may approve the purchase, and the acquittee must show a receipt to the team documenting the use of the cash to make the purchase. Acquittees are not allowed to carry or use credit/debit cards. Any credit cards will be stored with the acquittees' valuables.
N. Acquittee agrees not to carry backpacks or other containers for transporting items off of the ward. This stipulation may be waived by the IFPC only under extraordinary circumstances.
O. Acquittee understands he/she is not to have access to any firearms, weapons, or anything that could be used as a weapon nor associate with persons or places having such weapons. Acquittee agrees to submit to search upon return to the ward whenever requested by staff.
P. Acquittee is prohibited from being within ten (10) feet of any private vehicle except as must occur while entering the state vehicle used in transport on an escorted community visit or as otherwise specified in this RMP.
Q. The acquittee understands and agrees that even if it is not his/her fault or the result of any specific violation of the risk management plan, he/she will be returned to the hospital if staff believe his/her mental health is suffering due to the community visit. If necessary, police assistance will be requested to ensure safe return.
R. Acquittee is required to sign-in at the ward nursing office when returning to the unit. Acquittee agrees to submit to search upon return to the ward whenever requested by staff.
S. The (name of local) CSB has been contacted and agrees they will contact WSH if they receive a call about the acquittee in case of an emergency while on visits.
T. In the event of any failure to follow established rules, acquittee will have escorted community visits privilege suspended.
U. The treatment team will advise Western State Hospital's Forensic Coordinator of any revocation of escorted community privileges in order that all appropriate parties are notified.
The guidelines of the Risk Management Plan for Escorted Community Visits have been explained to me. My signature indicates my understanding of the need to have guidelines in place as well as my willingness to comply fully with them. I also understand that if I should attempt to escape, I could face criminal prosecution and be required to be placed in a more restrictive environment.
Acquittee: ____________________________ Witness: ____________________________ Date: ____________ ---
Section 3: Commitment & the Graduated Release Process
Sample Risk Management Plan: Unescorted Community Visits (Not Overnight)
Acquittee, ________, will be provided unescorted community visits to attend the following: (PROGRAM/ACTIVITY) (DURATION) (FREQUENCY)
Location: ____________________________ Transportation to: ____________________________ for the pass will be provided by: ____________________________
Name: ____________________________ Address: ____________________________ Telephone: ____________________________
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The acquittee agrees to abide by all municipal, county, state, and federal laws while on unescorted community visits.
The acquittee understands that he/she remains an acquittee hospitalized at Western State Hospital and under the legal control of the judge maintaining legal jurisdiction over him/her.
The acquittee agrees not to leave the Commonwealth of Virginia while on unescorted community visits.
The acquittee understands that any person placed in the temporary custody of the Commissioner pursuant to 19.2-182.2 or committed to the custody of the Commissioner pursuant to 19.2-182.3 who escapes from such custody is guilty of a Class 6 felony. Thus, if there is an escape, the acquittee will face criminal charges.
The acquittee has agreed that no efforts will be made to use or obtain any type of unauthorized substance such as alcohol or street drugs. The acquittee has agreed to submit to drug/alcohol screenings upon return to the ward whenever requested. Random drug/alcohol screenings will be conducted.
Acquittee understands he/she is not to have access to any firearms, weapons, or anything that could be used as a weapon nor associate with persons or places having such weapons. Acquittee agrees to submit to search upon return to the ward whenever requested by staff.
Prior to permitting the acquittee to leave the ward on unescorted community visits:
a. Physician will provide order for unescorted community visits.
b. RN will ensure acquittee is screened for the presence of any inappropriate thoughts and/or behavior which might place either the acquittee or someone else at risk for harm. This decision will be based on visual observation, acquittee interaction, recent documentation, and shift reports. If there is a question about the acquittee's appropriateness, the acquittee will not be granted unescorted community visits until evaluated by a psychiatrist.
c. Acquittee must have taken all daily-prescribed medications for the previous 30 days, including the day of the visit, in order to be eligible for the visit.
d. Staff will verify that a recent photograph is available to facilitate identification of the acquittee if needed.
e. Acquittee's schedule of activities in the community is posted in the ward nursing office. Posting will include name of a contact person and phone number.
Acquittee is required to be let off the ward by a staff member when leaving for an unescorted community visit. Staff will note the clothing being worn by the acquittee when leaving.
Acquittee will be provided with a telephone number of the ward/the facility/CSB NGRI liaison by which to access immediate assistance if a problem should arise during the unescorted community visit.
The acquittee must return to the ward at the designated time. If unavoidably delayed, the acquittee must call the ward and explain the situation.
The acquittee will provide cell phone number (if the acquittee has a cell phone) to ward staff members. The number will be included in this RMP and in the acquittee record. The number is ______. The acquittee must answer the phone if called by the hospital. The acquittee cannot utilize the cell phone while on UGP.
If the ward is contacted regarding an emergency or escape or if the acquittee is later than the expected arrival time or if there is reason to believe the acquittee may have escaped or otherwise poses a danger to self or others, staff will notify the RN and Hospital Instruction 4020 outlining procedures for responding to acquittee escape will be implemented. Communication will be via cell phone/telephone.
Acquittee is prohibited from being within ten (10) feet of any private vehicle and may not enter any private vehicle, except as specified in this RMP.
Acquittee is allowed to have a maximum of $50 cash in his/her possession. Exceptions to this involve situations in which the acquittee requests to make a purchase larger than $50, at which time the team may approve the purchase, and the acquittee must show a receipt to the team documenting the use of the cash to make the purchase. Acquittees are not allowed to carry or use credit/debit cards. Any credit cards will be stored with the acquittees' valuables.
Acquittee agrees not to carry backpacks or other containers for transporting items off of the ward. This stipulation may be waived by the IFPC only under extraordinary circumstances.
Acquittee agrees not to purchase or otherwise obtain items of any kind for other persons/patients while on unescorted privilege.
Upon return to grounds from unescorted visits, acquittee agrees to return to ward immediately to check in and have any items brought back checked.
Acquittee agrees to submit to search for contraband in accordance with hospital policy.
In the event of any failure to follow established rules, acquittee will have unescorted community visits privilege suspended.
The treatment team will advise Western State Hospital's Forensic Coordinator of any suspension of unescorted community privileges in order that all appropriate parties are notified.
(Catchment area) CSB has been contacted and agrees they will contact WSH if they receive a call about the acquittee in case of an emergency while on visits.
The guidelines of the Risk Management Plan for Unescorted Community Visits have been explained to me. My signature indicates my understanding of the need to have guidelines in place as well as my willingness to comply fully with them. I also understand that if I should attempt to escape, I could face criminal prosecution and be required to be placed in a more restrictive environment.
Acquittee: ____________________________ Witness: ____________________________ Date: ____________
Conditional Release Plan: Court-Ordered
FOR (Name of Acquittee)
The signatures at the end of this conditional release plan indicate that I understand that I have been found not guilty by reason of insanity for ________, pursuant to Virginia Code Section 19.2-182.2, and I am under the continuing jurisdiction of the Court as a result of that finding.
Pursuant to Virginia Code Section 19.2-182.7, the ____ Community Services Board will be responsible for the implementation and monitoring of my conditional release plan.
The undersigned parties and I have reviewed this conditional release plan and agree to follow the terms and conditions.
A. GENERAL CONDITIONS
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I agree to abide by all municipal, county, state, and federal laws.
I agree not to leave the Commonwealth of Virginia without first obtaining the written permission of the judge maintaining jurisdiction over my case and the Community Services Board (CSB). I further understand that, pursuant to § 19.2-182.15 Code of Virginia, I may be charged with a class 6 Felony if I leave the Commonwealth of Virginia without the permission of the Court.
I agree not to use alcoholic beverages.
I agree not to use or possess any illegal drugs or prescribed medications unless prescribed by a licensed physician for me.
I understand that I am under the legal control of the judge maintaining jurisdiction over me and under the supervision of the CSB (and/or CSB designee) implementing my conditional release plan. I agree to follow their directives and treatment plans and to make myself available for supervision at all reasonable times.
I agree to follow the conditions of my release and conduct myself in a manner that will maintain my mental health.
I understand that, even if it is not my fault or the result of any specific violation of conditions, I may be returned to a state hospital if my mental health deteriorates. I further understand that, if I am hospitalized in the custody of the Commissioner while on...
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
Conditional release, my conditional release is considered revoked unless I am voluntarily admitted. ---
Section 2: The Temporary Custody Period & Outcomes
8) I agree to pay for all treatment services on a fee schedule set by the CSB and/or other community providers.
124 | P a g e COURT -ORDERED CONDITIONAL RELEASE PLAN FOR Name (Template )
9) I agree that I will not own, possess, or have access to firearms and/or other illegal weapons of any kind. I further agree not to associate with persons or places that own, possess, or have access to firearms and/or other illegal weapons of any kind.
10) Prior to and after discharge on conditional release, I agree to release all information and records concerning my mental health and my compliance with the conditions of release to the supervising CSB, other community providers, attorney, and other participating parties.
11) I agree to participate in 30-40 hours per week of structured activities while I am on conditional release. These weekly activities (and any changes) must be approved in advance by the CSB.
B. SPECIAL CONDITIONS
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1) I agree to reside where authorized by the supervising CSB. Initially, I agree to reside at the following: (Name of family member, name of placement, type of residential placement, or self) Address Phone If, at any point during the conditional release, I choose not to live at the above location or am asked to move out, then the supervising CSB will evaluate the situation and recommend an alternative living placement. The supervising CSB will coordinate any changes in my residence. If I choose not to reside at the CSB recommended placement, I shall be considered to be in noncompliance with the conditions of release. Any change in residence requires notification to the court by the supervising CSB. I agree to be financially responsible for the cost of my living arrangements/residential placement(s).
2) I will receive approximately $ per month in benefit funds or earn a salary upon discharge from the hospital. I agree to apply for entitlements and health insurance for which I may be eligible in the community.
3) I agree that I will participate in structured daytime activities for the duration of my conditional release, i.e., employment, volunteer work, school, clubhouse, AA, NA, other special groups, etc. My initial plan is the following: Type of daytime activity/ies: Frequency of daytime activity/ies:
4) Staff at the supervising CSB (or CSB designee) will provide case management for me. I agree to meet with my case manager for the purpose of monitoring compliance with the conditions of release. The name and phone number of my case manager is: 125 | P a g e COURT -ORDERED CONDITIONAL RELEASE PLAN FOR Name (Template ) Name and phone number of case manager: Duration of case management contacts: _____ Frequency of case management office visit contacts: Frequency of case management home visits contacts: ____
5) I agree to work with the CSB staff responsible for conducting ongoing assessments of my mental status and associated risk factors. I understand that this may be conducted as part of case management visits, individual therapy appointments or a separate meeting as directed by the CSB. The CSB will provide qualified staff persons for the purpose of conducting mental status and risk factor assessments. The responsible person is and the frequency of my mental status assessment and risk assessment will be .
6) When applicable, I agree to participate in individual therapy or supportive counseling with treatment staff of the supervising CSB (or CSB designee). The initial schedule for my individual therapy is: Duration of Therapy: Frequency of Individual Sessions: Location of Therapy Sessions:
7) I agree to take psychotropic medication as recommended by my treating psychiatrist. I agree to meet with my treating psychiatrist (or psychiatrist's designee) at the supervising CSB (or CSB designee) for the purposes of monitoring my psychotropic medications and to have my prescriptions renewed and refilled. I will participate in psychiatric treatment for the duration of conditional release. Psychotropic medications: Location of meetings with psychiatrist: Frequency of meetings with psychiatrist:
8) I agree to submit to periodic blood or urine analysis as directed by treatment staff of the supervising CSB for the purposes of monitoring psychotropic medication compliance and tolerance.
9) I agree to receive recommended medical treatment for the duration of my conditional release. My current medical conditions and providers are listed below: My current medical condition(s) is: Name and office location of medical provider(s):
10) I agree to participate in the following substance abuse service(s): Type of substance abuse service(s): Provider and location of substance abuse service(s): 126 | P a g e COURT -ORDERED CONDITIONAL RELEASE PLAN FOR Name (Template ) Frequency of substance abuse service(s): Duration of substance abuse service(s):
11) I agree to submit to random and/or periodic breathalyzer, blood or urine analysis as directed by treatment staff of the supervising CSB for purposes of monitoring alcohol consumption, illicit drug use and/or other prohibited substances. Drug/alcohol screens will be given for the duration of conditional release. When indicated, I agree to a full drug panel screening. I further agree to pay any lab fees associated with this screening. Detection of any illicit substances, detection of alcohol use, or refusal to participate in these screenings shall constitute noncompliance with the conditional release plan. The screening schedule is as follows: Frequency of SA screening: Duration of SA screening:
12) If applicable, I agree to be assessed by a vocational rehabilitation counselor and to follow the recommendations made from this assessment. The vocational assessment may be provided by treatment staff of the supervising CSB or can be conducted by another agency designated by the CSB.
13) I agree that, if cannot attend a meeting or session as required by this conditional release plan, I will provide advance notice by calling the person. If I am unable to contact that person, I must contact one of the following individuals: Alternative contact #1: Phone #: Alternative contact #2: Phone #:
14) I am responsible for arranging transportation between home and activities required under this conditional release plan. I may arrange for rides through family or friends. Lack of transportation may not be accepted as an excuse for missing activities specified by this conditional release plan.
15) I agree to additional special conditions that may be deemed necessary by the supervising CSB in the future.
127 | P a g e COURT -ORDERED CONDITIONAL RELEASE PLAN FOR Name (Template )
NOTE TO CSB:
Other special conditions should be added here as appropriate to the individual acquittee and their special management needs in the community. Delete this note when you have completed the plan.
** I have read or have read to me and understand and accept the conditions under which the Court will release me from the hospital.
I fully understand that failure to conform to the conditions may result in one or more of the following:
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• Notification to the court of jurisdiction;
• Notification of the proper legal authorities;
• Modification of the conditional release plan pursuant to § 19.2 -182.11;
• Revocation of conditional release and hospitalization pursuant to § 19.2 -182.8;
• Emergency custody and hospitalization pursuant to § 19.2 -182.9;
• Charged with contempt of court pursuant to § 19.2 -182.7; or
• Arrest and prosecution
** I understand that my conditional release plan is part of a court document and could potentially be accessed by the public. [Signature block]
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__________________________________________ _______________ Signature of Acquittee Date
____________________ ______________________ ______________ Signature of Witness for Acquittee’s signature Date
__________________________________________ ______________ Signature of NGRI Coordinator or designee for CSB Date
Section 3: Commitment & the Graduated Release Process
128 | P a g e COURT -ORDERED CONDITIONAL RELEASE PLAN FOR Name (Template ) ---
C. COMMUNITY SERVICES BOARD
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1) The CSB will coordinate the conditional release plan. As of the beginning of the conditional release plan, the designated case manager is: Name: Title: Community Services Board: Address: City, State, Zip: Phone: FAX:
2) The CSB shall provide the court written reports no less frequently than once every six months, to begin six months from the date of the conditional release, in accordance with § 19.2 -182.7. These reports shall address the acquittee's progress, compliance with conditions of release, and adjustment in the community. Additionally, a copy of all 6-month reports shall be sent to Office of Forensic Services DBHDS P.O. Box 1797 Richmond, VA 23218 PHONE: (804) 786-8044 FAX: (804) 786-9621
3) The CSB shall provide Forensic Services Section of DBHDS with monthly written reports for the first twelve consecutive months on conditional release. The monthly reports will address the acquittee’s progress, compliance with conditions of release, and adjustment in the community. These reports are due to the Forensic Services Section at the above address no later than the 10th day of the month following the month to be reported.
4) Pursuant to § 19.2 -182.11, the CSB understands that the court of jurisdiction must approve any proposed changes or deviations from this conditional release plan.
5) The CSB shall immediately provide copies of all court orders and notices related to the disposition of the acquittee to DBHDS, Forensic Services Section, at the above address.
D. SIGNATURES
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This conditional release plan has been developed jointly and approved by the following community services board and hospital staff: _________________________________ ________________________ Signature Date Name Title Community Services Board _________________________________ ________________________ Signature Date Name Title Community Services Board _________________________________ ________________________ Signature Date Name Title Facility _________________________________ ________________________ Signature Date Name Title Facility _________________________________ ________________________ Signature Date Name Title Facility
130 | P a g e COURT -ORDERED CONDITIONAL RELEASE PLAN FOR Name (Template )
E. Community Services Board Recommendations and Comments
This is an opportunity for the supervising Community Services Board staff to provide recommendations and comments to the Forensic Review Panel. Please indicate the CSB’s support for or against conditional release and an explanation for the CSB’s position: [Signature/Print Name, Title/CSB, Date]
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_______________________________ ____________________________________ __________
_______________________________ ___________
_______________________ __________
_______________________________ ____________________________________ __________
Sample: CSB is Supportive of CR
COURT -ORDERED CONDITIONAL RELEASE PLAN FOR _ Acquittee Name
The signatures at the end of this conditional release plan indicate that I understand that I have been found not guilty by reason of insanity for Aggravated Malicious Wounding, pursuant to Virginia Code Section 19.2 -182.2, and I am under the continuing jurisdiction of the City of Sample Circuit Court as a result of that finding.
Pursuant to Virginia Code Section 19.2 -182.7, the Sample Community Services Board will be responsible for the implementation and monitoring of my conditional release plan.
The undersigned parties and I have reviewed this conditional release plan and agree to follow the terms and conditions. ---
A. GENERAL CONDITIONS
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1) I agree to abide by all municipal, county, state, and federal laws.
2) I agree not to leave the Commonwealth of Virginia without first obtaining the written permission of the judge maintaining jurisdiction over my case and the
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
Sample Community Services Board (CSB). I further understand that, pursuant to § 19.2-182.15 Code of Virginia, I may be charged with a class 6 Felony if I leave the Commonwealth of Virginia without the permission of the Court.
3) I agree not to use alcoholic beverages.
4) I agree not to use or possess any illegal drugs or prescribed medications unless prescribed by a licensed physician for me.
5) I understand that I am under the legal control of the judge maintaining jurisdiction over me and under the supervision of the CSB (and/or CSB designee) implementing my conditional release plan. I agree to follow their directives and treatment plans and to make myself available for supervision at all reasonable times.
6) I agree to follow the conditions of my release and conduct myself in a manner that will maintain my mental health.
7) I understand that, even if it is not my fault or the result of any specific violation of conditions, I may be returned to a state hospital if my mental health deteriorates. I further understand that, if I am hospitalized in the custody of the Commissioner while on conditional release, my conditional release is considered revoked unless I am voluntarily admitted.
8) I agree to pay for all treatment services on a fee schedule set by the CSB and/or other community providers.
132 | P a g e COURT-ORDERED CONDITIONAL RELEASE PLAN FOR __ (Sample CSB is Supportive) _
9) I agree that I will not own, possess, or have access to firearms and/or other illegal weapons of any kind. I further agree not to associate with persons or places that own, possess, or have access to firearms and/or other illegal weapons of any kind.
10) Prior to and after discharge on conditional release, I agree to release all information and records concerning my mental health and my compliance with the conditions of release to the supervising CSB, other community providers, attorney, and other participating parties.
11) I agree to participate in 30-40 hours per week of structured activities while I am on conditional release. These weekly activities (and any changes) must be approved in advance by the CSB.
B. SPECIAL CONDITIONS
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1) I agree to reside where authorized by the supervising CSB. Initially, I agree to reside at the following:
Address: Sample Group Home 123 Sample Rd. Sample City, VA 12345
Phone: Sample Phone
Sample Group Home is a transitional, structured residential living facility that provides on-site supportive services during waking hours, with after-hours crisis services available as needed. Staff assists residents with meal preparation, medication administration, and activities of daily living. An emphasis is placed on securing resources and developing natural supports that will enable individuals to transition into permanent independent housing.
If, at any point during the conditional release, I choose not to live at the above location or am asked to move out, then the supervising CSB will evaluate the situation and recommend an alternative living placement. The supervising CSB will coordinate any changes in my residence. If I choose not to reside at the CSB recommended placement, I shall be considered to be in noncompliance with the conditions of release. Any change in residence requires notification to the court by the supervising CSB.
I agree to be financially responsible for the cost of my living arrangements/residential placement(s).
2) I will receive approximately $710.00 per month in SSI benefit funds or earn a salary upon discharge from the hospital. I agree to apply for entitlements and health insurance for which I may be eligible in the community.
3) I agree that I will participate in structured daytime activities for the duration of my conditional release, i.e., employment, volunteer work, school, clubhouse, AA, NA, other special groups, etc. My initial plan is the following:
Type of daytime activity:
a) Sample County Clubhouse Program 456 Sample Street Sample City, VA 98765 Sample Phone
Sample Clubhouse is a community-based rehabilitation program. The program promotes the highest level of community integration and independence for adults diagnosed with serious mental illness. The program seeks to prevent psychiatric hospitalization by providing a complete array of services to clients. These services include: psychosocial rehabilitation, case management, vocational opportunities, crisis intervention, medication services, and social opportunities.
The location of the daytime activity may be evaluated and changed at a later date if clinically indicated and approved by the treatment team.
Frequency of daytime activity: five days per week
b) Mr. Acquittee will attend AA/NA meetings no less than five times per week for the first six months after discharge. If a reduction in the frequency of these meetings is requested, his request will be assessed by the NGRI Coordinator and reduced if clinically appropriate at that time.
4) Staff at the supervising CSB (or CSB designee) will provide case management for me. I agree to meet with my case manager for the purpose of monitoring compliance with the conditions of release. The name and phone number of my case manager is:
Name of case manager: Sample Name
Address/location of case management meetings: Sample County Clubhouse 456 Sample Street Sample City, VA 98765 Sample Phone
Duration of case management contacts: For the duration of conditional release.
Frequency of case management home visits: once per month
Frequency of case management office visits: Case management sessions will occur once per week for the first six months after discharge. If a reduction in the frequency of these visits is requested, the request will be assessed by the NGRI Coordinator and reduced if clinically appropriate at that time. The frequency of visits, if reduced, will occur no less than once per month for the duration of conditional release.
5) I agree to work with the CSB staff responsible for conducting ongoing assessments of my mental status and associated risk factors. I understand that this may be conducted as part of case management visits, individual therapy appointments, or a separate meeting as directed by the CSB. The CSB will provide qualified staff persons for the purpose of conducting mental status and risk factor assessments. The responsible person is Sample Name and the frequency of my mental status assessment and risk assessment will be during regularly scheduled therapy and case management office visit contacts.
6) When applicable, I agree to participate in individual therapy with treatment staff of the supervising CSB (or CSB designee). The initial schedule for my individual therapy is:
Name of therapist: Sample Name
Address/location of therapy sessions: Sample County CSB 123 Sample Road Sample City, VA 12345 Sample Phone
Duration of Therapy: For the duration of conditional release
a) Frequency of Individual Sessions: Therapy sessions will occur once per week for the first six months after discharge. If a reduction in the frequency of these visits is requested, the request will be assessed by the NGRI Coordinator and reduced if clinically appropriate at that time.
7) I agree to take psychotropic medication as recommended by my treating psychiatrist. I agree to meet with my treating psychiatrist (or psychiatrist's designee) at the supervising CSB (or CSB designee) for the purposes of monitoring my psychotropic medications and to have my prescriptions renewed and refilled. I will participate in psychiatric treatment for the duration of conditional release.
Current Diagnosis:
Axis I: Schizophrenia, Paranoid Type
Posttraumatic Stress Disorder
Polysubstance Dependence
Axis II: No Diagnosis
Axis III: Constipation, GERD, Diabetes Mellitus, Type II, Vitamin D Deficiency
Axis IV: Adjudication, Unemployed, History of Trauma
Axis V: GAF 67
Psychotropic medications: Clozaril 50 mg at 9am and 200mg at bedtime, Wellbutrin HCL XL 450mg daily, Zyprexa 10mg every morning, Diphenhydramine 75 mg at bedtime, Prozac 20mg every morning.
Location of meetings with psychiatrist: Sample County Clubhouse 456 Sample St. Sample City, VA 98765 Sample Phone
Frequency of meetings with psychiatrist: Once per month
8) I agree to submit to periodic blood or urine analysis as directed by treatment staff of the supervising CSB for the purposes of monitoring psychotropic medication compliance and tolerance.
9) I agree to receive recommended medical treatment for the duration of my conditional release. My current medical conditions and providers are listed below:
Medical Medications:
Calcium 600mg with vitamin D twice daily
Omeprazole 20mg daily
Docusate Sodium 100mg twice daily
Multivitamin 1 tablet daily
Aspirin 81mg daily
Simvastatin 5mg at bedtime
Fish Oil 1,000mg twice per day
Lisinopril 2.5mg daily
Metamucil 1 packet in 8oz of juice twice daily
Vitamin D 50,000 tablet daily
My current medical condition(s) is: Constipation, GERD, Diabetes Mellitus, Type II, Vitamin D Deficiency.
Name and office location of medical provider(s): The CSB discharge planner will coordinate all appointments prior to Mr. Acquittee’s discharge from the hospital.
10) I agree to be assessed by a substance abuse counselor at the supervising CSB (or CSB designee) and to follow the treatment recommendations made as a result of this assessment.
11) I agree to submit to random and/or periodic breathalyzer, blood, or urine analysis as directed by treatment staff of the supervising CSB for purposes of monitoring alcohol consumption, illicit drug use, and/or other prohibited substances.
Drug/alcohol screens will be given for the duration of conditional release. When indicated, I agree to a full drug panel screening. I further agree to pay any lab fees associated with this screening.
Detection of any illicit substances, detection of alcohol use, or refusal to participate in these screenings shall constitute noncompliance with the conditional release plan.
The screening schedule is as follows:
Frequency of SA screening: Drug/alcohol screens will be conducted by the case manager at least once per week for the first six months. Results of such tests will be submitted monthly to the NGRI Coordinator in monthly progress reports.
If a reduction in the frequency of these screens is requested, the request will be assessed by the NGRI Coordinator and reduced if clinically appropriate at that time.
Duration of SA screening: For the duration of conditional release.
12) If applicable, I agree to be assessed by a vocational rehabilitation counselor and to follow the recommendations made from this assessment. The vocational assessment may be provided by treatment staff of the supervising CSB or can be conducted by another agency designated by the CSB.
13) I agree that, if cannot attend a meeting or session as required by this conditional release plan, I will provide advance notice by calling the person. If I am unable to contact that person, I must contact one of the following individuals:
Alternative contact #1: Sample Name, Clubhouse Program Manager
Phone #: Sample Phone
Alternative contact #2: Sample Name, MA, Sample NGRI Coordinator
Phone #: Sample Phone
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
Content not provided in the raw text.]
Section 2: The Temporary Custody Period & Outcomes
Content not provided in the raw text.]
Section 3: Commitment & the Graduated Release Process
Content not provided in the raw text.]
COURT - ORDERED CONDITIONAL RELEASE PLAN FOR __ (Sample CSB is Supportive) __
C. COMMUNITY SERVICES BOARD
1) The Sample CSB will coordinate the conditional release plan. As of the beginning of the conditional release plan, the designated case manager is:
-
Name: Sample Name
Title: Case Manager
Community Services Board: Sample County
Address: 456 Sample Street
City, State, Zip: Sample City, VA 98765
Phone: Sample Phone
FAX: Sample Fax
2) The CSB shall provide the court written reports no less frequently than once every six months, to begin six months from the date of the conditional release, in accordance with § 19.2 -182.7. These reports shall address the acquittee's progress, compliance with conditions of release, and adjustment in the community. Additionally, a copy of all 6-month reports shall be sent to:
-
Office of Forensic Services
DBHDS
P.O. Box 1797
Richmond, VA 23218
PHONE: (804) 786 -8044
FAX: (804) 786 -9621
3) The CSB shall provide Forensic Services Section of DBHDS with monthly written reports for the first twelve consecutive months on conditional release. The monthly reports will address the acquittee’s progress, compliance with conditions of release, and adjustment in the community. These reports are due to the Forensic Services Section at the above address no later than the 10th day of the month following the month to be reported.
4) Pursuant to § 19.2-182.11, the CSB understands that the court of jurisdiction must approve any proposed changes or deviations from this conditional release plan.
5) The CSB shall immediately provide copies of all court orders and notices related to the disposition of the acquittee to DBHDS, Forensic Services Section, at the above address.
D. SIGNATURES
This conditional release plan has been developed jointly and approved by the following community services board and hospital staff:
-
_______________________________ ________________________ Signature Date
Sample Name NGRI Coordinator Community Services Board
_______________________________ ________________________ Signature Date
Name Title Community Services Board
_______________________________ ________________________ Signature Date
Name Title Facility
_______________________________ ________________________ Signature Date
Name Title Facility
E. Community Services Board Recommendations and Comments
This is an opportunity for the supervising Community Services Board staff to provide recommendations and comments to the Forensic Review Panel. Please indicate the CSB’s support for or against conditional release and an explanation for the CSB’s position:
Sample County CSB is in support of Mr. Acquittee’s conditional release at this time. It is anticipated that the housing plan and daytime activities will provide adequate structure and support to ensure Mr. Acquittee’s safety and the safety of the community. Mr. Acquittee will be monitored closely by the therapist and case manager as well as the NGRI Coordinator. Also, Mr. Acquittee will be reminded, as necessary, that he cannot leave the state without permission from the adjudicating judge and the NGRI Coordinator.
-
Signature/Print Name Title/CSB Date
_______________________________ ____________________________________ __________
_______________________________ ____________________________________ __________
_______________________________ ____________________________________ __________
Sample: CSB is NOT Supportive of CR
COURT - ORDERED CONDITIONAL RELEASE PLAN FOR Acquittee Name
The signatures at the end of this conditional release plan indicate that I understand that I have been found not guilty by reason of insanity for Assault and Battery, Malicious Injury by Caustic Substance and Abduction by Force, pursuant to Virginia Code Section 19.2-182.2, and I am under the continuing jurisdiction of the Sample County Circuit Court as a result of that finding.
Pursuant to Virginia Code Section 19.2-182.7, the Sample Community Services Board will be responsible for the implementation and monitoring of my conditional release plan. The undersigned parties and I have reviewed this conditional release plan and agree to follow the terms and conditions.
A. GENERAL CONDITIONS
-
I agree to abide by all municipal, county, state, and federal laws.
I agree not to leave the Commonwealth of Virginia without first obtaining the written permission of the judge maintaining jurisdiction over my case and the Sample Community Services Board (CSB). I further understand that, pursuant to § 19.2-182.15 Code of Virginia, I may be charged with a class 6 Felony if I leave the Commonwealth of Virginia without the permission of the Court.
I agree not to use alcoholic beverages.
I agree not to use or possess any illegal drugs or prescribed medications unless prescribed by a licensed physician for me.
I understand that I am under the legal control of the judge maintaining jurisdiction over me and under the supervision of the CSB (and/or CSB designee) implementing my conditional release plan. I agree to follow their directives and treatment plans and to make myself available for supervision at all reasonable times.
I agree to follow the conditions of my release and conduct myself in a manner that will maintain my mental health.
I understand that, even if it is not my fault or the result of any specific violation of conditions, I may be returned to a state hospital if my mental health deteriorates. I further understand that, if I am hospitalized in the custody of the Commissioner while on conditional release, my conditional release is considered revoked unless I am voluntarily admitted.
I agree to pay for all treatment services on a fee schedule set by the CSB and/or other community providers.
I agree that I will not own, possess, or have access to firearms and/or other illegal weapons of any kind. I further agree not to associate with persons or places that own, possess, or have access to firearms and/or other illegal weapons of any kind.
Prior to and after discharge on conditional release, I agree to release all information and records concerning my mental health and my compliance with the conditions of release to the supervising CSB, other community providers, attorney, and other participating parties.
I agree to participate in 30-40 hours per week of structured activities while I am on conditional release. These weekly activities (and any changes) must be approved in advance by the CSB.
B. SPECIAL CONDITIONS
-
I agree to reside where authorized by the supervising CSB. Initially, I agree to reside at the following:
XXXX (mother)
Address: 123 Sample Street, Sample City, VA 22222
Phone: Sample Phone
Mr. Acquittee has agreed to reside temporarily with his mother until suitable housing can be identified in Sample County. Ms. XXXX has agreed to allow Mr. Acquittee to live in his home as long as he is following all medical and mental health treatment as required. Mr. Acquittee will agree to re-locate to housing identified by Sample CSB at a later time.
If, at any point during the conditional release, I choose not to live at the above location or am asked to move out, then the supervising CSB will evaluate the situation and recommend an alternative living placement. The supervising CSB will coordinate any changes in my residence. If I choose not to reside at the CSB recommended placement, I shall be considered to be in noncompliance with the conditions of release. Any change in residence requires notification to the court by the supervising CSB.
I agree to be financially responsible for the cost of my living arrangements/residential placement(s).
2) I will receive approximately $0 per month in SSI/SSDI benefits and will not have any source of income upon discharge from the hospital. I agree to apply for entitlements and health insurance for which I may be eligible in the community.
3) I agree that I will participate in structured daytime activities for the duration of my conditional release, i.e., employment, volunteer work, school, clubhouse, AA, NA, other special groups, etc. My initial plan is the following: Type of daytime activity/ies: Sample Peer Recovery Center 321 Sample Pike Sample City, VA 22222 Sample phone Frequency of daytime activity/ies: Four days per week, 10 am - 4 pm
a. The Sample City Peers Helping Peers Center is a peer-run center for those experiencing mental illness and/or substance abuse issues. They offer various peer-run groups throughout the day that focus on topics/issues such as dual recovery, substance abuse, wellness recovery action planning (WRAP), nutritional training, and computer training. This will account for only twenty-four hours of activity for Mr. Acquittee; therefore, further structured activities will be identified if released into the community and/or he will be re-referred to the Sample Clubhouse who has declined to allow him to participate in programming at this time.
b. Mr. Acquittee will attend AA/NA meetings no less than three times per week for the first six months after discharge. If a reduction in the frequency of these meetings is requested, his request will be assessed by the NGRI Coordinator and reduced if clinically appropriate at that time.
4) Staff at the supervising CSB (or CSB designee) will provide case management for me. I agree to meet with my case manager for the purpose of monitoring compliance with the conditions of release. The name and phone number of my case manager is: Name, address, and phone number of case manager: TBD Duration of case management contacts: For the duration of conditional release.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
Frequency of case management office visit:
If granted conditional release, an intake appointment will be scheduled for Mr. Acquittee for outpatient mental health services through Sample County Behavioral Healthcare. This will occur prior to discharge from Central State Hospital.
This intake appointment would be completed at 123 Sample Street, Sample City, VA 22222.
After completion of intake, a case manager will be identified.
Mr. Acquittee’s case management sessions will occur once per week for the first six months after discharge once a case manager is identified.
If a reduction in the frequency of these visits is requested, the request will be assessed by the NGRI Coordinator and reduced if clinically appropriate at that time.
The frequency of visits, if reduced, will occur no less than once per month for the duration of conditional release.
Section 2: The Temporary Custody Period & Outcomes
Frequency of home visit case management contacts: TBD
Section 3: Commitment & the Graduated Release Process
145 | P a g e COURT -ORDERED CONDITIONAL RELEASE PLAN FOR (Sample CSB Not Supportive)
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I agree to work with the CSB staff responsible for conducting ongoing assessments of my mental status and associated risk factors. I understand that this may be conducted as part of case management visits, individual therapy appointments or a separate meeting as directed by the CSB. The CSB will provide qualified staff persons for the purpose of conducting mental status and risk factor assessments. The responsible person is TBD and the frequency of my mental status assessment and risk assessment will be conducted once per week for the first 6 months and then no less than monthly thereafter.
When applicable, I agree to participate in individual therapy with treatment staff of the supervising CSB (or CSB designee). The initial schedule for my individual therapy is:
Duration of Therapy: TBD
Frequency of Individual Sessions: TBD
Location of Therapy Sessions: TBD
I agree to take psychotropic medication as recommended by my treating psychiatrist. I agree to meet with my treating psychiatrist (or psychiatrist's designee) at the supervising CSB (or CSB designee) for the purposes of monitoring my psychotropic medications and to have my prescriptions renewed and refilled. I will participate in psychiatric treatment for the duration of conditional release.
Psychotropic medications: None at present
Location of meetings with psychiatrist: TBD
Frequency of meetings with psychiatrist: Once per month for the duration of conditional release. If Mr. Acquittee is prescribed medication he will agree to take the medication as prescribed.
I agree to submit to periodic blood or urine analysis as directed by treatment staff of the supervising CSB for the purposes of monitoring psychotropic medication compliance and tolerance.
I agree to receive recommended medical treatment for the duration of my conditional release. My current medical conditions and providers are listed below:
My current medical condition(s) is: No known medical conditions at this time
Name and office location of medical provider(s): TBD
I agree to be assessed by a substance abuse counselor at the supervising CSB (or CSB designee) and to follow the treatment recommendations made as a result of this assessment.
Location of Substance Abuse Assessment: TBD
Section 4: Community Services Board
1) The Sample CSB will coordinate the conditional release plan. As of the beginning of the conditional release plan, the designated case manager is: Name: Sample Name Title: Forensic Discharge Planner Community Services Board: Sample CSB Address: 123 Sample St. City, State, Zip: Sample City, VA 22222 Phone: Sample Phone FAX: Sample Fax
2) The CSB shall provide the court written reports no less frequently than once every six months, to begin six months from the date of the conditional release, in accordance with § 19.2-182.7. These reports shall address the acquittee's progress, compliance with conditions of release, and adjustment in the community. Additionally, a copy of all 6-month reports shall be sent to:
-
Office of Forensic Services DBHDS
P.O. Box 1797
Richmond, VA 23218
Phone: (804) 786-8044
Fax: (804) 786-9621
3) The CSB shall provide Forensic Services Section of DBHDS with monthly written reports for the first twelve consecutive months on conditional release. The monthly reports will address the acquittee’s progress, compliance with conditions of release, and adjustment in the community. These reports are due to the Forensic Services Section at the above address no later than the 10th day of the month following the month to be reported.
4) Pursuant to § 19.2-182.11, the CSB understands that the court of jurisdiction must approve any proposed changes or deviations from this conditional release plan.
5) The CSB shall immediately provide copies of all court orders and notices related to the disposition of the acquittee to DBHDS, Forensic Services Section, at the above address.
Section 5: Signatures
This conditional release plan has been developed jointly and approved by the following community services board and hospital staff:
-
_______________________________ ________________________
Signature Date
Kelly Nieman, MA NGRI Coordinator
Arlington Community Services Board
_______________________________ ________________________
Signature Date
Name Title Community Services Board
_______________________________ ________________________
Signature Date
Name Title Facility
_______________________________ ________________________
Signature Date
Name Title Facility
_______________________________ ________________________
Signature Date
Name Title Facility
Section 6: Community Services Board Recommendations and Comments
This is an opportunity for the supervising Community Services Board staff to provide recommendations and comments to the Forensic Review Panel. Please indicate the CSB’s support for or against conditional release and an explanation for the CSB’s position:
The Sample County CSB is not in support of Mr. Acquittee’s conditional release at this time. Mr. Acquittee continues to have several risk factors for future aggression, such as a history of aggression, limited social supports, untreated mental illness, history of substance abuse, and lack of insight.
He is not following all treatment recommendations at this time (i.e., taking medications as prescribed) and continues to believe that mental health treatment is not necessary in his case.
Furthermore, he has had an additional incident of aggression since admission to Central State Hospital.
It is in this writer’s opinion that Mr. Acquittee has not made sufficient progression in his mental health treatment/recovery to warrant conditional release at this time or to mitigate the general risk of harm to the community.
Furthermore, it is in the opinion of this writer that if granted conditional release, he is likely to have limited success on an outpatient basis.
It is this writer’s recommendation that he requires inpatient treatment at this time.
Appendix E: Sample: 6-Month Report Cover Letter - Compliant/Continue CR
July 29, 2014
The Honorable Dennis L. Hupp, Judge
Warren County Circuit Court
1 East Main Street
Front Royal, VA 22630
Acquittee Name: XX
Court Case Nos.: CRXXXX
Date of Conditional Release Order: X/XX/XXXX
Dear Judge Hupp,
I am writing to you in my role as NGRI Coordinator for Northwestern Community Services Board, who works with insanity acquittee Mr. XX. Enclosed is the Six-Month Report to the Court reviewing insanity acquittee Mr. XX’s conditional release status for the past six months from January 29, 2014, to July 29, 2014 (pursuant to Virginia Code Section 19.2-182.7).
Mr. XX has been compliant with the conditions of his release and at this time the Community Services Board is recommending continuation of his conditional release without modification.
Please let...
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
The Not Guilty by Reason of Insanity (NGRI) defense is a legal concept used when an individual accused of a crime was suffering from a mental illness at the time of the offense, rendering them not responsible for their actions under the law.
When a defendant is found NGRI, the court may order a commitment for treatment rather than traditional sentencing. The goal is to provide appropriate mental health treatment while ensuring community safety. ---
Section 2: The Temporary Custody Period & Outcomes
Following an NGRI verdict, the individual may be placed under temporary custody for evaluation and treatment. During this period, community services boards (CSBs) and behavioral health authorities monitor compliance and progress.
-
1. Monitoring compliance with treatment and conditions.
a. Regular assessments and reports.
• Coordination with legal and mental health professionals.
Outcomes of the custody period can include:
-
a. Continued treatment in the community with modified conditions.
b. Unconditional release if the individual demonstrates stability and compliance.
c. Revocation of conditional release and hospitalization if non-compliance or risk is identified.
Section 3: Commitment & the Graduated Release Process
The commitment process involves a series of evaluations and reviews to determine the appropriate level of supervision and treatment for the individual.
The graduated release process is designed to gradually increase independence, starting with supervised community placement and progressing to full release based on compliance and stability.
-
1. Initial commitment for evaluation and treatment.
a. Regular progress reviews.
• Adjustment of conditions as needed.
2. Conditional release with specific conditions and monitoring.
a. Periodic assessments to determine readiness for less restrictive placement.
3. Unconditional release when criteria are met, allowing full community integration.
Sample Correspondence and Reports
6-Month Report Cover Letter - Compliant/Modify Conditions of CR
January 29, 2015
The Honorable Dennis L. Hupp, Judge
Warren County Circuit Court
1 East Main Street
Front Royal, VA 22630
Acquittee Name: XX
Court Case Nos.: CRXXXX
Date of Conditional Release Order: X/XX/XXXX
Dear Judge Hupp,
I am writing to you in my role as NGRI Coordinator for Northwestern Community Services Board, who works with insanity acquittee Mr. XX.
Enclosed is the Six-Month Report to the Court reviewing Mr. XX’s conditional release status for the past six months from July 29, 2014 to January 29, 2015 (pursuant to Virginia Code Section 19.2-182.7).
Mr. XX has been compliant with the conditions of his release and at this time the Community Services Board is recommending continuation of his conditional release with the following modifications:
-
Special Condition #3: Mr. XX has obtained new part-time employment; therefore, he will be completing approximately 40 hours of structured activity at the following location:
Name of Employer
123 Sample Address, Sample City, VA 12345
(540-542-XXXX)
Special Condition #4 & 6: Mr. XX’s therapy/case management meetings have been reduced to monthly as he has been psychiatrically stable since discharge and has been making progress towards more independence. It is believed that monthly therapy/case management visits will be sufficient for Mr. XX at this time; however, if at any point additional meetings are needed or there is an observed change in mental status, these visits will be increased in frequency.
If there are any concerns with the above-mentioned modifications, please contact me at the address or telephone number below.
Sincerely,
Name Here
NGRI Coordinator, Northwestern Community Services
209 W. Criser Road, Suite 300, Front Royal, VA 22630
(540) 636-XXXX
cc: Name, Attorney for the Commonwealth
Name, Attorney for the Acquittee
Name, DBHDS Office of Forensic Services ---
6-Month Report Cover Letter - Compliant/Recommend UCR
December 1, 2015
The Honorable Dennis L. Hupp, Judge
Warren County Circuit Court
1 East Main Street
Front Royal, VA 22630
Acquittee Name: ZZ
Court Case Nos.: CRXXXX
Date of Conditional Release Order: X/XX/XXXX
Dear Judge Hupp,
I am writing to you in my role as NGRI Coordinator for Northwestern Community Services Board, who works with insanity acquittee Mr. ZZ.
Enclosed is the Six-Month Report to the Court reviewing Mr. ZZ’s conditional release status for the past six months from June 1, 2015 to December 1, 2015 (pursuant to Virginia Code Section 19.2-182.7).
Since his conditional release from the hospital on June 1, 2010, Mr. ZZ has complied with all conditions of his release. He has demonstrated the ability to manage increasing levels of independence over the past five years while on conditional release. He has successfully maintained his apartment and has obtained a part-time job as a mail clerk. He has demonstrated a commitment to his treatment and it is the opinion of the Community Services Board that he will continue to follow the treatment recommendations of his providers even without the oversight of the Court.
At this time, the Community Services Board is recommending Unconditional Release for Mr. ZZ. Enclosed is a model order for removal of conditions pursuant to Virginia Code Section 19.2-182.11 should the court agree with these recommendations.
If there are any questions, please contact me at the address or telephone number below.
Sincerely,
Name Here
NGRI Coordinator, Northwestern Community Services
209 W. Criser Road, Suite 300, Front Royal, VA 22630
(540) 636-XXXX
cc: Name, Attorney for the Commonwealth
Name, Attorney for the Acquittee
Name, DBHDS Office of Forensic Services ---
6-Month Report Cover Letter - Non-Compliance/Modify CR
May 1, 2015
The Honorable Dennis L. Hupp, Judge
Warren County Circuit Court
1 East Main Street
Front Royal, VA 22630
Acquittee Name: YY; Court Case Nos.: CRXXXX
Date of Conditional Release Order: X/XX/XXXX
Dear Judge Hupp,
I am writing to you in my role as NGRI Coordinator for Northwestern Community Services Board (CSB), who works with insanity acquittee Mr. YY.
Enclosed is the Six-Month Report to the Court reviewing Mr. YY’s conditional release status for the past six months, from November 1, 2014 to May 1, 2015 (pursuant to Virginia Code Section 19.2-182.7).
Mr. YY has been struggling with non-compliance with the conditions of his release during this reporting period. Mr. YY experienced a relapse of his alcohol use during this period. On April 14, 2015, he arrived at his psychosocial day program smelling of alcohol and slurring his speech. His case manager alerted the NGRI Coordinator of this incident, and he was asked to leave the program that day.
Again, on April 22, 2015, Mr. YY was at his day program when he was asked to leave due to disruptive behavior. At that time, he admitted to drinking alcohol. The NGRI Coordinator, the case manager, and the therapist for Mr. YY called him to a meeting on April 24, 2015, to assess the severity of his alcohol use and discuss modifications to his treatment plan.
-
Special Conditions #8 & 10: Although Mr. YY acknowledged his relapse, he reported that he was dedicated to remaining sober.
The treatment team decided to assist Mr. YY with enrollment in the CSB’s relapse prevention group, which he will begin attending immediately.
Mr. YY was also instructed to increase his AA meeting attendance to weekly, and complete random breathalyzer tests whenever requested by his case manager or NGRI Coordinator.
He has also reached out to his sponsor and plans to call his sponsor weekly and more often if needed.
At this time, the Community Services Board is monitoring Mr. YY’s compliance with these modifications and is not requesting revocation or further action from the Court.
If there are any further compliance issues, the NGRI Coordinator will immediately notify the Court and take the appropriate steps to ensure the safety of Mr. YY and the community.
If there are any concerns with the above-mentioned modifications, please contact me at the address or telephone number below.
Sincerely,
Name Here
NGRI Coordinator, Northwestern Community Services
209 W. Criser Road, Suite 300, Front Royal, VA 22630
(540) 636-XXXX
cc: Name, Attorney for the Commonwealth
Name, Attorney for the Acquittee
Name, DBHDS Office of Forensic Services ---
Notice to the Court of Emergency Hospitalization/Revocation
January 2, 2015
The Honorable William T. Newman
Arlington County Circuit Court
1425 N. Courthouse Road
Arlington, Virginia 22201
Re: Mr. XX; Case No.: CRXXXXX
Dear Judge Newman,
I am writing to you as the NGRI Coordinator for the Arlington Community Board (CSB). In my role, I provide clinical and legal oversight to insanity acquittee XX while he remains on conditional release in our community.
I am reporting Mr. XX’s recent hospitalization and emergency revocation of conditional release.
This NGRI Coordinator was alerted during the week of December 1, 2014, that Mr. XX had missed several of his scheduled appointments with the PACT team and had not been attending clubhouse as required in his conditional release plan.
Efforts were made by the PACT team to locate Mr. XX in the community and began making daily welfare checks at his home. He was located by the PACT team and Arlington County Police on December 16, 2014, at his apartment.
However, as he did not appear to require hospitalization, an appointment was scheduled for Mr. XX on December 17, 2014, to meet with the PACT team and this NGRI Coordinator to discuss the non-compliance with his conditional release plan.
Mr. XX did not attend this appointment as scheduled. Daily attempts to locate Mr. XX were again initiated on December 17, 2014. A missing person report was filed for Mr. XX by this NGRI Coordinator on December 24, 2014.
Mr. XX was eventually found on December 31, 2014, by Falls Church Police. He was transported to Virginia Hospital Center on an Emergency Custody Order (ECO) and evaluated by Emergency Services staff and this NGRI Coordinator.
At that time, it was determined that he was no longer an appropriate candidate for conditional release, as he had violated conditions of his release and was psychiatrically unstable. He was subsequently hospitalized at Northern Virginia Mental Health Institute on a Temporary Detention Order (TDO).
An emergency revocation hearing was held on January 2, 2015, in Fairfax County at the Northern Virginia Mental Health Institute. The special justice of Fairfax County Courts revoked Mr. XX’s conditional release and returned him to the custody of the Commissioner pursuant to Virginia Code Sections 19.2-182.9 and 19.2-182.10.
It is this NGRI coordinator’s hope that this matter will be scheduled in front of you at the end of the 60-day period, to determine if Mr. XX can return to the community on conditional release or whether he needs to be committed to the custody of the Commissioner of DBHDS for ongoing inpatient hospitalization and treatment.
Should there be any questions or concerns, please feel free to contact me at the address or telephone number listed below.
Sincerely,
Name Here, NGRI Coordinator
Arlington Community Services Board
1810 N. Edison Street, Arlington, VA 22207
(703) 228-XXXX
cc: Name, Defense Attorney
Name, Office of Commonwealth’s Attorney
Name, DBHDS Office of Forensic Services ---
Notice to the Court of Non-Compliance/Request for Hearing
July 12, 2015
The Honorable William T. Newman
Arlington County Circuit Court
1425 N. Courthouse Road
Arlington, Virginia 22201
Re: Mr. AA Case No.: CRXXXXX
Dear Judge Newman,
I am writing to you as the NGRI Coordinator for the Arlington Community Board (CSB). In my role, I provide clinical and legal oversight to insanity acquittee AA while he remains on conditional release in our community.
I am writing the court to report violations of the conditions of his release and request a hearing to address these violations.
This NGRI Coordinator was notified on June 15, 2015, that Mr. AA had been disruptive at his apartment building and that the landlord had called the police to address the issue. The Arlington County Police Department responded and was able to resolve the incident without arrest.
Mr. AA had been discovered with several individuals who had been staying in his apartment illegally. These people were asked to leave and they did so. However, the landlord has since discovered that they have returned. The landlord has issued an eviction notice, and Mr. AA will be required to leave the apartment in 30 days.
In addition to his eviction for violating his lease, Mr. AA has refused to participate in his day program activities despite continued prompting and encouragement from his providers. When he has shown up at the day program, he was suspected of delivering alcohol to other consumers and charging money for this service. Other consumers have acknowledged this to be true, but Mr. AA continues to deny this. He has been discharged from the day program as a result of his behaviors.
At this time, Mr. AA does not meet conditions for revocation to the state hospital. He remains psychiatrically stable and does not need inpatient treatment. However, the continued violations of his release plan do put Mr. AA and the community at risk.
This writer is requesting a hearing to address these violations and recommends that the Court consider its option of finding the acquittee in contempt for violation of his court-ordered release (pursuant to Virginia Code Section 19.2-182.7). It is this writer’s hope that this matter
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
The insanity defense is a legal concept used to determine whether an individual accused of a crime should be held responsible for their actions based on their mental state at the time of the offense. When a defendant is found not guilty by reason of insanity (NGRI), they are typically committed to a mental health facility for treatment rather than being sentenced to prison.
Section 2: The Temporary Custody Period & Outcomes
Following an NGRI verdict, the individual may be placed in temporary custody for evaluation and treatment. The outcomes of this period can include continued hospitalization, conditional release, or discharge based on their progress and stability. The process involves regular reviews and assessments to determine readiness for community reintegration.
Section 3: Commitment & the Graduated Release Process
The commitment process involves a structured plan for gradually releasing the individual back into the community. This graduated release process includes multiple stages, such as supervised community placement, conditional release, and eventual full discharge, contingent upon ongoing evaluation and compliance with treatment and legal conditions.
Sample Documents and Correspondence
Below are examples of official correspondence related to NGRI cases, including notices to the court, requests for modifications, and review reports.
Sample: Notice to the Court of Change of Residence
June 13, 2014
The Honorable William T. Newman, Jr.
Arlington County Circuit Court
1425 Courthouse Road
Arlington, Virginia 22201
Re: Ms. XX Case No.: CRXXXXXX, CRXXXXX, CRXXXXX
Dear Judge Newman,
I am writing to you as the NGRI Coordinator for the Arlington Community Services Board (CSB). In my role, I provide clinical and legal oversight to individuals on conditional release in our community.
I am writing regarding insanity acquittee Ms. XX to notify the court of a modification to Ms. XX’s Conditional Release Plan:
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Special Condition #1: Upon her initial conditional release, Ms. XX was discharged to the Transitional Group Home in accordance with her court-ordered conditional release plan. She has been successful with this placement but she has met the limit of her allotted time in the house, and the transitional group home is discharging her as of today’s date.
The Arlington CSB NGRI Coordinator has agreed with Ms. XX’s plan to return to live with her sister until she can be placed in an apartment through the Arlington Permanent Supportive Housing Program.
As of June 13, 2014, Ms. XX has subsequently returned to her sister’s home in Woodbridge, VA, while she waits for her apartment.
Ms. XX’s sister, Ms. YY, has agreed to allow her to temporarily reside in her home. The address of her sister’s home is as follows:
123 Sample Ave.
Woodbridge, VA 12345
It is anticipated that Ms. XX will remain at this home until September of 2014, when an apartment will become available for her use.
Should there be any questions or concerns about this proposed change, please feel free to contact me at the address or telephone number listed below.
Sincerely,
Name Here, NGRI Coordinator
Arlington County Community Services Board
1810 N. Edison Street, Arlington, VA 22207
(703) 228 -XXXX
cc: Name, Assistant Commonwealth’s Attorney
Name, Defense Attorney
Name, Forensic Office, DBHDS
Sample: Request for CRP Modification - Out of State Travel Permission
January 1, 2015
The Honorable Craig D. Johnston
Prince William County Circuit Court
9311 Lee Ave., Manassas, VA 20110
Re: Ms. YY Case No.: CRXXX-XXX
Judge Johnston,
I am writing to you as the NGRI Coordinator for the Arlington Community Services Board (CSB). In my role, I provide clinical and legal oversight to insanity acquittee Ms. YY while on conditional release.
I am requesting a modification to Ms. YY’s Conditional Release Plan pursuant to Virginia Code Section 19.2-182.11. This letter aims to inform the court about the request for out-of-state passes for Ms. YY, who has expressed interest in traveling to Washington, DC, and Maryland to search for employment.
Typically, when an insanity acquittee wishes to travel outside of Virginia, they seek the court’s permission. Once granted, I assume responsibility for monitoring the use of these passes in the community.
Ms. YY has expressed the desire to travel to and from Washington, DC, and Maryland for employment searches. I have spoken with her and support these passes with conditions:
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The acquittee must inform me in advance of any travel plans and dates (both day trips and overnight trips outside Virginia).
The acquittee must contact me upon return to inform me of their arrival.
I will monitor the use of these passes if the court approves them.
Since her discharge from the Northern Virginia Mental Health Institute, Ms. YY has kept all scheduled appointments with her treatment providers and this NGRI Coordinator. She has managed the transition to independent living successfully and remains stable.
She appears committed to continuing treatment and adhering to the restrictions of her Conditional Release Plan.
I hope this letter clarifies how these passes will be monitored in the community if approved. Attached is a model order for Travel Permission for Ms. Bates should the court decide to grant this request.
Please feel free to contact me at any time for further discussion.
Sincerely,
Name Here, Arlington County NGRI Coordinator
1810 N. Edison Street, Arlington, VA 22207
(703) 228 -XXXX
cc: Name, Defense Attorney
Name, Prince William County Office of the Commonwealth’s Attorney
Name, DBDHS, Forensic Services
Appendix F: THE MONTHLY REVIEW OF CONDITIONAL RELEASE REPORT INSTRUCTIONS
INSTRUCTIONS FOR COMPLETING THE FORM:
GENERAL GUIDANCE:
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Read the currently approved conditional release plan carefully. Do not assume that any of the general or special conditions have been modified or deleted unless you have a court order or letter from the NGRI judge of jurisdiction confirming that status. If the court has deleted or modified a condition, label that status in the comment section.
If the conditional release plan was written so that the CSB has the authority to discontinue a service, only then is it allowed to discontinue the condition(s) without the court’s specific approval. Note these distinctions appropriately in the comment section.
Do not use local names of programs, e.g., Rainbow House, or abbreviations, e.g., ACR. Describe the program type instead, e.g., clubhouse, detox program, adult home, etc.
The 6-month report to the court does NOT substitute for the monthly report.
The reporting form is available on disk for your convenience.
The monthly review of conditional release report is required for the first 12 months only.
SPECIFIC INSTRUCTIONS FOR THE FORM:
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1. NAME OF ACQUITTEE - Complete the full name of the acquittee.
2. DATE - Complete the date that the report is written.
3. COURT HOLDING JURISDICTION - Complete the name of the court that holds jurisdiction for the acquittee. If there are 2 or more courts, complete all that apply.
4. TIME PERIOD COVERED IN REVIEW - Complete the calendar month and year for which the report is written. Always for a full calendar month, e.g., September 2000. Do not write reports for “split” months, e.g., November 14 - December 14, 2000.
5. CHARGED WITH ANY CRIMES - Complete any crimes for which the acquittee has been charged during the reporting month.
6. CONVICTED OF ANY CRIMES - Complete any crimes for which the acquittee has been convicted during the reporting month.
7. GENERAL CONDITIONS OF RELEASE - Read the current conditional release plan and write/type all general conditions in detail and by number. If not fully written, describe the conditions meaningfully. Check “never”, “sometimes”, or “always” for compliance. Add comments as needed.
8. SPECIAL CONDITIONS OF RELEASE - List all special conditions similarly, with compliance checked and comments added as needed.
9. DATE OF LAST FACE-TO-FACE WITH THE ACQUITTEE - Complete the date of last face-to-face contact.
10. DATES AND RESULTS OF SUBSTANCE ABUSE SCREENINGS - Complete details or write “not applicable”.
11. OTHER COMMENTS ON PROGRESS AND ADJUSTMENT - Additional information about progress, compliance, or other factors.
12. SIGNATURE AND PRINTED NAME - The case manager signs and prints their name, including credentials.
13. TITLE - The title of the case manager.
14. CSB AND MAILING ADDRESS - The name and address of the CSB.
15. PHONE AND FAX NUMBERS - Contact information for the case manager.
OTHER INFORMATION:
• The Monthly Review of Conditional Release form is due on the 10th of the month following the reporting month. For example, the November 2000 report is due December 10, 2000.
• Only fax or mail the report. Do not send both.
Mailing address:
Sarah Shrum
Forensic Mental Health Consultant
Department of Behavioral Health and Developmental Services
Forensic Office
P.O. Box 1797
Richmond, Virginia 23218-1797
Fax number:
Attn: Sarah Shrum
Fax: 804-786-9621
QUESTIONS OR CONSULTATION? Call Sarah Shrum at 804-786-9084
Blank Template: Monthly Review of Conditional Release
NAME OF ACQUITTEE: ________________________________
DATE: ________________________
COURT HOLDING JURISDICTION: ________________________________
TIME PERIOD COVERED IN REVIEW: ________________________________ TO: ________________________________
Office of Forensic Services, Division of Facilities Management
DBHDS
P.O. Box 1797
Phone: 804/786-9084
Richmond, VA 23218
Fax: 804-786-9621
If the acquittee has been charged with any crime(s)* during this period, please note offense & date: ________________________________________________________________
If the acquittee has been convicted of any crime(s)* during this time period, please note: ________________________________________________________________
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
offense & date: ________________________________________________________________ *Includes traffic violations other than routine parking tickets. ---
Section 2: The Temporary Custody Period & Outcomes
GENERAL CONDITIONS OF RELEASE
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ACQUITTEE'S COMPLIANCE COMMENTS: NEVER / SOMETIMES / ALWAYS
Date of last face-to-face contact with acquittee: _____________________________________
Dates and results of any substance abuse screening tests: TYPE TEST DATE(s) ADMINISTERED RESULTS OF TESTS __________________ ___________________ ___________________ ___________________ ___________________ (If more than 5 screenings administered, please continue listing on back of form)
Other comments on acquittee’s progress and adjustment in the community: _____________________________________________________________________________
Signature: ___________________________________/__________________________________________
Name (Print): _________________________________________________________________________
Title: _________________________________________________ CSB ________________________________
Phone: ____________________________ Fax: ____________________________
Section 3: Commitment & the Graduated Release Process
Appendix G: SIX-MONTH REPORT TO COURT REVIEWING CONDITIONAL RELEASE OF INSANITY ACQUITTEES
INSTRUCTIONS FOR COMPLETING THE FORM: GENERAL GUIDANCE:
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Report is submitted to the NGRI judge of jurisdiction. If there are two or more courts of jurisdiction, one report should be addressed to all judges or separate reports can be submitted to each NGRI judge of jurisdiction.
The report should be completed and submitted every 6 months after the acquittee is placed on conditional release.
Read the currently approved conditional release plan carefully. Do not assume that any of the general or special conditions have been modified or deleted unless you have a court order or letter from the NGRI judge of jurisdiction confirming that status. If the court has deleted or modified a condition, label that status in the comment section. If the conditional release plan was written so that the CSB has the authority to discontinue a service, only then it is allowed to discontinue the condition without the court’s specific approval. Note the two distinctions appropriately in the comment section.
Don’t use local names of programs, i.e., Rainbow House or abbreviations, i.e., ACR. Describe the program type instead, i.e., clubhouse, detox program, adult home, etc.
The 6-month report to the court does NOT substitute for the monthly report.
The reporting form is available on disk for your convenience.
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TO - Complete the name(s) of the NGRI judge(s) of jurisdiction and their address(es).
DATE - Complete the date that the report is written.
RE - Complete the full name of the acquittee, the court case number, and the date of the conditional release order.
CONDITIONS OF RELEASE - Complete all the general and special conditions of release in this section.
A. GENERAL CONDITIONS OF RELEASE
Read the currently approved conditional release plan and write/type all general conditions in detail and by their number on the left side column. If the general conditions are not written/typed in their entirety, write/type meaningful phrases for each general condition that represents the court’s intent of the general conditions. Check off “never”, “sometimes”, or “always” to describe the acquittee’s compliance with each general condition of their release. Write/type in comments as needed to describe the acquittee’s compliance with each general condition of their release. If you condense the wording of the general condition on the report, ensure that your version of the condition still represents the Court’s intent and that it can be appropriately answered by the choices - “never”, “sometimes” or “always”. Do not just write/type in a number without a description of the general condition. Do not just write/type in that “all general conditions are fine”.
B. SPECIAL CONDITIONS OF RELEASE
Read the currently approved conditional release plan and list all special conditions in detail and by their number on the left side column. If the special conditions are not written/typed in their entirety, write/type meaningful phrases for each special condition that represent the court’s intent for the special conditions. Check off “never”, “sometimes”, or “always” to describe the acquittee’s compliance with each special condition of their release. Write/type in comments to describe variations in the acquittee’s compliance with each special condition of their release. If you condense the wording of the special condition on the report, ensure that your version of the condition still represents the Court’s intent and that it can be appropriately answered by the choices - “never”, “sometimes” or “always”. Do not just write/type in a number without a description of the special condition. Do not just write/type in that “all special conditions are fine”.
Only fax or mail the Six-Month Report to Court Reviewing the Conditional Release of Insanity Acquittee. Do not send the report by both mail and fax.
Mailing address : Sarah Shrum, Forensic Mental Health Consultant, Department of Behavioral Health and Developmental Services - Forensic Office, P.O. Box 1797, Richmond, Virginia 23218-1797
Fax number: Attn: Sarah Shrum, Fax number - 804-786-9621 ---
QUESTIONS OR CONSULTATION?
Call Sarah Shrum at 804-786-9084 ---
Appendix H: Blank Template DISCHARGE PLAN - Unconditional Release
FOR ________________________________
The signatures at the end of this discharge plan indicate that __________________________________ understands he or she has been found not guilty by reason of insanity of ________________________________, and committed to the custody of the Commissioner of DBHDS pursuant to Virginia Code Section 19.2-182.2.
The acquittee understands that this discharge plan is being provided to the Court pursuant to the requirements of 19.2-182.6 of the Code of Virginia. The acquittee agrees to follow the terms and conditions.
A. GENERAL CONDITIONS
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The acquittee agrees to abide by all municipal, county, state, and federal laws.
The acquittee agrees not to use alcoholic beverages at all. Any use of alcoholic beverages may disrupt or interfere with his or her mental health, medications, domestic life, employment, or proper community conduct.
The acquittee agrees not to use or possess any illegal drugs or prescribed medications unless prescribed by a licensed physician for him or her.
The acquittee agrees to follow the recommendations of his outpatient treatment provider(s) and conduct him or herself in a manner which will maintain his mental health.
The acquittee agrees that he or she will not own, possess, or have access to firearms and/or other illegal weapons of any kind. The acquittee further agrees not to associate with those persons or places which do.
B. Recommended Treatment and Support Activities
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The acquittee will reside in the following placement: (Name)_____________________________________________________ (Relationship)________________________________________________ at: Address_____________________________________________________ Phone_________________________________
The acquittee agrees to follow up with outpatient treatment services with the following agency or provider:
The acquittee agrees to take psychotropic medication as recommended by his or her treating psychiatrist. Psychiatric follow-up will be provided by the following agency or provider:
The acquittee will also receive the following outpatient services:
** I HAVE READ OR HAD READ TO ME AND UNDERSTAND AND ACCEPT THE DISCHARGE PLAN TO WHICH I WILL BE RELEASED BY THE COURT.
__________________________________________ _______________
Signature of Acquittee: ____________________________ Date: ____________
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
The defendant may be found not guilty by reason of insanity if, at the time of the offense, they were legally insane. This legal determination involves evaluating the mental state of the defendant during the commission of the crime. The Not Guilty by Reason of Insanity (NGRI) verdict results in a different legal process, often involving hospitalization and treatment rather than traditional sentencing.
Section 2: The Temporary Custody Period & Outcomes
When a defendant is found not guilty by reason of insanity, they are typically placed in temporary custody for evaluation. This period allows mental health professionals to assess the individual's condition and determine appropriate treatment or release plans. The outcomes of this process include potential release with conditions, continued hospitalization, or further legal proceedings for commitment or recommitment.
Section 3: Commitment & the Graduated Release Process
The commitment process involves several legal orders and evaluations to ensure the safety of the individual and the community. The graduated release process includes initial commitment, periodic evaluations, development of conditional release plans, and hearings to determine eligibility for release or further hospitalization.
Appendix I: NGRI Finding & Temporary Custody Order
Virginia: In the General District Court or Circuit Court of ________________________________
VS _____________________________________ Case No.: ________________________ NOT GUILTY BY REASON OF INSANITY - INITIAL EVALUATIONS AND HEARING
The defendant having been found not guilty by reason of insanity of the charge(s) of _____________________, it is hereby ORDERED AND ADJUDGED that:
ENTERED: _______________________________ DATE ______________________________________
SIGNATURE OF JUDGE
NAME OF JUDGE
cc: Commonwealth’s Attorney, Acquittee’s Attorney, Community Services Board, Commissioner of DBHDS, Attn: Forensic Section, P.O. Box 1797, Richmond, VA 23218 ---
Model Order for Extension of Temporary Custody
VIRGINIA: IN THE __________________ COURT OF _____________________
COMMONWEALTH OF VIRGINIA VS. ________________________________
Docket No.: -CR______________________ SSN ________________________________
FELONY ______________________________ Misdemeanor _______________________
OFFENSE DATE _______________________ Not Guilty by Reason of Insanity Extension of Temporary Custody Period for Development of Conditional Release Plan and Hearing Date
The defendant previously having been found not guilty by reason of insanity and placed in the temporary custody of the Commissioner of the Department of Behavioral Health and Developmental Services for evaluation, and evaluations of the acquittee having been conducted resulting in a determination that the acquittee is mentally ill or mentally retarded, and a recommendation by at least one evaluator that the acquittee be released on conditions. Therefore, the Court ORDERS that:
Entered: ____________________________ Date ____________________________
Signature ____________________________ Name of Judge
pc: Commonwealth’s Attorney, Acquittee’s Attorney, Supervising Community Services Board, Chief Forensic Coordinator, Central State Hospital, Commissioner of DBHDS, Attention: Forensic Services, P.O. Box 1797, Richmond, VA 23218 ---
Model Order for Initial Commitment
VIRGINIA: IN THE __________________ COURT OF _____________________
COMMONWEALTH OF VIRGINIA VS. ________________________________
Docket No.: -CR____________________ FELONY ______________________________
DOB: ______________________________
MISDEMEANOR _______________________ OFFENSE DATE(S) _____________________ Not Guilty by Reason of Insanity Hearing on Temporary Custody Evaluation Reports and Inpatient Hospitalization
The acquittee having been found not guilty by reason of insanity to the charge(s) of ___________________ on ____________ and placed in temporary custody for evaluation. This day came the attorney for the Commonwealth, ____________. The acquittee _____________, was present in the Court throughout the proceedings and was ably represented by counsel, ___________. Based upon the written evaluations submitted by _____________, the oral testimony of _________ _____, and the arguments of counsel, the Court finds that the acquittee is ___ mentally ill or ___ mentally retarded and in need of hospitalization based on the factors in VA Code § 19.2-182.3. Therefore, the Court orders that the acquittee be committed to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services. Therefore, the Court ORDERS that:
ENTERED: ____________________________ Date ____________________________
Signature ____________________________ Name of Judge
cc: Commonwealth’s Attorney, Acquittee’s Attorney, Supervising Community Services Board, Chief Forensic Coordinator, Central State Hospital, Commissioner of DBHDS, Attention: Director of Forensic Services, P.O. Box 1797, Richmond, VA 23218 ---
Model Order for Recommitment
Virginia: In the General District Court or Circuit Court of _____________________________________________
VS.__________________________________________ Case No: ____________________________
NOT GUILTY BY REASON OF INSANITY - RECOMMITMENT FOR INPATIENT HOSPITALIZATION
This day came the Attorney for the Commonwealth, _____________________________________ The Acquittee, ___________ , was present in the Court throughout the proceedings and was represented by Counsel, . Based upon the evaluation(s) submitted by , the testimony of , and the arguments of counsel, the Court finds that the Acquittee is mentally ill, or mentally retarded, and in need of hospitalization based on the factors in Virginia Code Section 19.2-182.3. Therefore, the Court ORDERS that the Acquittee be recommitted to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services. THE COURT FURTHER ORDERS THAT:
ENTERED: ___________________________________ SIGNATURE OF JUDGE: _______________________
NAME OF JUDGE:_______________________________
cc: Commonwealth’s Attorney, Acquittee’s Attorney, Community Services Board, Commissioner of DBHDS, Attn: Forensic Section, P.0. Box 1797, Richmond, Va. 23218 ---
Model Order for Evaluations upon Petition for Release
Virginia: In the General District Court or Circuit Court of _____________________________________________
VS. __________________________________________ Case No: ____________________________
NOT GUILTY BY REASON OF INSANITY - ORDER FOR EVALUATIONS & HEARING DATE UPON PETITION FOR RELEASE FROM INPATIENT HOSPITALIZATION
The Acquittee having been previously found not guilty by reason of insanity and committed to the custody of the Commissioner of the Department of Behavioral and Developmental Services, for inpatient hospitalization, and the Court having been petitioned for the Acquittee’s conditional release by the Commissioner who has presented the Court with a conditional release plan prepared jointly by the hospital and the appropriate community services board, it is hereby ORDER AND ADJUDGED that:
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
Section 1: The Insanity Defense & the NGRI Finding
The manner as set forth in Virginia Code Section 19.2-182.2 to assess and report on the Acquittee’s need for inpatient hospitalization by reviewing his/her condition with respect to the factors set forth in Virginia Code Sections 19.2-182.3 and 19.2-182.7.
Section 2: The Temporary Custody Period & Outcomes
2. The evaluations shall be completed and findings reported within forty-five days of the date of the Commissioner’s receipt of this order. Copies of the report shall be sent to the Acquittee’s attorney, the attorney for the Commonwealth of the jurisdiction where the Acquittee was acquitted, the community services board serving the locality where the Acquittee was acquitted, and the Commissioner of DBHDS.
3. A hearing shall be held in this court on the _________ day of ____________________, 20___, at _________ o’clock, to determine whether the Acquittee shall be released with or without conditions or requires continued inpatient hospitalization. The Acquittee shall have the right to be present at the hearing, the right to the assistance of counsel in preparation for and during the hearing, and the right to introduce evidence and cross-examine witnesses at the hearing.
4. Copies of this order shall be sent to the Acquittee, the counsel for the Acquittee, the attorney for the Commonwealth of the jurisdiction where the Acquitte was acquitted, the community services board where the Acquittee shall reside upon discharge, and the Commissioner of DBHDS.
5. In the event the Acquittee’s presence is required at any hearing in this cause, the Court shall issue an Order to Transport, directing the Sheriff of _______________________ County, or his designee, to resume custody of and transport the Acquittee back to the jurisdiction of this Court.
6. This Court retains jurisdiction on this cause and the Acquittee shall not be discharged or released from custody of the Commissioner without further Order of this Court.
cc: Commonwealth’s Attorney Acquittee’s Attorney Community Services Board Commissioner of DBHDS Attn: Forensic Section P.O. Box 1797 Richmond, Va. 23218
Order for Conditional Release
Virginia: In the General District Court or Circuit Court of _____________________________________________
Commonwealth of Virginia VS.__________________________________________ Case No: ____________________________
NOT GUILTY BY REASON OF INSANITY - ORDER FOR CONDITIONAL RELEASE
Upon a petition submitted by the Forensic Review Panel, on behalf of the Commissioner of the Department of Behavioral Health and Developmental Services (DBHDS), pursuant to Virginia Code Section 19.2-182.6, this day came the Attorney for the Commonwealth, ____________________, and the Acquittee __________________. The Acquittee was present in the Court throughout the proceedings and was represented by Counsel, _________________________.
After review of the report of clinical findings and a conditional release plan prepared in accordance with Virginia Code Section 19.2-182.6, it is hereby ORDERED AND ADJUDGED that:
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1. The Acquittee meets the criteria for conditional release as provided in Virginia Code Section 19.2-182.7.
2. The Acquittee shall be conditionally released pursuant to Virginia Code Section 19.2-182.7, subject to the following orders and conditions, which the Court deems will best meet the Acquittee’s need for treatment and supervision, and best serve the interests of justice and society:
*[The conditional release plan jointly prepared by the hospital staff and the community services board, which is attached and is hereby incorporated by reference.]
*[Other terms and conditions imposed by the court.]*
3. The community services board serving the locality in which the Acquittee will reside upon release shall implement the Court’s conditional release orders, pursuant to Virginia Code Section 19.2-182.7, and shall submit written reports to the Court on the Acquittee’s progress and adjustment in the community no less frequently than every six months from the date of this order.
4. Copies of this order shall be sent to the Acquittee, the counsel for the Acquittee, the attorney for the Commonwealth of the jurisdiction where the Acquittee was acquitted, the community services board implementing the conditional release plan, and the Commissioner of DBHDS.
5. The Court retains jurisdiction in this cause, and the Acquittee shall not be released from conditional release without further Order of this Court.
ENTERED: _______ _________________________ SIGNATURE OF JUDGE DATE: _____________________
cc:
Commonwealth’s Attorney Acquittee’s Attorney Community Services Board Commissioner of DBHDS, Attn: Office of Forensic Services, P.O. Box 1797, Richmond, VA 23218Order for Continuation of Conditional Release
Virginia: In the Circuit Court of __________________________ County
COMMONWEALTH OF VIRGINIA VS. ___________________ Case Number: ___________________ SSN: ___________________ Offense Date: ___________________ DOB: ___________________
Not Guilty by Reason of Insanity - Conditional Release Review
On this day came the Attorney for the Commonwealth, ___________ _____________, counsel for the Acquittee, and the Acquittee, ________________________________, for a review of the progress of the Acquittee who was previously Conditionally Released by this Court on ____________________.
The Court having heard the remarks of counsel and having reviewed the reports of the ____________________ Community Services Board submitted pursuant to Virginia Code §19.2-182.7 and the Conditional Release Plan developed by the ___________________ Community Services Board, finds that the Acquittee is in compliance with the Conditional Release Order previously entered by this Court.
It is therefore ORDERED that the Acquittee shall remain on Conditional Release as provided in the Conditional Release Order and that the named agencies continue to submit reports every six (6) months, and this case is continued to _________________________.
The Court retains jurisdiction in this case and the Acquittee shall not be released from conditional release without further Order of this Court.
The Court certifies that at all times during the hearing the Acquittee was personally present with his attorney.
Enter: ______________________ ____________________________ , Judge
Seen: Seen: _______________________ __________________________ Attorney for Acquittee For the Commonwealth
Order for Revocation of Conditional Release (Non-Emergency)
Virginia: In the General District Court or Circuit Court of _____________________________________________
Commonwealth of Virginia VS.__________________________________________ Case No: ____________________________
NOT GUILTY BY REASON OF INSANITY - REVOCATION OF CONDITIONAL RELEASE
The Acquittee having been previously found not guilty by reason of insanity and later placed on conditional release, pursuant to Virginia Code Section 19.2-182.7, and the Court having held a hearing pursuant to Virginia Code Section 19.2-182.8 after receipt of an evaluation addressing factors pertaining to whether the Acquittee’s conditional release should be revoked, hereby ORDERS AND ADJUDGES that:
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1. The Court finds by a preponderance of the evidence that the Acquittee has violated the conditions of his / her release or is no longer a proper subject for conditional release based on application of the criteria for conditional release and requires inpatient hospitalization.
2. Pursuant to Virginia Code Section 19.2-182.8, the Acquittee’s conditional release is revoked and the Acquittee shall be returned to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services.
3. Within 60 days of resumption of custody, if in the opinion of hospital staff treating the Acquittee, the Acquittée’s condition improves to the degree that the Acquittee is an appropriate candidate for conditional release, he / she may be, with the approval of the Court, conditionally released as if revocation has not taken place.
4. If the Acquittee is not released, pursuant to Virginia Code Section 19.2-182.10, within 60 days of resumption of custody, then before the expiration of one year from the date of this order, the Commissioner shall, in accordance with Virginia Code Section 19.2-182.5, provide a report evaluating the Acquittee’s condition and recommending treatment.
5. Copies of this order shall be sent to the Acquittee, the counsel for the Acquittee, the attorney for the Commonwealth of the jurisdiction where the Acquittee was acquitted, the community services board supervising the Acquittee’s conditional release, and the Commissioner of Department of Behavioral Health and Developmental Services.
6. In the event the Acquittee’s presence is required at any hearing in this cause, the Court shall issue an Order to Transport, directing the Sheriff of _________________, or his designee, to resume custody of and transport the Acquittee back to the jurisdiction of this Court.
7. This Court retains jurisdiction in this cause, and the Acquittee shall not be discharged or released from custody of the Commissioner without further Order of this Court.
cc: Commonwealth’s Attorney Acquittee’s Attorney Community Services Board Commissioner of DBHDS Attn: Forensic Section P.O. Box 1797 Richmond, Va. 23218
Order for Emergency Revocation
Virginia: In the General District Court or Circuit Court of _____________________________________________
Commonwealth of Virginia VS.__________________________________________ Case No: ____________________________
NOT GUILTY BY REASON OF INSANITY - REVOCATION OF CONDITIONAL RELEASE
The Acquittee having been previously found not guilty by reason of insanity and later placed on conditional release, pursuant to Virginia Code Section 19.2-182.7, and the Court having held a hearing pursuant to Virginia Code Section 19.2-182.9 after receipt of an evaluation addressing factors pertaining to whether the Acquittee’s conditional release should be revoked, hereby ORDERS AND ADJUDGES that:
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1. The Court finds by a preponderance of the evidence that the Acquittee has violated the conditions of his / her release or is no longer a proper subject for conditional release based on application of the criteria for conditional release and requires inpatient hospitalization.
2. Pursuant to Virginia Code Section 19.2-182.9, the Acquittee’s conditional release is revoked and the Acquittee shall be returned to the custody of the Commissioner of the Department of Behavioral Health and Developmental Services.
3. Within 60 days of resumption of custody, if in the opinion of hospital staff treating the Acquittee, the Acquittée’s condition improves to the degree that the Acquittee is an appropriate candidate for conditional release, he / she may be, with the approval of the Court, conditionally released as if revocation has not taken place.
4. If the Acquittee is not released, pursuant to Virginia Code Section 19.2-182.10, within 60 days of resumption of custody, then before the expiration of one year from the date of this order, the Commissioner shall, in accordance with Virginia Code Section 19.2-182.5, provide a report evaluating the Acquittee’s condition and recommending treatment.
5. Copies of this order shall be sent to the Acquittee, the counsel for the Acquittee, the attorney for the Commonwealth of the jurisdiction where the Acquittee was acquitted, the community services board supervising the Acquittee’s conditional release, and the Commissioner of Department of Behavioral Health and Developmental Services.
6. In the event the Acquittee’s presence is required at any hearing in this cause, the Court shall issue an Order to Transport, directing the Sheriff of _________________, or his designee, to resume custody of and transport the Acquittee back to the jurisdiction of this Court.
7. This Court retains jurisdiction in this cause, and the Acquittee shall not be discharged or released from custody of the Commissioner without further Order of this Court.
cc: Commonwealth’s Attorney Acquittee’s Attorney Community Services Board Commissioner of DBHDS Attn: Forensic Section P.O. Box 1797 Richmond, Va. 23218
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
discharged or released from custody of the Commissioner without further Order of this Court.
cc: Commonwealth’s Attorney Acquittee’s Attorney Community Services Board Commissioner of DBHDS Attn: Forensic Section P.O. Box 1797 Richmond, Va. 23218
ENTERED: DATE SIGNATURE OF JUDGE NAME OF JUDGE ---
Section 2: The Temporary Custody Period & Outcomes
Model Order for Modification of CRP
Virginia: In the General District Court or Circuit Court of _____________________________________________
Commonwealth of Virginia VS.__________________________________________
Case No: ____________________________
NOT GUILTY BY REASON OF INSANITY - HEARING REGARDING MODIFICATION OF CONDITIONS OF RELEASEThe Court having held a hearing pursuant to Virginia Code Section 19.2-182.11 regarding its proposed order of __________________, 20____, hereby ORDERS AND ADJUDGES that
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1. Pursuant to Virginia Code Section 19.2-182.11, the existing conditions of the Acquittee's release shall be modified as follows: (APPEND CONDITIONAL RELEASE PLAN)
2. Copies of this order shall be sent to the Acquittee, the counsel for the Acquittee, the attorney for the Commonwealth for the committing jurisdiction, the attorney for the Commonwealth of the jurisdiction where the Acquittee is residing on conditional release, the supervising community services board, and the Commissioner of DBHDS.
3. This Court retains jurisdiction in this cause, and the Acquittee shall not be released from jurisdiction without further Order of this Court.
cc: Commonwealth’s Attorney Acquittee’s Attorney Community Services Board Commissioner of DBHDS Attn: Forensic Section P.O. Box 1797 Richmond, Va. 23218
ENTERED: DATE SIGNATURE OF JUDGE NAME OF JUDGE ---
Model Order for Removal of Conditions
Virginia: In the General District Court or Circuit Court of _____________________________________________
Commonwealth of Virginia VS.__________________________________________
Case No: ____________________________
REMOVAL OF CONDITIONS OF RELEASEThe Court having held a hearing pursuant to Virginia Code Section 19.2-182.11 regarding its proposed order of __________________, 20____, hereby ORDERS AND ADJUDGES that
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1. Pursuant to Virginia Code Section 19.2-182.11, the existing conditions of the Acquittees release shall be removed.
2. Copies of this order shall be sent to the Acquittee, the counsel for the Acquittee, the attorney for the Commonwealth for the committing jurisdiction, the attorney for the jurisdiction where the Acquittee is residing on conditional release, the supervising community services board, and the Commissioner of DBHDS.
3. This Court no longer retains jurisdiction in this cause.
cc: Commonwealth’s Attorney Acquittee’s Attorney Community Services Board Commissioner of DBHDS Attn: Forensic Section P.O. Box 1797 Richmond, Va. 23218
ENTERED: DATE SIGNATURE OF JUDGE NAME OF JUDGE ---
Section 3: Commitment & the Graduated Release Process
Petition for Involuntary Treatment/TDO (For Emergency Revocations)
185 | P a g e
186 | P a g e ---
Appendix J: Code of Virginia Title 19.2. Criminal Procedure Chapter 11. Proceedings on Question of Insanity
§ 19.2-169.5. Evaluation of sanity at the time of the offense; disclosure of evaluation results.
A. Raising issue of sanity at the time of offense; appointment of evaluators.
-- If, at any time before trial, the court finds, upon hearing evidence or representations of counsel for the defendant, that there is probable cause to believe that the defendant's sanity will be a significant factor in his defense and that the defendant is financially unable to pay for expert assistance, the court shall appoint one or more qualified mental health experts to evaluate the defendant's sanity at the time of the offense and, where appropriate, to assist in the development of an insanity defense. Such mental health expert shall be (i) a psychiatrist, a clinical psychologist, or an individual with a doctorate degree in clinical psychology who has successfully completed forensic evaluation training as approved by the Commissioner of Behavioral Health and Developmental Services and (ii) qualified by specialized training and experience to perform forensic evaluations. The defendant shall not be entitled to a mental health expert of his own choosing or to funds to employ such expert.
B. Location of evaluation.
-- The evaluation shall be performed on an outpatient basis, at a mental health facility or in jail, unless the court specifically finds that outpatient services are unavailable, or unless the results of the outpatient evaluation indicate that hospitalization of the defendant for further evaluation of his sanity at the time of the offense is necessary. If either finding is made, the court, under authority of this subsection, may order that the defendant be sent to a hospital designated by the Commissioner of Behavioral Health and Developmental Services as appropriate for evaluation of the defendant under criminal charge. The defendant shall be hospitalized for such time as the director of the hospital deems necessary to perform an adequate evaluation of the defendant's sanity at the time of the offense, but not to exceed 30 days from the date of admission to the hospital.
C. Provision of information to evaluator.
-- The court shall require the party making the motion for the evaluation, and such other parties as the court deems appropriate, to provide to the evaluators appointed under subsection A any information relevant to the evaluation, including, but not limited to (i) copy of the warrant or indictment; (ii) the names and addresses of the attorney for the Commonwealth, the attorney for the defendant and the judge who appointed the expert; (iii) information pertaining to the alleged crime, including statements by the defendant made to the police and transcripts of preliminary hearings, if any; (iv) a summary of the reasons for the evaluation request; (v) any available psychiatric, psychological, medical or social records that are deemed relevant; and (vi) a copy of the defendant's criminal record, to the extent reasonably available.
D. The evaluators shall prepare a full report concerning the defendant's sanity at the time of the offense, including whether he may have had a significant mental disease or defect which rendered him insane at the time of the offense. The report shall be prepared within the time period designated by the court, said period to include the time necessary to obtain and evaluate the information specified in subsection C.
E. Disclosure of evaluation results.
-- The report described in subsection D shall be sent solely to the attorney for the defendant and shall be deemed to be protected by the lawyer-client privilege. However, the Commonwealth shall be given the report in all felony cases, the results of any other evaluation of the defendant's sanity at the time of the offense, and copies of psychiatric, psychological, medical, or other records obtained during the course of any such evaluation, after the attorney for the defendant gives notice of an intent to present psychiatric or psychological evidence pursuant to § 19.2-168.
F. In any case where the defendant obtains his own expert to evaluate the defendant's sanity at the time of the offense, the provisions of subsections D and E, relating to the disclosure of the evaluation results, shall apply.
1982, c. 653; 1986, c. 535; 1987, c. 439; 1996, cc. 937, 980; 2005, c. 428; 2009, cc. 813, 840. ---
§ 19.2-168. Notice to Commonwealth of intention to present evidence of insanity; continuance if notice not given
-- In any case in which a person charged with a crime intends (i) to put in issue his sanity at the time of the crime charged and (ii) to present testimony of an expert to support his claim on this issue at his trial, he, or his counsel, shall give notice in writing to the attorney for the Commonwealth, at least 60 days prior to his trial, of his intention to present such evidence. However, if the period between indictment and trial is less than 120 days, the person or his counsel shall give such notice no later than 60 days following indictment. In the event that such notice is not given, and the person proffers such evidence at his trial as a defense, then the court may in its discretion, either allow the Commonwealth a continuance or, under appropriate circumstances, bar the defendant from presenting such evidence. The period of any such continuance shall not be counted for speedy trial purposes under § 19.2-243. Code 1950, § 19.1-227.1; 1970, c. 336; 1975, c. 495; 1986, c. 535; 2008, c. 372. ---
§ 19.2-168.1. Evaluation on motion of the Commonwealth after notice
-- A. If the attorney for the defendant gives notice pursuant to § 19.2-168, and the Commonwealth thereafter seeks an evaluation of the defendant's sanity at the time of the offense, the court shall appoint one or more qualified mental health experts to perform such an evaluation. The court shall order the defendant to submit to such an evaluation and advise the defendant on the record in court that a refusal to cooperate with the Commonwealth's expert could result in exclusion of the defendant's expert evidence. The qualification of the experts shall be governed by subsection A of § 19.2-169.5. The location of the evaluation shall be governed by subsection B of § 19.2-169.5. The attorney for the Commonwealth shall be responsible for providing the experts the information specified in subsection C of § 19.2-169.5. After performing their evaluation, the experts shall report their findings and opinions, and provide copies of psychiatric, psychological, medical or other records obtained during the course of the evaluation to the attorneys for the Commonwealth and the defense.
-- B. If the court finds, after hearing evidence presented by the parties, that the defendant has refused to cooperate with an evaluation requested by the Commonwealth, it may admit evidence of such refusal or, in the discretion of the court, bar the defendant from presenting expert psychiatric or psychological evidence at trial on the issue of his sanity at the time of the offense.
1982, c. 653; 1986, c. 535. ---
Title 19.2. Criminal Procedure Chapter 11.1. Disposition of Persons Acquitted by Reason of Insanity
§ 19.2-182.2. Verdict of acquittal by reason of insanity to state the fact; temporary custody and evaluation.
When the defense is insanity of the defendant at the time the offense was committed, the jurors shall be instructed, if they acquit him on that ground, to state the fact with their verdict.
The court shall place the person so acquitted (the acquittee) in temporary custody of the Commissioner of Behavioral Health and Developmental Services (hereinafter referred to in this chapter as the Commissioner) for evaluation as to whether the acquittee may be released with or without conditions or requires commitment.
The evaluation shall be conducted by (i) one psychiatrist and (ii) one clinical psychologist. The psychiatrist or clinical psychologist shall be skilled in the diagnosis of mental illness and intellectual disability and qualified by training and experience to perform such evaluations.
The Commissioner shall appoint both evaluators, at least one of whom shall not be employed by the hospital in which the acquittee is primarily confined.
The evaluators shall determine whether the acquittee currently has mental illness or intellectual disability and shall assess the acquittee and report on his condition and need for hospitalization with respect to the factors set forth in § 19.2-182.3.
The evaluators shall conduct their examinations and report their findings separately within 45 days of the Commissioner's assumption of custody.
Copies of the report shall be sent to the acquittee's attorney, the attorney for the Commonwealth for the jurisdiction where the person was acquitted and the community services board or behavioral health authority as designated by the Commissioner.
If either evaluator recommends conditional
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
The court shall extend the evaluation period to permit the hospital in which the acquittee is confined and the appropriate community services board or behavioral health authority to jointly prepare a conditional release or discharge plan, as applicable, prior to the hearing. 1991, c. 427; 1993, c. 295; 1996, cc. 937, 980; 2007, cc. 485, 565; 2009, cc. 813, 840; 2012, cc. 476, 507.
Section 2: The Temporary Custody Period & Outcomes
§ 19.2 -182.3. Commitment; civil proceedings
Upon receipt of the evaluation report and, if applicable, a conditional release or discharge plan, the court shall schedule the matter for hearing on an expedited basis, giving the matter priority over other civil matters before the court, to determine the appropriate disposition of the acquittee.
Except as otherwise ordered by the court, the attorney who represented the defendant at the criminal proceedings shall represent the acquittee through the proceedings pursuant to this section. The matter may be continued on motion of either party for good cause shown.
The acquittee shall be provided with adequate notice of the hearing, of the right to be present at the hearing, the right to the assistance of counsel in preparation for and during the hearing, and the right to introduce evidence and cross-examine witnesses at the hearing.
The hearing is a civil proceeding. At the conclusion of the hearing, the court shall commit the acquittee if it finds that he has mental illness or intellectual disability and is in need of inpatient hospitalization.
For the purposes of this chapter, mental illness includes any mental illness, as defined in § 37.2 -100, in a state of remission when the illness may, with reasonable probability, become active.
The decision of the court shall be based upon consideration of the following factors:
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To what extent the acquittee has mental illness or intellectual disability, as those terms are defined in § 37.2 -100;
The likelihood that the acquittee will engage in conduct presenting a substantial risk of bodily harm to other persons or to himself in the foreseeable future;
The likelihood that the acquittee can be adequately controlled with supervision and treatment on an outpatient basis; and
Such other factors as the court deems relevant.
If the court determines that an acquittee does not need inpatient hospitalization solely because of treatment or habilitation he is currently receiving, but the court is not persuaded that the acquittee will continue to receive such treatment or habilitation, it may commit him for inpatient hospitalization.
The court shall order the acquittee released with conditions pursuant to §§ 19.2 -182.7, 19.2 -182.8, and 19.2 -182.9 if it finds that he is not in need of inpatient hospitalization but that he meets the criteria for conditional release set forth in § 19.2 -182.7.
If the court finds that the acquittee does not need inpatient hospitalization nor does he meet the criteria for conditional release, it shall release him without conditions, provided the court has approved a discharge plan prepared by the appropriate community services board or behavioral health authority in consultation with the appropriate hospital staff.
§ 19.2 -182.4. Confinement and treatment; interfacility transfers; out-of-hospital visits; notice of change in treatment
A. Upon commitment of an acquittee for inpatient hospitalization, the Commissioner shall determine the appropriate placement for him, based on his clinical needs and security requirements.
The Commissioner may make interfacility transfers and treatment and management decisions regarding acquittees in his custody without obtaining prior approval of or review by the committing court.
If the Commissioner is of the opinion that a temporary visit from the hospital would be therapeutic for the acquittee and that such visit would pose no substantial danger to others, the Commissioner may grant such visit not to exceed forty-eight hours.
B. The Commissioner shall give notice of the granting of an unescorted community visit to any victim of a felony offense against the person punishable by more than five years in prison that resulted in the charges on which the acquittee was acquitted or the next-of-kin of the victim at the last known address, provided the person seeking notice submits a written request for such notice to the Commissioner.
C. The Commissioner shall notify the attorney for the Commonwealth for the committing jurisdiction in writing of changes in an acquittee's course of treatment which will involve authorization for the acquittee to leave the grounds of the hospital in which he is confined.
§ 19.2 -182.5. Review of continuation of confinement hearing; procedure and reports; disposition
A. The committing court shall conduct a hearing twelve months after the date of commitment to assess the need for inpatient hospitalization of each acquittee who is acquitted of a felony by reason of insanity.
A hearing for assessment shall be conducted at yearly intervals for five years and at biennial intervals thereafter.
The court shall schedule the matter for hearing as soon as possible after it becomes due, giving the matter priority over all pending matters before the court.
B. Prior to the hearing, the Commissioner shall provide to the court a report evaluating the acquittee's condition and recommending treatment, to be prepared by a psychiatrist or a psychologist.
The psychologist who prepares the report shall be a clinical psychologist and any evaluating psychiatrist or clinical psychologist shall be skilled in the diagnosis of mental illness and qualified by training and experience to perform forensic evaluations.
If the examiner recommends release or the acquittee requests release, the acquittee's condition and need for inpatient hospitalization shall be evaluated by a second person with such credentials who is not currently treating the acquittee.
A copy of any report submitted pursuant to this subsection shall be sent to the attorney for the Commonwealth for the jurisdiction from which the acquittee was committed.
C. The acquittee shall be provided with adequate notice of the hearing, of the right to be present at the hearing, the right to the assistance of counsel in preparation for and during the hearing, and the right to introduce evidence and cross-examine witnesses at the hearing.
Written notice of the hearing shall be provided to the attorney for the Commonwealth for the committing jurisdiction.
The hearing is a civil proceeding. According to the determination of the court following the hearing, and based upon the report and other evidence provided at the hearing, the court shall (i) release the acquittee from confinement if he does not need inpatient hospitalization and does not meet the criteria for conditional release set forth in § 19.2 -182.7, provided the court has approved a discharge plan prepared jointly by the hospital staff and the appropriate community services board or behavioral health authority; (ii) place the acquittee on conditional release if he meets the criteria for conditional release, and the court has approved a conditional release plan prepared jointly by the hospital staff and the appropriate community services board or behavioral health authority; or (iii) order that he remain in the custody of the Commissioner if he continues to require inpatient hospitalization based on consideration of the factors set forth in § 19.2 -182.3.
D. An acquittee who is found not guilty of a misdemeanor by reason of insanity on or after July 1, 2002, shall remain in the custody of the Commissioner pursuant to this chapter for a period not to exceed one year from the date of acquittal.
If, prior to or at the conclusion of one year, the Commissioner determines that the acquittee meets the criteria for conditional release or release without conditions pursuant to § 19.2 -182.7, emergency custody pursuant to § 37.2 -808, temporary detention pursuant to §§ 37.2 -809 to 37.2 -813, or involuntary commitment pursuant to Article 5 (§ 37.2 -814 et seq.) of Chapter 8 of Title 37.2, he shall petition the committing court.
Written notice of an acquittee's scheduled release shall be provided by the Commissioner to the attorney for the Commonwealth for the committing jurisdiction not less than thirty days prior to the scheduled release.
The Commissioner's duty to file a petition upon such determination shall not preclude the ability of any other person meeting the requirements of § 37.2 -808 to file the petition.
§ 19.2 -182.12. Representation of Commonwealth and acquittee
The attorney for the Commonwealth shall represent the Commonwealth in all proceedings held pursuant to this chapter. The court shall appoint counsel for the acquittee unless the acquittee waives his right to counsel. The court shall consider appointment of the person who represented the acquittee at the last proceeding.
§ 19.2 -182.13. Authority of Commissioner; delegation to board; liability
The Commissioner may delegate any of the duties and powers imposed on or granted to him by this chapter to an administrative board composed of persons with demonstrated expertise in such matters. The Department of Behavioral Health and Developmental Services shall assist the board in its administrative and technical duties.
Members of the board shall exercise their powers and duties without compensation and shall be immune from personal liability while acting within the scope of their duties except for intentional misconduct.
§ 19.2 -182.14. Escape of persons placed or committed; penalty
Any person placed in the temporary custody of the Commissioner pursuant to § 19.2 -182.2 or committed to the custody of the Commissioner pursuant to § 19.2 -182.3 who escapes from such custody shall be guilty of a Class 6 felony.
§ 19.2 -182.6. Petition for release; conditional release hearing; notice; disposition
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A. The Commissioner may petition the committing court for conditional or unconditional release of the acquittee at any time he believes the acquittee no longer needs hospitalization. The petition shall be accompanied by a report of clinical findings supporting the petition with respect to the factors set forth in § 19.2 -182.3 and by a conditional release or discharge plan, as applicable, prepared jointly by the hospital and the appropriate community services board or behavioral health authority.
The acquittee may petition the committing court for release only once in each year in which no annual judicial review is required pursuant to § 19.2 -182.5.
The party petitioning for release shall transmit a copy of the petition to the attorney for the Commonwealth for the committing jurisdiction.
B. When a petition for release is made by the acquittee, the court shall order the Commissioner to appoint two persons in the same manner as set forth in § 19.2 -182.2 to assess and report on the acquittee's need for inpatient hospitalization by reviewing his condition with respect to the factors set forth in § 19.2 -182.3.
The evaluators shall conduct their evaluations and report their findings in accordance with the provisions of § 19.2 -182.2, except that the evaluations shall be completed and findings reported within 45 days of issuance of the court's order for evaluation.
2. When a petition for release is made by the Commissioner, no further evaluations of the acquittee shall be required unless otherwise deemed necessary by the court. If the court determines that further evaluation is necessary, the court shall order the Commissioner to appoint two persons in the same manner as set forth in § 19.2 -182.2.
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
To assess and report on the acquittee's need for inpatient hospitalization by reviewing his condition with respect to the factors set forth in § 19.2-182.3. The evaluators shall conduct their evaluations and report their findings in accordance with the provisions of § 19.2-182.2, except that the evaluations shall be completed and findings reported within 45 days of issuance of the court's order for evaluation.
The Commissioner shall give notice of the hearing to any victim of the act resulting in the charges on which the acquittee was acquitted or the next of kin of the victim at the last known address, provided that the person submits a written request for such notification to the Commissioner. ---
Section 2: The Temporary Custody Period & Outcomes
C. Upon receipt of the reports of evaluation, the court shall conduct a hearing on the petition. The hearing shall be scheduled on an expedited basis and given priority over other civil matters before the court.
The acquittee shall be provided with adequate notice of the hearing, of the right to be present at the hearing, the right to the assistance of counsel in preparation for and during the hearing, and the right to introduce evidence and cross-examine witnesses.
Written notice of the hearing shall be provided to the attorney for the Commonwealth for the committing jurisdiction.
The hearing is a civil proceeding. At the conclusion of the hearing, based upon the report and other evidence provided at the hearing, the court shall order the acquittee (i) released from confinement if he does not need inpatient hospitalization and does not meet the criteria for conditional release set forth in § 19.2-182.3, provided the court has approved a discharge plan prepared jointly by the hospital and the appropriate community services board or behavioral health authority; (ii) placed on conditional release if he meets the criteria for such release as set forth in § 19.2-182.7, and the court has approved a conditional release plan prepared jointly by the hospital and the appropriate community services board or behavioral health authority; or (iii) retained in the custody of the Commissioner if he continues to require inpatient hospitalization based on consideration of the factors set forth in § 19.2-182.3.
D. Persons committed pursuant to this chapter shall be released only in accordance with the procedures set forth governing release and conditional release. ---
Section 3: Commitment & the Graduated Release Process
1991, c. 427; 1993, c. 295; 2007, cc. 485, 565, 785.
§ 19.2-182.7. Conditional release; criteria; conditions; reports
At any time the court considers the acquittee's need for inpatient hospitalization pursuant to this chapter, it shall place the acquittee on conditional release if it finds that (i) based on consideration of the factors which the court must consider in its commitment decision, he does not need inpatient hospitalization but needs outpatient treatment or monitoring to prevent his condition from deteriorating to a degree that he would need inpatient hospitalization; (ii) appropriate outpatient supervision and treatment are reasonably available; (iii) there is significant reason to believe that the acquittee, if conditionally released, would comply with the conditions specified; and (iv) conditional release will not present an undue risk to public safety.
The court shall subject a conditionally released acquittee to such orders and conditions it deems will best meet the acquittee's need for treatment and supervision and best serve the interests of justice and society.
The community services board or behavioral health authority as designated by the Commissioner shall implement the court's conditional release orders and shall submit written reports to the court on the acquittee's progress and adjustment in the community no less frequently than every six months.
An acquittee's conditional release shall not be revoked solely because of his voluntary admission to a state hospital.
After a finding by the court that the acquittee has violated the conditions of his release but does not require inpatient hospitalization pursuant to § 19.2-182.8, the court may hold the acquittee in contempt of court for violation of the conditional release order. ---
§ 19.2-182.8. Revocation of conditional release
If at any time the court that released an acquittee pursuant to § 19.2-182.7 finds reasonable ground to believe that an acquittee on conditional release (i) has violated the conditions of his release or is no longer a proper subject for conditional release based on application of the criteria for conditional release and (ii) requires inpatient hospitalization, it may order an evaluation of the acquittee by a psychiatrist or clinical psychologist, provided the psychiatrist or clinical psychologist is qualified by training and experience to perform forensic evaluations.
If the court, based on the evaluation and after hearing evidence on the issue, finds by a preponderance of the evidence that an acquittee on conditional release (a) has violated the conditions of his release or is no longer a proper subject for conditional release based on application of the criteria for conditional release and (b) has mental illness or intellectual disability and requires inpatient hospitalization, the court may revoke the acquittee's conditional release and order him returned to the custody of the Commissioner.
At any hearing pursuant to this section, the acquittee shall be provided with adequate notice of the hearing, of the right to be present at the hearing, the right to the assistance of counsel in preparation for and during the hearing, and the right to introduce evidence and cross-examine witnesses at the hearing.
The hearing shall be scheduled on an expedited basis and shall be given priority over other civil matters before the court.
Written notice of the hearing shall be provided to the attorney for the Commonwealth for the committing jurisdiction.
The hearing is a civil proceeding. ---
§ 19.2-182.9. Emergency custody of conditionally released acquittee
When exigent circumstances do not permit compliance with revocation procedures set forth in § 19.2-182.8, any district court judge or a special justice, as defined in § 37.2-100, or a magistrate may issue an emergency custody order, upon the sworn petition of any responsible person or upon his own motion based upon probable cause to believe that an acquittee on conditional release (i) has violated the conditions of his release or is no longer a proper subject for conditional release and (ii) requires inpatient hospitalization.
The emergency custody order shall require the acquittee within his judicial district to be taken into custody and transported to a convenient location where a person designated by the community services board or behavioral health authority who is skilled in the diagnosis and treatment of mental illness shall evaluate such acquittee and assess his need for inpatient hospitalization.
A law-enforcement officer who, based on his observation or the reliable reports of others, has probable cause to believe that any acquittee on conditional release has violated the conditions of his release and is no longer a proper subject for conditional release and requires emergency evaluation to assess the need for inpatient hospitalization, may take the acquittee into custody and transport him to an appropriate location to assess the need for hospitalization without prior judicial authorization.
The evaluation shall be conducted immediately. The acquittee shall remain in custody until a temporary detention order is issued or until he is released, but in no event shall the period of custody exceed eight hours.
If it appears from all evidence readily available (a) that the acquittee has violated the conditions of his release or is no longer a proper subject for conditional release and (b) that he requires emergency evaluation to assess the need for inpatient hospitalization, the district court judge or a special justice, as defined in § 37.2-100, or magistrate, upon the advice of such person skilled in the diagnosis and treatment of mental illness, may issue a temporary detention order authorizing the executing officer to place the acquittee in an appropriate institution for a period not to exceed 72 hours prior to a hearing.
If the 72-hour period terminates on a Saturday, Sunday, legal holiday, or day on which the court is lawfully closed, the acquittee may be detained until the next day which is not a Saturday, Sunday, legal holiday, or day on which the court is lawfully closed.
The committing court or any district court judge or a special justice, as defined in § 37.2-100, shall have jurisdiction to hear the matter.
Prior to the hearing, the acquittee shall be examined by a psychiatrist or licensed clinical psychologist, provided the psychiatrist or clinical psychologist is skilled in the diagnosis of mental illness, who shall certify whether the person is in need of hospitalization.
At the hearing the acquittee shall be provided with adequate notice of the hearing, of the right to be present at the hearing, the right to the assistance of counsel in preparation for and during the hearing, and the right to introduce evidence and cross-examine witnesses at the hearing.
Following the hearing, if the court determines, based on a preponderance of the evidence presented at the hearing, that the acquittee (1) has violated the conditions of his release or is no longer a proper subject for conditional release and (2) has mental illness or intellectual disability and is in need of inpatient hospitalization, the court shall revoke the acquittee's conditional release and place him in the custody of the Commissioner.
When an acquittee on conditional release pursuant to this chapter is taken into emergency custody, detained, or hospitalized, such action shall be considered to have been taken pursuant to this section, notwithstanding the fact that his status as an insanity acquittee was not known at the time of custody, detention, or hospitalization.
Detention or hospitalization of an acquittee pursuant to provisions of law other than those applicable to insanity acquittees pursuant to this chapter shall not render the detention or hospitalization invalid.
If a person's status as an insanity acquittee on conditional release is not recognized at the time of emergency custody or detention, at the time his status as such is verified, the provisions applicable to such persons shall be applied and the court hearing the matter shall notify the committing court of the proceedings. ---
§ 19.2-182.10. Release of person whose conditional release was revoked
If an acquittee is returned to the custody of the Commissioner for inpatient treatment pursuant to revocation proceedings, and his condition improves to the degree that, within 60 days of resumption of custody following the hearing, the acquittee, in the opinion of hospital staff treating the acquittee and the supervising community services board or behavioral health authority, is an appropriate candidate for conditional release, he may be, with the approval of the court, conditionally released as if revocation had not taken place.
If treatment is required for longer than 60 days, the acquittee shall be returned to the custody of the Commissioner for a period of hospitalization and treatment which is governed by the provisions of this chapter applicable to committed acquittees. ---
§ 19.2-182.15. Escape of persons placed on conditional release; penalty
Any person...
Not Guilty by Reason of Insanity: Reference Manual for Community Services Boards & Behavioral Health Authorities
---Section 1: The Insanity Defense & the NGRI Finding
Placed on conditional release pursuant to § 19.2-182.7, who leaves the Commonwealth without permission from the court that conditionally released the person shall be guilty of a Class 6 felony. 1993, c. 295. § 19.2-182.11.
Modification or removal of conditions; notice; objections; review.
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A. The committing court may modify conditions of release or remove conditions placed on release pursuant to § 19.2-182.7, upon petition of the supervising community services board or behavioral health authority, the attorney for the Commonwealth, or the acquittee or upon its own motion based on reports of the supervising community services board or behavioral health authority. However, the acquittee may petition only annually commencing six months after the conditional release order is issued. Upon petition, the court shall require the supervising community services board or behavioral health authority to provide a report on the acquittee's progress while on conditional release.
B. As it deems appropriate based on the community services board's or behavioral health authority's report and any other evidence provided to it, the court may issue a proposed order for modification or removal of conditions. The court shall provide notice of the order, and their right to object to it within ten days of its issuance, to the acquittee, the supervising community services board or behavioral health authority, and the attorney for the Commonwealth for the committing jurisdiction and for the jurisdiction where the acquittee is residing on conditional release. The proposed order shall become final if no objection is filed within ten days of its issuance. If an objection is so filed, the court shall conduct a hearing at which the acquittee, the attorney for the Commonwealth, and the supervising community services board or behavioral health authority have an opportunity to present evidence challenging the proposed order. At the conclusion of the hearing, the court shall issue an order specifying conditions of release or removing existing conditions of release.
1991, c. 427; 2007, cc. 485, 565. ---
Section 2: The Temporary Custody Period & Outcomes
Appendix K: Forensic Coordinator/Facility Staff
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Facility: Catawba Hospital
Address: P.O. Box 200, Catawba, VA 24070; 5525 Catawba Hospital Dr., Catawba, VA 24070-0200
Staff:
• Walton Mitchell, MSW, Acting Forensic Director & Hospital Director
• Sherry Weaver, Executive Assistant/Forensic Secretary (FIMS user)
Contact:
Phone: (540) 375-4201
Fax: (540) 375-4394
Email: walton.mitchell@dbhds.virginia.gov
Email: sherry.weaver@dbhds.virginia.gov
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Facility: Central State Hospital
Address: P.O. Box 4030, Petersburg, VA 23803-0030; 23617 West Washington St., Petersburg, VA 23803-0030
Staff:
• Ted Simpson, Psy.D., Chief Forensic Coordinator
• Martin N. Bauer, Ph.D., Forensic Coordinator
• Shawn Ben, Administrative Assistant (FIMS user)
• Spencer Timberlake, CSWS Forensic Intake Coordinator
Contact:
Phone: (804) 524-7054
Fax: (804) 524-7069
Email: ted.simpson@dbhds.virginia.gov
Email: martin.bauer@dbhds.virginia.gov
Email: shawn.ben@dbhds.virginia.gov
Email: spencer.timberlake@dbhds.virginia.gov
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Facility: Commonwealth Center For Children & Adolescents
Address: P.O. Box 4000, Staunton, VA 24402-4000; 1355 Richmond Road, Staunton, VA 24402
Staff:
• Gary Pelton, Ph.D., Forensic Coordinator
• Diane Randolph, Administrative Support Specialist (FIMS user)
Contact:
Phone: (540) 332-2121
Fax: (540) 332-2210
Email: gary.pelton@dbhds.virginia.gov
Email: diane.randolph@dbhds.virginia.gov
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Facility: Eastern State Hospital
Address: 4601 Ironbound Road, Williamsburg, VA 23188
Staff:
• Michael Kohn, Psy.D., Forensic Coordinator - NGRI
• Ann VanSkiver, Psy.D., Assistant Forensic Coordinator
• Kristen Hudacek, Psy.D., Psychology Director and Forensic Coordinator - Pre-Trial
• Roberta Ferrell, Forensic Admissions Coordinator
• Patty Thomas, Forensic Administrative Assistant (FIMS user)
Contact:
Phone: (757) 208-7609
Fax: (757) 253-4703
Email: michael.kohn@dbhds.virginia.gov
Email: ann.vanskiver@dbhds.virginia.gov
Email: Kristen.hudacek@dbhds.virginia.gov
Email: Roberta.Ferrell-Holiday@dbhds.virginia.gov
Email: Patty.thomas@dbhds.virginia.gov
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Facility: Northern Virginia Mental Health Institute
Address: 3302 Gallows Road, Falls Church, VA 22042
Staff:
• Azure Baron, Psy.D., Director of Psychology and Forensic Coordinator
• Diane Corum, Forensic Administrative Assistant (FIMS user)
Contact:
Phone: (703) 645-4004
Fax: (703) 645-4006
Email: Azure.Baron@dbhds.virginia.gov
Email: diane.corum@dbhds.virginia.gov
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Facility: Piedmont Geriatric Hospital
Address: P.O. Box 427, Burkeville, VA 23922-0427; 5001 E. Patrick Henry Hwy., Burkeville, VA 23922-0427
Staff:
• Lindsey K. Slaughter, Psy.D., ABPP, Psychology Director and Forensic Coordinator
• Kristen Wilborn, Administrative Assistant for Psychology Department (FIMS user)
Contact:
Phone: (434) 767-4424
Fax: (434) 767-2381
Email: lindsey.slaughter@dbhds.virginia.gov
Email: kristen.wilbornr@dbhds.virginia.gov
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Facility: Southern Virginia Mental Health Institute
Address: 382 Taylor Drive, Danville, VA 24541-4023
Staff:
• Blanche Williams, Ph.D., Director of Psychology & Forensic Coordinator
• Dora Reynolds, Administrative & Office Specialist (FIMS user)
Contact:
Phone: (434) 773-4237
Fax: (434) 791-5403
Email: Blanche.williams@dbhds.virginia.gov
Email: dora.reynolds@dbhds.virginia.gov
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Facility: Southwestern Virginia Mental Health Institute
Address: 340 Bagley Circle, Marion, VA 24354-3390
Staff:
• Colin Barrom, Ph.D., Director of Psychology & Forensic Coordinator
• Connie Adams, Office Services Assistant (FIMS user)
Contact:
Phone: (276) 783-0805
Fax: (276) 783-0840
Email: colin.barrom@dbhds.virginia.gov
Email: connie.adams@dbhds.virginia.gov
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Facility: Western State Hospital
Address: P.O. Box 2500, Staunton, VA 24402-2500; 103 Valley Center Drive, Staunton, VA 24402
Staff:
• David Rawls, Ph.D., Pre-Trial Forensic Coordinator
• Brian Kiernan, Ph.D., NGRI Forensic Coordinator
• Doris Kessler, Forensic Administrative Specialist (FIMS user)
Contact:
Phone: (540) 332-8072
Email: david.rawls@dbhds.virginia.gov
Phone: (540) 332-8007
Email: brian.kiernan@dbhds.virginia.gov
Doris Kessler, Phone: (540) 332-8072, Fax: (540) 332-8145, Email: doris.kessler@dbhds.virginia.gov
Section 3: The Graduated Release Process
Office of Forensic Services - Central Office Staff
-
Address: P.O. Box 1797, Richmond, VA 23218
Location: Jefferson Building, 1220 Bank Street, Richmond, VA 23219
Fax: (804) 786-9621
Staff:
• Michael Schaefer, Ph.D., ABPP, Assistant Commissioner of Forensic Services
• Richard Wright, M.S., Forensic Mental Health Consultant
• Sarah Shrum, M.A., Statewide Jail Diversion Program Coordinator
• Jana Braswell, M.S., Statewide Crisis Intervention Team (CIT) Program Coordinator
• Stephen Craver, Statewide CIT Assessment Center Coordinator
• Diana Peña, Forensic Program Specialist (FIMS User)
Contact:
Phone: (804) 786-2615
Cell: (804) 363-9306
Email: michael.schaefer@dbhds.virginia.gov
Email: richard.wright@dbhds.virginia.gov
Email: sarah.shrum@dbhds.virginia.gov
Email: jana.braswell@dbhds.virginia.gov
Email: stephen.craver@dbhds.virginia.gov
Email: diana.pena@dbhds.virginia.gov
Guidance for Medical Radioactive Material Use (3942_ORH-720-G.pdf)
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
1 Commonwealth of Virginia Radiation Protection Regulatory Guide
Guidance for Medical Use of Radioactive Material
ORH -720 G
Virginia Department of Health Radioactive Materials Program
109 Governor Street, Room 730 Richmond, VA 23219
Phone: (804) 864 -8150
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Virginia Regulatory Guides (VAREGS) are issued to describe and make available to the applicant or licensee, acceptable methods of implementing specific parts of the 12VAC5 -481 ‘Virginia Radiation Protection Regulations’ to delineate techniques used by staff in evaluating past specific problems or postulated accidents, and to provide guidance to applicants or licensees.
VAREGS are not substitutes for 12VAC5 -481 ‘Virginia Radiation Protection Regulations’; therefore, compliance with them is not required.
Methods and solutions different from those set forth in this guide will be acceptable if they provide a basis for the Virginia Department of Health (VDH), Radioactive Materials Program, to determine if a radiation protection program meets the current rule and protects health and safety.
Comments and suggestions for improvements in this VAREG are encouraged at all times and it will be revised, as appropriate, to accommodate comments and to reflect new information or experience.
Comments should be sent to Virginia Department of Health, Radioactive Materials Program, 109 Governor Street, Room 730, Richmond, VA 23219.
Requests for single copies of this guide (which may be reproduced) can be made in writing to Virginia Department of Health, Radioactive Materials Program, 109 Governor Street, Room 730, Richmond, VA 23219.
This guide is also available on our website: http://www.vdh.virginia.gov/radiological-health/radiological-health/materials/forms-postings/.
This VAREG, ‘Guidance for Medical Use of Radioactive Material’ has been developed to streamline the application process for a Medical Use of Radioactive Material License.
A web link to a copy of the VDH Form, ‘Application for Radioactive Material License for Medical Use’ is located in Appendix A of this guide.
Appendix D through Z provide examples, models and additional information that can be used when completing the application.
It typically takes 60-90 days for a license to be processed and issued if the application is complete.
When submitting the application be sure to include the appropriate application fee listed in 12VAC5 -490 for:
-
Category 7A: Teletherapy, HDR, or stereotactic radiosurgery (including mobile)
Category 7B: Broad scope except Teletherapy, HDR or stereotactic radiosurgery
Category 7C: Mobile Nuclear Medicine
Category 7D: Medical-all others, including SNM Pacemakers
In summary, the applicant will need to do the following to submit an application for a Medical Use license:
-
Use this regulatory guide to prepare the VDH Form, ‘Application for Radioactive Material License for Medical Use’ (Appendix A).
Complete VDH Form, ‘Application for Radioactive Material License for Medical Use’ (Appendix A). See ‘Contents of Application’ of the guide for additional information.
Include any additional attachments. All supplemental pages should be submitted on 8 ½” x 11” paper. Please identify all attachments with the applicant’s name and license number (if a renewal).
Avoid submitting proprietary information unless it is absolutely necessary. If submitted, proprietary information and other sensitive information should be clearly identified and a request made to withhold from public disclosure.
Submit an original signed application along with attachments (if any). This submission can be made via scanned copies forwarded via facsimile or electronic mail or via postal mail of the documents.
Submit the application fee (for new licenses only).
Retain one copy of the license application and attachments (if any) for your future reference. You will need this information because the license will require that radioactive material be possessed and used in accordance with statements, representation, and procedures provided in the application and supporting documentation.
If you have any questions about the application process, please contact this office at (804) 864 -8150.
CONTENTS
-
Executive Summary ................................ ................................ ................................ ................................ ................ 2
Contents 4
List of Appendices ................................ ................................ ................................ ................................ .................. 5
List of Tables 5
List of Figures 6
Abbreviations 7
Purpose of Guide ................................ ................................ ................................ ................................ ..................... 9
Licenses ................................ ................................ ................................ ................................ ................................ ................................ ... 11
General In Vitro License ................................ ................................ ................................ ................................ ................................ .......... 11
Specific License of Limited Scope ................................ ................................ ................................ ................................ .......................... 12
Specific License of Broad Scope ................................ ................................ ................................ ................................ ............................. 13
The "ALARA" Concept ................................ ................................ ................................ ................................ ................................ ............ 14
Written Directive (WD) Procedures ................................ ................................ ................................ ................................ ........................ 15
Research Involving Human Subjects ................................ ................................ ................................ ................................ ....................... 16
Who Regulates at Federal Facilities in Wisconsin ................................ ................................ ............................... 17
Management Responsibility ................................ ................................ ................................ ................................ .. 18
Licenses ................................ ................................ ................................ ................................ ................................ ................................ ... 19
Applicable Rule ................................ ................................ ................................ ................................ .................... 20
How to File Where to File 22
License Fees 23
Contents of an Application Item 1 Type of Application ................................ ................................ ................................ ................................ ..... 24
Item 2 Applicant's Name and Mailing Address ................................ ................................ ................................ ................................ 24
Item 3 Person To Be Contacted About This Application ................................ ................................ ................................ ........................ 26
Item 4 Addresses(es) Where Radioactive Material Will be Used or Possessed ................................ ................................ 26
Radiation Safety Officer and Authorized User(s) Item 5 Individual(s) Responsible for Radiation Safety Program and Their Training and Experience ................................ .................... 27
Item 5.1 Radiation Safety Officer (RSO) ................................ ................................ ................................ ................................ ................ 28
Item 5.2 Associate Radiation Safety Officer (ARSO) ................................ ................................ ................................ ............................. 29
Item 5.3 Authorized Users (AU) ................................ ................................ ................................ ................................ ............................. 31
Item 5.4 Authorized Nuclear Pharmacist (ANP) ................................ ................................ ................................ ................................ ....
Item 5.5 Authorized Medical Physicist (AMP) or Ophthalmic Physicist ................................ ................................ ............................... 33
Item 6 Training for Individuals Working In or Frequenting Restricted Areas ................................ ................................ ........................ 33
Radioactive Material Item 7 Radioactive Material ................................ ................................ ................................ ................................ ................................ .... 34
Item 7.1 Radioactive Material, Chemical & Physical Form, Possession Limit & Type of Use ................................ .............................. 35
Item 7.2 Recordkeeping for Decommissioning and Financial Assurance ................................ ................................ ............................... 39
Item 7.3 Sealed Sources and Devices ................................ ................................ ................................ ................................ ..................... 40
Item 7.4 Disposition of Material and Termination of License ................................ ................................ ................................ ................ 41
Facilities and Equipment Item 8 Facilities and Equipment ................................ ................................ ................................ ................................ ............................. 42
Item 8.1 Facilities Diagram ................................ ................................ ................................ ................................ ................................ ..... 42
Item 8.2 Radiation Monitoring Instrumentation ................................ ................................ ................................ ................................ ..... 45
Item 8.3 Dose Calibrator and other Equipment used to Measure Dosages of Unsealed Radioactive Material ................................ ....... 46
Item 8.4 Dosimetry Equipment - Calibration and Use ................................ ................................ ................................ ............................ 47
Item 8.5 Other Equipment and Facilities ................................ ................................ ................................ ................................ ................ 48
Radiation Protection Program Item 9 Radiation Protection Program ................................ ................................ ................................ ...................... 50
Item 9.1 Audit Program ................................ ................................ ................................ ................................ ................................ .......... 51
Item 9. 2 Occupational Dose ................................ ................................ ................................ ................................ ................................ .... 52
Item 9.3 Public Dose ................................ ................................ ................................ ................................ ................................ ............... 54
Item 9.4 Minimization
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance to an applicant in preparing a medical use of radioactive materials license application.
It also provides guidance on VDH’s criteria for evaluating a medical use license application.
It is not intended to address the commercial aspects of manufacturing, distribution, and service of sources in devices.
It does not specifically describe the possession and use of...
Description of VAREGS
Details about VAREGS are provided here.
Application Process and Guidance
Guidance on the application process, including necessary documentation and procedures, is outlined in this section.
Appendices
Appendix A: Application for Radioactive Material License for Medical Use
Appendix B: Reserved
Appendix C: DPH Form 45007, ‘Certificate of Disposition of Materials’
Appendix D: Information Needed for Transfer of Control
Appendix E: Guidance on Financial Assurance Determination
Appendix F: Typical Duties and Responsibilities of the Radiation Safety Officer / Associate Radiation Safety Officer and Sample Delegation of Authority
Appendix G: Documentation of Training and Experience for Authorized User, Radiation Safety Officer, Authorized Nuclear Pharmacist, Authorized Medical Physicist or Ophthalmologic Physicist
Appendix H: Training Programs
Appendix I: Radiation Monitoring Instrument Specifications and Model Survey Instrument Calibration Program
Appendix J: Model Emergency Procedures for Manual Brachytherapy Permanent Implants
Appendix K: Suggested Medical Licensee Audit
Appendix L: Procedures for an Occupational Dose Program
Appendix M: Reserved
Appendix N: Emergency Procedures
Appendix O: Procedures for Ordering and Receiving Packages
Appendix P: Model Procedure for Safely Opening Packages Containing Radioactive Material
Appendix Q: Leak Test Program
Appendix R: Procedure for Area Surveys
Appendix S: Model Procedure for Developing, Maintaining, and Implementing Written Directives
Appendix T: Procedure for Safe Use of Licensed Material
Appendix U: Release of Patients or Human Research Subjects Administered Radioactive Materials
Appendix V: Guidance for Mobile Medical Services
Appendix W: Summary of DOT Requirements for Transportation of Type A or Type B Quantities of Licensed Material
Appendix X: Procedure for Waste Disposal by Decay-In-Storage, Generator Return and Licensed Material Return
Appendix Y: Recordkeeping Requirements
Appendix Z: Reporting Requirements
Tables
-
Table 1: Who Regulates the Activity?
Figures
-
Figure 6: Facility Diagram for Nuclear Medicine Suite
Figure 7: Annual Occupational Dose Limits for Adults
Abbreviations
-
AAPM: American Association of Physicists in Medicine
ALARA: as low as is reasonably achievable
ALI: annual limit on intake
AMP: Authorized Medical Physicist
ANP: Authorized Nuclear Pharmacist
ANSI: American National Standards Institute
ARSO: Associate Radiation Safety Officer
AU: Authorized User
bkg: background
Bq: Becquerel
CFR: Code of Federal Regulations
Ci: Curie
cc: centimeter cubed
cm2: centimeter squared
Co-57: cobalt-57
Co-60: cobalt-60
cpm: counts per minute
Cs-137: cesium-137
DAC: derived air concentration
DOT: United States Department of Transportation
dpm: disintegrations per minute
FDA: United States Food and Drug Administration
GM: Geiger-Mueller
GSR: gamma stereotactic radiosurgery
HDR: high dose-rate
I-125: iodine-125
I-131: iodine-131
IN: Information Notice
Ir-192: iridium-192
LDR: low dose-rate
mCi: millicurie
ml: milliliter
mR: milliroentgen
mrem: millirem
mSv: millisievert
NaI(Tl): sodium iodide (thallium doped)
NCRP: National Council on Radiation Protection and Measurements
NIST: National Institute of Standards and Technology
NRC: United States Nuclear Regulatory Commission
NVLAP: National Voluntary Laboratory Accreditation Program
OCR: optical character reader
OSL: optically stimulated luminescence dosimeters
P-32: phosphorus-32
Pd-103: palladium-103
PDR: pulsed dose-rate
QA: quality assurance
Ra-226: radium-226
RG: Regulatory Guide
RSC: Radiation Safety Committee
RSO: Radiation Safety Officer
SDE: shallow-dose equivalent
SI: International System of Units (abbreviated SI from the French Le Système Internationale d’Unites)
Sr-90: strontium-90
SSDR: Sealed Source and Device Registration
Sv: Sievert
Tc-99m: technetium-99m
TEDE: total effective dose equivalent
TLD: thermoluminescent dosimeters
U-235: uranium-235
VDH: Virginia Department of Health, Radioactive Materials Program
WD: written directive
μCi: microcurie
%: percent
PURPOSE OF GUIDE
This document provides guidance to an applicant in preparing a medical use of radioactive materials license application.
It also provides guidance on VDH’s criteria for evaluating a medical use license application.
It is not intended to address the commercial aspects of manufacturing, distribution, and service of sources in devices.
It does not specifically describe the possession and use of...
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Pacemakers, which are addressed in 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part III, ‘Licensing of Radioactive Materials.’ The term “patient” is used to represent “patient” or “human research subject” throughout this guide.
The term “applicant” is used when describing the application process and the term “licensee” is used when describing a regulatory requirement.
This guide addresses the wide variety of radionuclides used in medicine. Typical uses are:
-
Diagnostic studies with unsealed radionuclides;
Therapeutic administrations with unsealed radionuclides;
Diagnostic studies with sealed radionuclides;
Manual brachytherapy with sealed sources; and
Therapeutic administrations with sealed sources in devices (i.e., teletherapy, remote afterloaders, and gamma stereotactic radiosurgery units).
This guide describes the information needed to complete VDH Form, ‘Application for Radioactive Material License for Medical Use’ (Appendix A).
This guide does not directly address complete radiation safety and licensing guidance for uses specified under 12VAC5-481-2060, ‘Other medical uses of byproduct material or radiation from byproduct material.’ Therefore, VDH Radioactive Material Program staff should be contacted with questions regarding information not provided.
The format for each item number in this guide is as follows:
-
Rule - references the requirements of 12VAC5-481 ‘Virginia Radiation Protection Regulations’ applicable to the item;
Criteria - outlines the criteria used to judge the adequacy of the applicant’s response;
Discussion - provides additional information on the topic sufficient to meet the needs of most readers.
The information submitted in the application must be sufficient to demonstrate that proposed equipment, facilities, personnel, and procedures are adequate to protect the health and safety of the citizens of the Virginia in accordance with agency guidelines.
Submission of incomplete or inadequate information will result in delays in the approval process for the license.
Additional information will be requested when necessary to ensure that an adequate radiation safety program has been established.
Such requests for additional information will delay completion of the application’s review and may be avoided by a thorough study of the rule and these instructions prior to submitting the application.
12VAC5-481, ‘Virginia Radiation Protection Regulations,’ requires the applicant and/or licensee to develop, document, and implement procedures that will ensure compliance with the rule.
The appendices describe radiation protection procedures. Each applicant should read the rule and procedures carefully and then decide if the procedure addresses specific radiation protection program needs at the applicant’s facility.
Applicants may adopt a procedure included in this VAREG or they may develop their own procedures to comply with the applicable rule.
In this guide, “dose” or “radiation dose” means absorbed dose, dose equivalent, effective dose equivalent, committed dose equivalent, committed effective dose equivalent, or total effective dose equivalent (TEDE).
These terms are defined in the 12VAC5-481-10.
Rem and Sievert (Sv), its SI equivalent (1 rem = 0.01 Sv), are used to describe units of radiation exposure or dose.
These units are used because 12VAC5-481, ‘Virginia Radiation Protection Regulations,’ Part IV ‘Standards for Protection Against Radiation,’ sets dose limits in terms of rem, not rad or roentgen.
Furthermore, radioactive materials commonly used in medicine emit beta and photon radiation, for which the quality factor is 1; a useful rule of thumb is an exposure of 1 roentgen is equivalent to an absorbed dose of 1 rad and dose equivalent of 1 rem.
This VAREG provides the latest guidance, shows the requirements in terms of the 12VAC5-481, and provides a user-friendly format to assist with the preparation of a license application.
Specific information has been included for technologies that are now more commonly used such as computerized remote afterloading brachytherapy and gamma stereotactic radiosurgery.
Applicants and licensees should be aware of other VAREGs that provide useful information for medical use licensees. For example, VAREG ‘Guidance for Licenses of Broad Scope’ provides additional licensing guidance on medical use programs of broad scope.
Revision 4 January 14, 2022
LICENSES
VDH regulates the intentional internal or external administration of radioactive material, or the radiation from radioactive material, to patients or human research subjects for medical use.
VDH issues three types of licenses for the use of radioactive material in medical practices and facilities. These are the general in vitro license, the specific license of limited scope, and the specific license of broad scope.
These licenses are issued pursuant to 12VAC5-481 ‘Virginia Radiation Protection Regulations,’ Part III ‘Licensing of Radioactive Materials.’
VDH usually issues a single radioactive material license to cover an entire radionuclide program.
A license including teletherapy may also contain the authorization for source material (i.e., depleted uranium) used as shielding in many teletherapy units.
Although VDH may issue separate licenses to individual licensees for different medical uses, it does not usually issue separate licenses to different departments in a medical facility or to individuals employed by or with whom the medical facility has contracted.
Only the facility’s management may sign the license application.
Applicants should review this document, related guidance, and all applicable regulations carefully before completing the VDH Form ‘Application for Radioactive Material License for Medical Use’.
VDH expects licensees to provide requested information on specific aspects of their proposed radiation protection program in attachments to the application.
When necessary, VDH may ask the applicant for additional information to gain reasonable assurance that an adequate radiation protection program has been established.
After a license is issued, the licensee must conduct its program in accordance with the following:
-
Statements, representations, and procedures contained in the application and in correspondence with VDH;
Terms and conditions of the license; and
12VAC 5-481 ‘Virginia Radiation Protection Regulations’.
GENERAL IN VITRO LICENSE
In 12VAC5-481-430 G, ‘General license for use of byproduct material for certain in vitro clinical or laboratory testing,’ VDH issues a general license authorizing physicians, veterinarians, clinical laboratories, and hospitals to receive, acquire, possess, or use small quantities of certain radioactive material for in vitro clinical or laboratory tests not involving ‘medical use’ (i.e., not involving administration to humans).
A summary of the above rule is available from the VDH website located at http://www.vdh.virginia.gov/radiological-health/radiological-health/materials/12vac5-481-virginia-radiation-protection-regulations/, which explains the requirements for using the materials listed.
If the general license alone meets the applicant’s needs, appropriate information should be provided to VDH.
Medical use licensees authorized pursuant to 12VAC5-481 ‘Virginia Radiation Protection Regulations, Part VII ‘Use of Radionuclides in the Healing Arts’ do not need to file the form.
VDH limits possession to a total of 200 microcuries of photon-emitting materials listed in 12VAC5-481-430 G at any one time, at any one location of storage or use.
The use of materials listed in 12VAC5-481-430 G within the inventory limits of that section is subject only to the requirements of that section and not to the requirements of 12VAC5-481 ‘Virginia Radiation Protection Regulations,’ Part IV ‘Standards for Protection Against Radiation’ and Part X, ‘Notices, Instructions and Reports to Workers,’ except as set forth in 12VAC5-481-430 G.
An applicant needing more than 200 microcuries of these materials must apply for a specific license and may request the increased inventory limit as a separate line item on VDH Form, ‘Application for Radioactive Material License for Medical Use’.
This type of applicant generally requests an increased limit of 3 millicuries.
If requesting an increased inventory limit, the applicant will be subject to the requirements of 12VAC5-481 ‘Virginia Radiation Protection Regulations,’ Part IV ‘Standards for Protection Against Radiation,’ including the requirements for waste disposal and Part X ‘Notices, Instructions and Reports to Workers’.
SPECIFIC LICENSE OF LIMITED SCOPE
VDH issues specific medical licenses of limited scope to private or group medical practices and to medical institutions.
A medical institution is an organization in which more than one medical discipline is practiced.
In general, individual physicians or physician groups located within a licensed medical facility (e.g., hospital) may not apply for a separate license because 12VAC5-481-450 refers to the applicant’s facilities.
Since a physician group does not normally have control over the facilities, the hospital remains responsible for activities conducted on its premises and must apply for the license.
On specific licenses of limited scope, the authorized users are individually listed in the license.
Radioactive material may be administered to patients on an inpatient (i.e., hospitalized) or outpatient basis.
For patients to whom radioactive material is administered, who are not releasable under 12VAC5-481-1870, inpatient facilities are required.
In general, facilities for private and group practices do not include inpatient rooms and, therefore, procedures requiring hospitalization of the patient cannot be performed.
A specific license of limited scope may also be issued to an entity requesting to perform mobile medical services (12VAC5-481-1880, 12VAC5-481-2040).
A medical institution or a private or group practice may apply for authorization to use radioactive material in a mobile medical service.
SPECIFIC LICENSE OF BROAD SCOPE
Medical institutions that provide patient care and conduct research programs that use radionuclides for in vitro, animal, and medical procedures may request a specific license of broad scope in accordance with 12VAC5-481 ‘Virginia Radiation Protection Regulations,’ Part III ‘Licensing of Radioactive Materials.’
The criteria for the various types of broad scope licenses are found in 12VAC 5-480-470.
Generally, VDH issues specific licenses of broad scope for medical use (i.e., licenses authorizing multiple quantities and types of radioactive material for unspecified uses) to institutions that (1) have experience successfully operating under a specific license of limited scope; and (2) are engaged in medical research and routine diagnostic and therapeutic uses of radioactive material.
VAREG ORH-720 I, ‘Guidance for Licenses of Broad Scope,’ offers additional guidance to applicants for a specific license of broad scope.
THE ‘AS LOW AS IS REASONABLY ACHIEVABLE (ALARA)’ CONCEPT
12VAC5-481-630, Radiation protection programs, states that “each licensee shall develop, document, and implement a radiation protection program commensurate with the scope and extent of licensed activities” and “the licensee shall use, to the extent practical, procedures and engineering controls based upon sound radiation protection principles to achieve occupational doses and doses to members of the public that are...ALARA.”
This section also requires that licensees review the content of the radiation protection program and its implementation annually.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
Protection Against Radiation’, is contained in:
-
NRC’s NUREG -1736, ‘Consolidated Guidance: 10 CFR Part 20 - Standards for Protection Against Radiation.’
Applicants should consider the ALA RA philosophy detailed in these reports when developing plans to work with licensed radioactive materials.
WRITTEN DIRECTIVE (WD) PROCEDURES
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12VAC5-481-1730 requires medical use licensees to develop, implement, and maintain written procedures to provide high confidence that before each administration requiring a WD, the patient’s identity is verified and the administration is in accordance with the WD.
This rule also specifies what, at a minimum, these procedures must address. Appendix S provides further information on developing these procedures.
RESEARCH INVOLVING HUMAN SUBJECTS
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12VAC5-481-10 defines “medical use” to include the administration of radioactive material to human research subjects.
Furthermore, 12VAC5-481-1670, ‘Provisions for the protection of human research subjects’, addresses the protection of the rights of human subjects involved in research conducted by limited specific medical use licensees and broad scope medical use licensees.
Prior VDH approval is not necessary if the research is conducted, funded, supported, or regulated by federal agencies that have implemented the ‘Federal Policy for the Protection of Human Subjects’ or an equivalent. Otherwise, the licensee must apply for a specific amendment and receive approval before conducting such research.
Whether or not a license amendment is required, licensees must obtain informed consent from human subjects and prior review and approval of the research activities by an ‘Institutional Review Board’ or equivalent under the meaning of these terms as defined and described in the ‘Federal Policy for the Protection of Human Subjects’.
In accordance with 12VAC5-481-1670, research involving human subjects shall be conducted only with radioactive materials listed in the license for the uses authorized in the license.
Licensees conducting human research using radioactive drugs, sealed sources, and/or devices are responsible for ensuring that, in addition to complying with 12VAC5-481-1670, they comply with all other applicable VDH requirements and license conditions.
Therefore, it is a licensee’s responsibility to ensure that:
• It is authorized to possess the materials and devices needed to participate in the research studies;
• The materials and devices to be used in the research are included in the specific medical uses authorized in the license;
• The procedures in the research protocols do not conflict with VDH regulatory and license requirements; and
• It is in compliance with 12VAC5-481-1670, its license, and any other VDH and federal regulatory requirements.
WHO REGULATES FACILITIES IN THE COMMONWEALTH OF VIRGINIA?
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In the special situation of work at federally controlled sites in the Commonwealth of Virginia, it is necessary to know the jurisdictional status of the land to determine whether Nuclear Regulatory Commission (NRC) or VDH has regulatory authority.
The NRC has regulatory authority over land determined to be under “exclusive federal jurisdiction,” while VDH has jurisdiction over non-exclusive federal jurisdiction land (see Table 1).
Applicants and licensees are responsible for finding out, in advance, the jurisdictional status of the specific areas where they plan to conduct licensed operations.
VDH recommends that applicants and licensees ask their local contacts for the federal agency controlling the site (e.g., contract officer, base environmental health officer, district office staff) to help determine the jurisdictional status of the land and to provide the information in writing, so that licensees can comply with VDH or NRC regulatory requirements, as appropriate.
Table 1: Who Regulates the Activity?
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Applicant and Proposed Location of Work
Regulatory Agency
Federal agency regardless of location (except that Department of Energy and, under most circumstances, its prime contractors are exempt from licensing [10 CFR 30.12])
NRC
Non-federal entity in non-Agreement State, U.S. territory, or possession
NRC
Non-federal entity in Virginia at non-federally controlled site
VDH
Non-federal entity in Virginia at federally-controlled site not subject to exclusive federal jurisdiction
VDH
Non-federal entity in Virginia at federally-controlled site subject to exclusive federal jurisdiction
NRC
Additional Information:
A current list of Agreement States (States that have entered into agreements with the NRC that give them the authority to license and inspect radioactive material used or possessed within their borders), including names, addresses, and telephone numbers of responsible officials, are maintained by the NRC Office of Federal and State Materials and Environmental Management Programs and is available on their website: https://www.nrc.gov/about-nrc/state-tribal/agreement-states.htmlMANAGEMENT RESPONSIBILITY
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VDH endorses the philosophy that effective radiation protection program management is vital to safe operations that comply with VDH regulatory requirements (see 12VAC5-481-1700).
“Management” refers to the chief executive officer or other individual having the authority to manage, direct, or administer the licensee’s activities or that person’s delegate or delegates.
To ensure adequate management involvement in accordance with 12VAC5-481-450 and 12VAC5-481-1700, a management representative (i.e., chief executive officer or delegate) must sign the submitted application acknowledging management’s commitments to and responsibility for the following:
• Radiation protection, security, and control of radioactive materials, and compliance with rule;
• Knowledge about the contents of the license application;
• Compliance with current VDH and United States Department of Transportation (DOT) regulations and the licensee’s operating and emergency procedures;
• Provision of adequate resources (including space, equipment, personnel, time, and, if needed, contractors) to the radiation protection program to ensure that patients, the public, and workers are protected from radiation hazards;
• Appointment of a qualified individual who has agreed in writing to work as the RSO or ARSO (if applicable);
• Approval of qualified individual(s) to serve as Authorized Medical Physicists (AMPs), Ophthalmic Physicists, Authorized Nuclear Pharmacists (ANPs), and Authorized Users (AUs) for licensed activities.
Management may delegate individuals (i.e., an RSO or other designated individual) to submit amendment requests to VDH. A delegation letter must be completed, signed by management, and submitted to VDH. A sample letter has been included in Appendix F.
SAFETY CULTURE
Table 2: Traits of a Positive Nuclear Safety Culture
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Leadership: Safety Values and Actions
APPLICABLE RULE
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Part I ‘General Provisions’
Part III ‘Licensing of Radioactive Material’
Part IV ‘Standards for Protection Against Radiation’
Part VII ‘Use of Radionuclides in the Healing Arts’
Part X ‘Notices, Instructions and Reports to Workers’
Part XIII ‘Transportation of Radioactive Material’
HOW TO FILE
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Applicants for a materials license should do the following:
• Be sure to use the current guidance from VDH in preparing an application.
• Complete VDH Form ‘Application for Radioactive Material License for Medical Use’ (Appendix A).
• For each separate sheet, other than submitted with the application, identify and key it to the item number on the application, or the topic to which it refers.
• Submit all documents on 8½ x 11 inch paper.
• Avoid submitting proprietary information unless it is absolutely necessary. If submitted, proprietary information and other sensitive information should be clearly identified and a request made to withhold from public disclosure.
• Submit an original, signed application. This submission can be made via scanned copies forwarded via facsimile or electronic mail or via postal mail of the documents. The application should be signed by an individual with authority to make binding agreements on behalf of the applicant.
• Retain one copy of the license application for your future reference.
Deviations from the suggested wording of responses as shown in this VAREG or submission of alternative procedures will require a more detailed review.
Note: Personal employee information (i.e., home address, home telephone number, etc.) should not be included unless specifically required.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
Social Security Number, date of birth, and radiation dose information should not be submitted unless specifically requested by VDH.
WHERE TO FILE
Applicants wishing to possess or use radioactive material in the Commonwealth of Virginia are subject to the requirements of 12VAC5-481 ‘Virginia Radiation Protection Regulations’ and must file a license application with:
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Virginia Department of Health Radioactive Materials Program
109 Governor Street, Room 730
Richmond, Virginia 23219
LICENSE FEES
The appropriate fee must accompany each application. Refer to 12VAC5-490 to determine the amount of the fee. VDH will not issue the new license prior to fee receipt. Once technical review has begun, no fees will be refunded. Application fees will be charged regardless of VDH’s disposition of an application or the withdrawal of an application.
Application fees and a link for credit card payments can be found at the following web link:
https://www.vdh.virginia.gov/radiological-health/radiological-health/12vac5-490-fee-schedule/
Licensees are also subject to annual fees; refer to 12VAC5-490. Direct all questions about VDH’s fees or completion of Item 11 of VDH Form ‘Application for Radioactive Material License for Medical Use’ (Appendix A) to:
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Virginia Department of Health, Radioactive Materials Program, 109 Governor Street, Room 730, Richmond, Virginia 23219
(804) 864-8150
CONTENTS OF AN APPLICATION
This section explains, item by item, the information requested on VDH Form ‘Application for Radioactive Material License for Medical Use’ (Appendix A). Items 9.1 through 9.23 on the form request specific information about the proposed radiation safety program. To assist the applicant in submitting complete information on these items, the applicable rule citations are referenced in the discussion of each item.
Applicants must provide detailed information about the following:
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Proposed facilities and equipment;
Training and experience of radioactive material users and the RSO;
Delegation of authority to RSO;
Training / experience and delegation of authority for each ARSO (if applicable);
Financial assurance (if applicable);
Mobile use of radioactive material (if applicable); and
Procedures as indicated by this VAREG and VDH Form ‘Application for Radioactive Material License for Medical Use’ (Appendix A). Procedures should provide for:
Instruction of individuals in the procedures;
Discussion of timeliness and frequency of conduct procedures;
Periodic verification through observation, records review, or some other audit method, that individuals know the procedures and follow them; and
Updating the procedures as necessary to accommodate changes in the license program, such as the introduction of new modalities (i.e., Remote Afterloaders, Teletherapy, Gamma Stereotactic Units).
Several appendices in this report present sample procedures that applicants may commit to follow or use to develop site-specific procedures.
Item 1: Type of Application
Obtain the correct application form for either a new license or a renewal, check the appropriate box and, if appropriate, list the license number for a renewal.
This guide is written to instruct a new licensee in the process of applying for a radioactive material license. Not all discussions will be appropriate to a licensee renewing an existing license.
Item 2: Applicant’s Name and Mailing Address
List the legal name of the applicant’s corporation or other legal entity with direct control over use of the radioactive material; a division or department within a legal entity may not be a licensee.
An individual may be designated as the applicant only if the individual is acting in a private capacity and the use of the radioactive material is not connected with employment in a corporation or other legal entity.
Provide the mailing address where correspondence should be sent. A post office box number is an acceptable mailing address.
Notify the agency of changes in mailing address.
The licensee must also provide sufficient information for the agency to ensure the proposed corporation or controlling legal entity is a valid entity. Verification of this identity can be accomplished by submitting a copy of the company’s license from the NRC or another Agreement State or a government contract or certification, etc.
Note: The agency must be notified immediately in the event of change of ownership or control and bankruptcy proceedings; see below for more details.
Timely Notification of Transfer of Control
Rule: 12VAC5-481-500, 12VAC5-481-1690
Criteria: Licensees must provide full information and obtain VDH’s written consent prior to transferring ownership or control of the license, or the process sometimes referred to as ‘transferring the license’.
Discussion: Transfer of control may result from mergers, buyouts, or majority stock transfers. Although VDH does not intend to interfere with business decisions, prior written consent is necessary to ensure:
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Radioactive materials are possessed, used, or controlled only by persons with valid licenses issued by VDH;
Materials are properly handled and secured;
Persons using these materials are competent and committed to implementing appropriate radiological controls;
A clear chain of custody is established to identify who is responsible for final disposal of the possessed material; and
Public health and safety are not compromised by the use of such materials.
As provided in 12VAC5-481-1690, if the licensee’s name or mailing address changes, and the change does not constitute a transfer of control as described above, a licensee must file a written notification with VDH no later than 30 days after the change(s). Otherwise, VDH’s written consent must be obtained prior to the transfer.
Appendix D identifies the information to be provided about transferring control of a license.
Reference: Copies of NRC Information Notices and NUREGs including: IN 97-30, ‘Control of Licensed Material during Reorganizations, Employee-Management Disagreements, and Financial Crises,’ and NUREG-1556, Vol. 15, ‘Program-Specific Guidance About Changes of Control and About Bankruptcy Involving Byproduct, Source, or Special Nuclear Material Licenses,’ can be accessed at NRC’s web site, http://www.nrc.gov.
Notification of Bankruptcy Proceedings
Rule: 12VAC5-481-500
Criteria: 12VAC5-481-500 states: “Each licensee shall notify the agency in writing immediately following the filing of a voluntary or involuntary petition for bankruptcy under any Chapter of Title 11 (Bankruptcy) of the United States Code by or against:
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The licensee
An entity (as that term is defined in 11 USC §101(15)) controlling the licensee or listing the license or licensee as property of the estate; or
An affiliate (as that term is defined in 11 USC §101(2)) of the licensee”
and “...shall indicate the bankruptcy court in which the petition for bankruptcy was filed and the date of filing of the petition.”
Discussion: Even if a licensee has filed for bankruptcy, the licensee remains responsible for compliance with all regulatory requirements. VDH needs to know when licensees are in bankruptcy proceedings to determine whether all licensed material is accounted for and adequately controlled, and whether there are public health and safety concerns (e.g., contaminated facility). VDH shares the results of its determinations with other entities involved (e.g., trustees) so that health and safety issues can be resolved prior to completion of bankruptcy proceedings.
Licensees must notify VDH immediately of the filing of a bankruptcy petition.
Item 3: Person to be Contacted about this Application
Criteria: Identify the individual who can answer questions about the application and include his or her telephone number.
Discussion: This is typically the proposed RSO, unless the applicant has named a different person as the contact. The agency will contact this individual if there are questions about the application.
Notify the agency if the contact person or his or her telephone number changes so that the agency can contact the applicant or licensee in the future with questions, concerns, or information.
This notice is for ‘information only’ and does not require a license amendment.
The individual named in Item 3 of the application form may or may not be the same individual who signs the application as the ‘certifying officer’ on behalf of the licensee with the authority to make commitments to VDH (see Item 12 on VDH Form ‘Application for Radioactive Material License for Medical Use’ (Appendix A)).
Any commitments the applicant makes should be signed by the individual named in Item 12 since only that individual is considered by VDH to have the authority to make commitments on behalf of the applicant.
VDH will not accept license renewals signed by the individual identified in Item 3 if this person differs from the one named in Item 12.
The individual named in Item 12 may delegate the authority to submit routine license amendments to an assigned individual such as an RSO or authorized user.
VDH will accept a written delegation and incorporate this as a license commitment (tie-down), thus accepting routine license amendments from a designated individual.
Appendix F contains sample text which may be used to delegate correspondence authority to a designated individual.
VDH recognizes that licensees may use a consultant to help prepare the license application and provide support to the radiation protection program. However, licensees remain responsible for all aspects of the licensed program, including services performed by the consultant.
Item 4: Address(es) Where Radioactive Material Will Be Used Or Possessed
Rule: 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-1880
Criteria: Applicants must provide a specific address for each location where radioactive material will be used or stored.
Discussion: Specify the street address, city, state, and zip code or other descriptive address (e.g., on Highway 58, 5 miles east of the intersection of Highway 58 and State Route 16, Anytown, VA) for each facility.
The descriptive address should be sufficient to allow a VDH inspector to find the facility location. A post office box address is not acceptable.
Being granted a VDH license does not relieve a licensee from complying with other applicable federal, state, or local regulations (e.g., local zoning requirements for storage locations).
If radioactive material is to be used at more than one location under the license, the specific address (e.g., street and building) must be provided for each facility.
If applying for a license for a mobile medical service as authorized pursuant to 12VAC5-481-1880, the applicant should refer to Item 9.17, ‘Mobile Medical Service,’ and Appendix V of this report for specific licensing guidance.
Note
As discussed later under ‘Recordkeeping for Decommissioning and Financial Assurance,’ licensees must maintain permanent records on where the licensed material was used or stored while the license was in effect. These records are important for making future...
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
determinatio ns about the release of these locations for unrestricted use (e.g., before the license is terminated). For medical use licensees, acceptable records include sketches and written descriptions of the specific locations where material is (or was) used or stored and any information relevant to spills (e.g., where contamination remains after cleanup procedures or when there is reasonable likelihood that contaminants may have spread), damaged devices, or leaking radioactive sources.
Description of VAREGS
Item 5: Individual(s) Responsible for Radiation Safety Program and their Training and Experience Rule: 12VAC5 -481-450, 12VAC5 -481-1700, 12VAC5 -481-1750, 12VAC5 -481-1760, 12VAC5 -481-1770, 12VAC5 -481-1780, 12VAC5 -481-1790, 12VAC5 -481-1910, 12VAC5 -481-1940, 12VAC5 -481-1980, 12VAC5 -481-1990, 12VAC5 -481-2000, 12VAC5 -481-2001, 12VAC5 -481-2010, 12VAC5 -481-2030, 12VAC5 -481-2040.
Criteria: Licensees must ensure adequate oversight of their radioactive material program, and the RSO, ARSO, AUs, AMPs, and ANPs must have adequate training and experience.
Discussion: 12VAC5 -481-1700 provides the requirements regarding the authority and responsibilities for the radiation protection program, including those of the licensee’s management and the RSO or ARSO appointed by licensee management. Other personnel who have a role in the radiation protection program are AUs, AMPs, ANPs, ARSOs, and members of the Radiation Safety Committee (RSC) (if the licensee is required to establish a RSC).
12VAC5 -481-450 A requires that an applicant be qualified by training and experience to use licensed materials for the purposes requested in such a manner as to protect health and minimize danger to life or property.
12VAC5 -481-1750, 12VAC5 -481-1760, 12VAC5 -481-1770, 12VAC5 -481-1780, 12VAC5 -481-1910, 12VAC5 -481-1940, 12VAC5 -481-1980, 12VAC5 -481-1990, 12VAC5 -481-2000, 12VAC5 -481-2001; 12VAC 5-481-2010, 12VAC5 -481-2030, and 12VAC5 -481-2040 give specific criteria for acceptable training and experience for AUs for medical use, ANPs, the RSO, ARSOs, and AMPs.
A résumé or curriculum vitae is likely to be insufficient because such documents usually do not supply all the information needed to evaluate an individual’s training and experience for VDH purposes. Applicants should ensure that they submit the specific training information required by VDH. VDH Form ‘Training and Experience and Preceptor Statement’ provides a convenient format for submitting this information.
Appendix G provides detailed instructions on completing VDH Form ‘Training and Experience and Preceptor Statement’.
Licensees are responsible for their radiation protection programs; it is essential that strong management control and oversight exist to ensure that licensed activities are conducted properly. The licensee’s management must appoint an RSO, who agrees in writing to be responsible for implementing the radiation protection program, and must provide the RSO sufficient authority, organizational freedom, time, resources, and management prerogative to communicate with personnel and direct personnel regarding VDH rule and license provisions including: identifying radiation safety problems; initiating, recommending, or providing corrective actions; stopping unsafe operations; and verifying the implementation of corrective actions.
Nevertheless, the licensee retains the ultimate responsibility for the conduct of licensed activities.
Licensees that are authorized for two or more different types of uses of radioactive material under 12VAC5 - 481-1950, 12VAC5 -481-2010, 12VAC5 -481-2040 or two or more types of units under 12VAC5 - 481-2040 must establish an RSC to oversee all uses of radioactive material permitted by the license. Membership of the committee must include an AU of each type of use permitted by the license, the RSO, a representative of the nursing service, and a representative of management who is neither an AU nor the RSO. The committee may include other members the licensee considers appropriate.
Revision 4 January 14, 2022 28
Item 5.1: Radiation Safety Officer (RSO)
Rule:
12VAC5 -481-450, 12VAC5 -481-630, 12VAC5 -481-1680, 12VAC5 -481-1690, 12VAC5 -481-1700, 12VAC5 -481-1750, 12VAC5 -481-1760, 12VAC5 -481-1780, 12VAC5 -481-1790, 12VAC5 -481-2070Criteria:
RSOs must have adequate training and experience. The training and experience requirements for the RSO are described in 12VAC5 -481-1750 and allow for the following training pathways:-
Certification as provided in 12VAC5 -481-1750 by one of the professional boards recognized by the NRC (https://www.nrc.gov/materials/miau/med-use-toolkit/spec-board-cert.html).
Classroom and laboratory training (200 hours) and 1 year of work experience as described in 12VAC5 -481-1750 and written attestation signed by a preceptor RSO as provided in 12VAC5 -481-1750.
For medical physicists, certification by a specialty board whose certification process has been recognized by VDH under 12VAC5 -481-1760, experience in radiation safety aspects of similar types of radioactive material use for which the individual has RSO responsibilities.
Identification on the license as an AU, AMP, or ANP with experience in the radiation safety aspects of similar types of radioactive material use for which the individual has RSO responsibilities.
The licensee must also establish, in writing, the authority, duties, and responsibilities of the RSO. See Appendix F for typical duties and responsibilities of the RSO and a Model Delegation of Authority.
Discussion:
The RSO is responsible for day-to-day oversight of the radiation protection program. In accordance with 12VAC5 -481-1700, the licensee must provide the RSO sufficient authority, organizational freedom, time, and resources to perform his or her duties.Additionally, the RSO must have a sufficient commitment from management to fulfill the duties and responsibilities specified in 12VAC5 -481-1700 to ensure that radioactive materials are used in a safe manner.
VDH requires the name of the RSO on the license, and an agreement in writing from the RSO, to ensure that licensee management has identified a responsible, qualified person and that the named individual knows of his or her designation and assumes the responsibilities of an RSO.
Usually, the RSO is a full-time employee of the licensed facility. VDH has authorized individuals that are not employed by the licensee, such as a consultant, to fill the role of RSO or to provide support to the facility RSO.
In order to fulfill the duties and responsibilities, the RSO should be on-site periodically to conduct meaningful, person-to-person interactions with licensee staff, commensurate with the scope of licensed activities, to satisfy requirements of 12VAC5 -481-1700.
Applicants are reminded of recentness of training requirements described in 12VAC5 -481-1790. Specifically, RSO applicants must have successfully completed the applicable training and experience criteria described in 12VAC5 -481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ within 7 years preceding the date of the application.
Alternatively, RSO applicants must have had related continuing education and experience since completing the required training and experience. This time provision applies to board certification as well as to other recognized training pathways.
Notes:
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VDH Form ‘Training and Experience and Preceptor Statement’ may be used to document training and experience. Detailed instructions for completing VDH Form ‘Training and Experience and Preceptor Statement’ are found in Appendix G. This form is not required for board certified RSOs recognized by the NRC. The names of board certifications that have been recognized by the NRC or an Agreement State are posted on the NRC’s web page http://www.nrc.gov/materials/miau/med-use-toolkit.html.
The licensee must notify VDH within 30 days if an RSO permanently discontinues his or her duties under the license (12VAC5 -481-1690) and must request an amendment to change an RSO (12VAC5 -481-1680).
The licensee must notify VDH within 30 days if an RSO has a name change (12VAC5 -481-1690).
An AU, AMP, or ANP may be designated as the RSO on the license if the individual has training and experience with the radiation safety aspects of similar types of radioactive material use for which he or she has RSO responsibilities and, as required by 12VAC5 -481-1700, has sufficient time, authority, organizational freedom, resources, and management prerogative to perform the duties.
Descriptions of training and experience will be reviewed using the criteria listed above. VDH will review the documentation to determine if the applicable criteria in 12VAC 5-481-1750 are met. If the training and experience do not appear to meet the criteria in 12VAC 481-1750, VDH may request additional information from the applicant.
It is important to notify the agency and obtain a license amendment prior to making changes in the designation of the RSO responsible for the radiation safety program. If the RSO leaves the organization before an amendment is approved by VDH, a potential designee, who meets the RSO qualification requirements, is responsible for ensuring that the licensee's radiation safety program is implemented in accordance with the license and VDH rule.
Item 5.2: Associate Radiation Safety Officer (ARSO)
Rule:
12VAC5 -481-450, 12VAC5 -481-630, 12VAC5 -481-1680, 12VAC5 -481-1690, 12VAC5 -481-1700, 12VAC5 -481-1750, 12VAC5 -481-1760, 12VAC5 -481-1780, 12VAC5 -481-1790, 12VAC5 -481-2070Criteria:
ARSOs must have adequate training and experience. The training and experience requirements for the ARSO are described in 12VAC5 -481-1750 and allow for the following training pathways:-
Certification as provided in 12VAC5 -481-1750 by one of the professional boards recognized by the NRC (https://www.nrc.gov/materials/miau/med-use-toolkit/spec-board-cert.html).
Classroom and laboratory training (200 hours) and 1 year of work experience as described in 12VAC5 -481-1750 and written attestation signed by a preceptor ARSO/RSO as provided in 12VAC5 -481-1750.
For medical physicists, certification by a specialty board whose certification process has been recognized by VDH under 12VAC5 -481-1760, experience in radiation safety aspects of similar types of radioactive material use for which the individual has RSO or ARSO responsibilities.
Under 12VAC5 -481-1700, the licensee, through the RSO, shall ensure that radiation safety activities are being performed in accordance with licensee-approved procedures and regulatory requirements.
A licensee's management may appoint, in writing, one or more Associate Radiation Safety Officers to support the RSO. The RSO, with written agreement of the licensee's management, must assign the specific duties and tasks to each associate RSO. These duties and tasks are restricted to the types of use for which the associate radiation safety officer is listed on a license. The RSO may delegate duties and tasks to the associate radiation safety officer but shall not delegate the authority or responsibilities for implementing the radiation protection program.
Discussion:
A licensee may choose to identify one or more individuals as ARSOs to support the RSO in accordanceGuidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
The ARSOs may be assigned duties and tasks in the oversight of the radiation safety operations of designated sections of the licensed program, but the RSO retains responsibility for all sections of the program.
Introduction and Purpose
The ARSOs are required, per 12VAC5-481-1790, to complete the same training and experience requirements as the named RSO for their assigned sections of the radiation safety program.
The ARSOs would perform duties and tasks in the oversight of the radiation safety operations of their assigned sections of the program, while reporting to the named RSO.
Examples of Potential RSO and ARSO Arrangements:
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A moderate-sized program - the RSO is responsible for the entire program and has direct oversight over the 12VAC5-481-2010 and 12VAC5-481-2040 medical uses - a single ARSO has oversight duties and tasks for 12VAC5-481-1900, 12VAC5-481-1920, and 12VAC5-481-1950 medical uses and reports to the RSO.
A larger, single-campus program - the RSO is responsible for the entire program - there are one or more ARSOs with oversight duties and tasks over different sections of the program, and all report to the RSO.
A large, multi-campus program - the RSO is responsible for the entire program - there are one or more ARSOs with oversight duties and tasks over multiple smaller campuses. All ARSOs report to the RSO.
Before the ARSO may be assigned duties and tasks in the oversight of the radiation safety operations of a different section of the program, the licensee must amend the license and provide documentation that the individual meets the training and experience requirements for the new duties and tasks.
As the ARSOs have the same training and experience requirements as an RSO, the ARSOs will qualify to be named as the RSO on other licenses for the types of uses for which they are listed.
Applicants are reminded of recentness of training requirements described in 12VAC5-481-1790.
Specifically, ARSO applicants must have successfully completed the applicable training and experience criteria described in 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ within 7 years preceding the date of the application.
Alternatively, ARSO applicants must have had related continuing education and experience since completing the required training and experience.
This time provision applies to board certification as well as to other recognized training pathways.
Notes:
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VDH Form ‘Training and Experience and Preceptor Statement’ may be used to document training and experience. Detailed instructions for completing VDH Form ‘Training and Experience and Preceptor Statement’ are found in Appendix G. This form is not required for board-certified ARSOs recognized by the NRC. The names of board certifications that have been recognized by the NRC or an Agreement State are posted on the NRC’s web page http://www.nrc.gov/materials/miau/med-use-toolkit.html.
The licensee must notify VDH within 30 days if an ARSO permanently discontinues his or her duties under the license (12VAC5-481-1690).
The licensee must notify VDH within 30 days if an ARSO has a name change (12VAC5-481-1690).
Descriptions of training and experience will be reviewed using the criteria listed above. VDH will review the documentation to determine if the applicable criteria in 12VAC5-481-1750 are met. If the training and experience do not appear to meet the criteria in 12VAC5-481-1750, VDH may request additional information from the applicant.
Item 5.3: Authorized Users (AUs)
Rule: 12VAC5-481-450, 12VAC5-481-1670, 12VAC5-481-1690, 12VAC5-481-1710, 12VAC5-481-1780, 12VAC5-481-1790, 12VAC5-481-1910, 12VAC5-481-1940, 12VAC5-481-1980, 12VAC5-481-1990, 12VAC5-481-2000, 12VAC5-481-2001, 12VAC5-481-2010, 12VAC5-481-2020, 12VAC5-481-2030, 12VAC5-481-2040, 12VAC5-481-2270.
Criteria: Training and experience requirements for physician AUs are described in 12VAC5-481-1910; 12VAC5-481-1940; 12VAC5-481-1980; 12VAC5-481-1990; 12VAC5-481-2000; 12VAC5-481-2001; 12VAC5-481-2010; 12VAC5-481-2030; and 12VAC5-481-2040.
Discussion: An AU is defined in 12VAC5-481-10. The responsibilities of AUs involved in medical use include the following:
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Radiation safety commensurate with use of radioactive material;
Administration of a radiation dose or dosage and how it is prescribed;
Direction of individuals under the AU’s supervision in the preparation of radioactive material for medical use and in the medical use of radioactive material;
Preparation of written directives, if required.
12VAC5-481-1780 provides that experienced AUs who are named on a VDH, NRC, or another Agreement State license or permit in the preceding seven years are not required to comply with the training requirements in 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ to continue performing those medical uses.
Technologists, therapists, or other personnel may use radioactive material for medical use under an AU’s supervision in accordance with 12VAC5-481-1710 and in compliance with applicable FDA, other Federal, and State requirements (12VAC5-481-1670).
Examples include FDA requirements for conduct of certain types of clinical research after submission of applications for INDs (Investigational New Drugs) and under the auspices of a Radioactive Drug Research Committee (21 CFR 361.1).
There is no VDH requirement that an AU must provide an interpretation of a diagnostic image or results of a therapeutic procedure. VDH recognizes that the AU may or may not be the physician who interprets such studies.
Additionally, 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ does not restrict who can read and interpret diagnostic scans or the results of therapeutic procedures involving the administration of radioactive material to individuals.
AUs for Non-Medical Uses:
For in vitro studies, animal research, calibration of survey instruments, and other uses that do not involve the intentional exposure of humans, the list of proposed AUs should include the individuals who will actually be responsible for the safe use of the radioactive material for the requested use.
An applicant should note which user will be involved with a particular use by referring to Item 5.3 of the application and providing the user’s training and experience.
Authorized non-medical use or uses that do not involve the intentional exposure of humans (e.g., in vitro and animal research, calibration, dosimetry research) will be reviewed on a case-by-case basis.
Applicants are reminded of recentness of training requirements described in 12VAC5-481-1790.
Specifically, physician AU applicants must have successfully completed the applicable training and experience criteria described in 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ within 7 years preceding the date of the application.
Alternatively, physician AU applicants must have had related continuing education and experience since completing the required training and experience.
This time provision applies to board certification as well as to other recognized training pathways.
Revision 4 January 14, 2022
Licensees should designate at least one authorized user for each type of radioactive material requested in Item 7.1.
Notes:
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VDH Form ‘Training and Experience and Preceptor Statement’ may be used to document training and experience. Detailed instructions for completing VDH Form ‘Training and Experience and Preceptor Statement’ are found in Appendix G. This form is not required for board-certified AUs recognized by the NRC. The names of board certifications that have been recognized by the NRC or an Agreement State are posted on the NRC’s web page http://www.nrc.gov/materials/miau/med-use-toolkit.html.
Licensees must notify VDH within 30 days if an AU permanently discontinues his or her duties under the license or has a name change under 12VAC5-481-1690.
Descriptions of training and experience will be reviewed using the criteria listed above. VDH will review the documentation to determine if the applicable criteria in 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ are met. If the training and experience do not appear to meet the criteria, VDH may request additional information from the applicant.
Item 5.4: Authorized Nuclear Pharmacist (ANP)
Rule: 12VAC5-481-450, 12VAC5-481-1670, 12VAC5-481-1690, 12VAC5-481-1710, 12VAC5-481-1770, 12VAC5-481-1780, 12VAC5-481-1790.
Criteria: Training and experience requirements for ANPs are described in 12VAC5-481-1770.
Discussion: An ANP is defined in 12VAC5-481-10. At many licensed medical facilities, an ANP is directly involved with the preparation and administration of radiopharmaceuticals.
Technologists, or other personnel, may prepare radioactive material for medical use under an ANP’s supervision, in accordance with 12VAC5-481-1710, and in compliance with applicable U.S. Food and Drug Administration (FDA), other Federal and State requirements (12VAC5-481-1670).
Preparation of radioactive material for medical use may also be performed under the supervision of a physician who is an authorized user.
Applicants are reminded of recentness of training requirements described in 12VAC5-481-1790.
Specifically, nuclear pharmacist applicants must have successfully completed the applicable training and experience criteria described in 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ within 7 years preceding the date of the application.
Alternatively, nuclear pharmacist applicants must have had related continuing education and experience since initially completing the required training and experience.
This time provision applies to board certification as well as to other recognized training pathways.
Notes:
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VDH Form ‘Training and Experience and Preceptor Statement’ may be used to document training and experience. Detailed instructions for completing VDH Form ‘Training and Experience and Preceptor Statement’ are found in Appendix G. This form is not required for board-certified ANPs recognized by the NRC. The names of board certifications that have been recognized by the NRC or an Agreement State are posted on the NRC’s web page http://www.nrc.gov/materials/miau/med-use-toolkit.html.
Licensees must notify VDH within 30 days if an ANP permanently discontinues his or her duties under the license or has a name change under 12VAC5-481-1690.
Descriptions of training and experience will be reviewed using the criteria listed above. VDH will review the documentation to determine if the applicable criteria in 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ are met. If the training and experience do not appear to meet the criteria in 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’, VDH may request additional information from the applicant.
Item 5.5: Authorized Medical Physicist (AMP) or Ophthalmic Physicist
Rule: 12VAC5-481-450, 12VAC5-481-1690, 12VAC5-481-1760, 12VAC5-481-1780, 12VAC5-481-1790.
Criteria: Training and experience requirements for AMPs and Ophthalmic Physicists are described in 12VAC5-481-1760 and 12VAC5-481-2016.
Discussion: AMP and Ophthalmic Physicist are defined in 12VAC5-481-10. At many licensed medical facilities conducting radiation therapy treatments, an AMP is directly involved with the calculation and administration of the radiation dose. The American Association of Physicists in Medicine
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
(AAPM) suggests that a medical physicist limit his or her involvement in radiation therapy to areas for which he or she has established competency.
Applicants are reminded of recentness of training requirements described in 12VAC5-481-1790.
Specifically, medical physicist applicants must have successfully completed the applicable training and experience criteria described in 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ within 7 years preceding the date of the application.
Alternatively, medical physicist applicants must have had related continuing education and experience since completing the required training and experience.
This time provision applies to board certification as well as to other recognized training pathways.
Notes:
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VDH Form ‘Training and Experience and Preceptor Statement’ may be used to document training and experience. Detailed instructions for completing VDH Form ‘Training and Experience and Preceptor Statement’ are found in Appendix G. This form is not required for board certified AMPs recognized by the NRC.
The names of board certifications that have been recognized by the NRC or an Agreement State are posted on the NRC’s web page http://www.nrc.gov/materials/miau/med-use-toolkit.html.
Licensees must notify VDH within 30 days if an AMP permanently discontinues his or her duties under the license or has a name change (12VAC5-481-1690).
Descriptions of training and experience will be reviewed using the criteria listed above. VDH will review the documentation to determine if the applicable criteria in 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ are met.
If the training and experience do not appear to meet the criteria in 12VAC5-481, VDH may request additional information from the applicant.
Item 6: Training for Individuals Working in or Frequenting Restricted Areas
Rule: 12VAC5-481-1710, 12VAC5-481-1870, 12VAC5-481-1960, 12VAC5-481-1970, 12VAC5-481-2010, 12VAC5-481-2040, 12VAC5-481-2070, 12VAC5-481-2270
Criteria: Individuals working with or in the vicinity of licensed material must have adequate safety instruction as required by 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ and Part X ‘Notices, Instructions and Reports to Workers; Inspections’.
For individuals who, in the course of employment, are likely to receive in a year an occupational dose of radiation over 1 mSv (100 mrem), the licensee must provide annual safety instructions as required in 12VAC5-481-2270.
Additional requirements for training in radiation safety for individuals involved with therapeutic treatment of patients are described in 12VAC5-481-1960, 12VAC5-481-2010, and 12VAC5-481-2040.
Records of safety instruction provided must be maintained in accordance with 12VAC5-481-2070.
12VAC5-481-1710 requires the licensee’s AUs and ANPs to provide safety instruction to all personnel using radioactive material under their supervision.
Revision 4 January 14, 2022
Discussion: AUs, ANPs, AMPs, RSOs, and their supervised employees are most likely to receive doses in excess of 1 mSv (100 mrem) in a year. However, licensees also must evaluate potential radiation doses received by any individual working in or frequenting restricted areas.
All individuals working with or around licensed materials should receive safety instruction commensurate with their assigned duties, and if it is likely that they could receive doses over 1 mSv (100 mrem) in a year, they must receive annual instruction as specified by 12VAC5-481-2270.
For example, a licensee might determine that housekeeping staff, while not likely to receive doses over 1 mSv (100 mrem), should be informed of the nature of the licensed material and the meaning of the radiation symbol, and instructed not to touch the licensed material and to remain out of the room if the door to the licensed material storage location is open.
Providing minimal instruction to ancillary staff (e.g., housekeeping, security, etc.) may assist in controlling abnormal events, such as loss of radioactive material.
In addition to safety instruction required by 12VAC5-481-2270 and in accordance with 12VAC5-481-1960, 12VAC5-481-2010, and 12VAC5-481-2040, the licensee must provide radiation safety instruction to personnel (e.g., nurses) caring for patients undergoing radiopharmaceutical therapy or implant therapy who cannot be released in accordance with 12VAC5-481-1870.
This safety instruction must be commensurate with the duties of the personnel and include safe handling, patient control, visitor control, contamination control, waste control, and notification of the RSO and the AU if the patient has a medical emergency or dies.
In accordance with 12VAC5-481-1710, individuals working with licensed material under the supervision of an AU must receive instruction on the licensee’s written radiation protection procedures, written directive procedures, and VDH rule and license conditions with respect to the use of radioactive material.
In accordance with 12VAC5-481-1710, a licensee that permits the preparation of radioactive material for medical use by an individual under the supervision of an ANP or an AU shall instruct supervised individuals in the preparation of radioactive material for medical use and require the individuals to follow their instructions, the licensee’s written radiation protection procedures, the license conditions, and VDH rule.
12VAC5-481-1710 states that a licensee that permits supervised activities is responsible for the acts and omissions of the supervised individuals.
Procedures describing the training programs are provided in Appendix H.
Item 7: Radioactive Material
Rule: 12VAC5-481-440, 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-1680, 12VAC5-481-1830, 12VAC5-481-1900, 12VAC5-481-1920, 12VAC5-481-1950, 12VAC5-481-2010, 12VAC5-481-2020, 12VAC5-481-2040, 12VAC5-481-2060
Criteria: 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’, divides radioactive material for medical use into the following types of use:
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12VAC5-481-1900 Use of unsealed byproduct material for uptake, dilution, and excretion studies for which a written directive is not required
12VAC5-481-1920 Use of unsealed byproduct material for imaging and localization studies for which a written directive is not required
12VAC5-481-1950 Use of unsealed byproduct material for which a written directive is required
12VAC5-481-2010 Manual brachytherapy
12VAC5-481-2020 Use of sealed sources for diagnosis
12VAC5-481-2040 Teletherapy Units
12VAC5-481-2040 Photon Emitting Remote Afterloader Units
12VAC5-481-2040 Stereotactic Radiosurgery Units
12VAC5-481-2060 Other medical uses of byproduct material or radiation from byproduct materials
Discussion: This section contains four subsections:
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Item 7.1: Radioactive Material, Chemical & Physical Form, Possession Limit & Type of Use
Item 7.2: Recordkeeping for Decommissioning and Financial Assurance
Item 7.3: Sealed Sources and Devices
Item 7.4: Disposition of Material and Termination of License
Item 7.1: Radioactive Material, Chemical & Physical Form, Possession Limit & Type of Use
Rule: 12VAC5-481-430, 12VAC5-481-440, 12VAC5-481-450, 12VAC5-481-470, 12VAC5-481-1680, 12VAC5-481-1830, 12VAC5-481-1900, 12VAC5-481-1920, 12VAC5-481-1950, 12VAC5-481-2010, 12VAC5-481-2020, 12VAC5-481-2040, 12VAC5-481-2060
Criteria: 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’, divides radioactive material for medical use into seven types of use:
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12VAC5-481-1900; 12VAC5-481-1920; 12VAC5-481-1950; 12VAC5-481-2010; 12VAC5-481-2020; 12VAC5-481-2040; and 12VAC5-481-2060.
Discussion: For in vitro use exceeding general license limits under 12VAC5-481-430 G, calibration sources exceeding the exemptions listed in 12VAC5-481-1830, uptake, dilution, and excretion studies under 12VAC5-481-1900, and imaging and localization studies under 12VAC5-481-1920, the applicant should select the type of use.
The use of unsealed radioactive material in therapy (12VAC5-481-1950) involves administering a radiopharmaceutical, either orally or by injection, to treat or palliate a particular disease.
The most common form of radiopharmaceutical therapy is the treatment of hyperthyroidism with iodine-131 (I-131) sodium iodide.
Other therapeutic procedures include ablation of thyroid cancer metastasis, treatment of malignant effusions, treatment of polycythemia vera and leukemia, palliation of bone pain in cancer patients, and radiation synovectomy for rheumatoid arthritis patients.
For 12VAC5-481-1950, the applicant should select the box and enter the maximum quantity (in curies) of radioactive material to be possessed.
If only requesting a specific radioisotope for therapy use under 12VAC5-481-1950, the applicant must provide a detailed description of radiopharmaceutical, form, route of administration, and therapeutic use (see Table 3).
Table 3: Radiopharmaceuticals Used in Therapy
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I-131 sodium iodide solution/capsules – oral – Hyperthyroidism, Thyroid carcinoma, Whole body scan for thyroid metastasis (diagnostic)
I-131 Tositumomab – solution – IV – Non-Hodgkin’s lymphoma
Phosphorus-32 (P-32) – chromic phosphate colloidal suspension – intraperitoneal or intrapleural cavity injection – Peritoneal or pleural effusions
P-32 sodium phosphate – solution – oral or IV – Polycythemia vera, leukemia
Strontium-89 – chloride – solution – IV – Skeletal metastasis
Samarium-153 EDTMP – solution – IV – Skeletal metastasis
Rhenium-186 HEDP – solution – IV – Skeletal metastasis
Tin-117m DTPA – solution – IV – Skeletal metastasis
Dysprosium-165 FHMA – aggregate in solution – IV – Rheumatoid arthritis
Yttrium-90 FHMA – aggregate in solution – IV – Rheumatoid arthritis
Yttrium-90 Ibritumomab tiuxetan – solution – IV – Non-Hodgkin’s lymphoma
For manual brachytherapy under 12VAC5-481-2010, several types of treatments are available. These may include:
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Interstitial Treatment of Cancer. The following sources are routinely used:
• Cs-137 and Co-60 as a sealed source in needles and applicator cells;
• Iridium-192 (Ir-192) as seeds encased in nylon ribbon;
• Gold-198 (Au-198) as a sealed source in seeds; and
• Iodine-125 (I-125), and Palladium-103 (Pd-103) as sealed sources in seeds used for permanent implants.
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Eye Plaque Implants. The eye plaque consists of a curved soft plastic insert that has a series of grooves molded into the rear convex surface that are designed to hold radioactive seeds.
After the plastic insert is loaded with the seeds, a solid gold cover, matched in size to the insert, is placed over the convex surface of the insert and cemented in place to seal the seeds into a fixed array within the plaque.
The insert is completely surrounded by the gold cover except for the concave surface that is placed against the eye.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
When used with I-125 and Pd-103 seeds, the gold cover provides considerable shielding of the normal tissues surrounding the eye and limits the external dose rates surrounding the patient.
Although not implanted into the tumor, because the plaque is placed in the orbit of the eye over the tumor site and sutured to the sclera of the eye to stabilize its position on the tumor while in the orbit, this is considered interstitial, not topical, treatment.
Intracavitary Treatment of Cancer
Intraluminal use is considered analogous to intracavitary use. The following sources are routinely used for the intracavitary treatment of cancer:
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Cs-137 and Co-60 as a sealed source in needles and applicator cells;
Ir-192 and Pd-103 seeds.
Topical (Surface) Applications
The following sources are routinely used for topical applications:
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Cs-137 and Co-60 as sealed sources in needles and applicator cells;
Sr-90 as a sealed source in an applicator for treatment of superficial eye conditions.
For use of Sr-90 in ophthalmic eye applicators only, as referenced in 12VAC5-481-2010, applicant should select the box and provide the following information:
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the maximum quantity (in curies) of radioactive material to be possessed;
the sealed source and device registration number for each sealed source and/or device;
the sealed source manufacturer or distributor model number; and
the device manufacturer or distributor model number.
For 12VAC5-481-2010 material, the applicant should select the box, and provide the following information:
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the maximum quantity (in curies) of radioactive material to be possessed;
the sealed source and device registration number for each sealed source and/or device;
the sealed source manufacturer or distributor model number; and
the device manufacturer or distributor model number.
For 12VAC5-481-2020 material, the applicant should select the box, and provide the following information:
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the maximum quantity (in curies) of radioactive material to be possessed;
the sealed source and device registration number for each sealed source and/or device;
the sealed source manufacturer or distributor model number; and
the device manufacturer or distributor model number.
Examples of 12VAC5-481-2020 uses include I-125, americium-241, or gadolinium-153 as a sealed source in a device for bone mineral analysis and I-125 as a sealed source in a portable imaging device.
For 12VAC5-481-2040 material, the applicant should select the box(es) for each desired modality (i.e., teletherapy, remote afterloader unit, or gamma stereotactic radiosurgery unit), and provide the following information:
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the maximum quantity (in curies) of radioactive material to be possessed;
the sealed source and device registration number for each sealed source and/or device;
the sealed source manufacturer or distributor model number; and
the device manufacturer or distributor model number.
For sealed sources used in devices, an applicant may wish to request two sources, one to be used in the device and one to be stored in its shipping container, to accommodate the total quantity of material in the licensee’s possession during replacement of the source in the device.
Under 12VAC5-481-440, the maximum activity for a single source or source loading may not exceed the activity specified by the manufacturer for the specific device and source combination as stated in the Sealed Source Device Registration certificate.
However, it is permissible to request a maximum activity for the source in the shipping container that exceeds the maximum activity allowed in the device.
To request this authorization, applicants should provide certification that the source transport container is approved for the requested activity.
A source that is received with a higher activity than permitted in the device must be allowed to decay to or below the device source activity limit prior to installation in the device.
12VAC5-481-2060 Other Medical Uses of Radioactive Material or Radiation from Radioactive Material (e.g., Emerging Technology)
Applicants must apply for authorization to use radioactive material, or radiation therefrom, in medical applications under 12VAC5-481-2060 when the desired type of use isn’t covered elsewhere in 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’.
Use of radioactive material in a source or device after approval by the U.S. Food and Drug Administration (e.g., under an investigational device exemption or an investigational new drug exemption) does not preclude the necessity for applicants to obtain a VDH license for the radioactive material.
For 12VAC5-481-2060 material, the applicant should attach a detailed description of the radioactive material (i.e., radionuclide, form, and maximum quantity in curies) and intended use along with the following information required by 12VAC5-481-1680:
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Radiation safety precautions and instructions;
Training and experience of proposed users;
Methodology for measurement of dosages or doses to be administered to patients or human research subjects; and
Calibration, maintenance and repair of instruments and equipment necessary for radiation safety.
If the material is a sealed source, also provide the following:
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the sealed source and device registration number for each sealed source and/or device;
the sealed source manufacturer or distributor model number; and
the device manufacturer or distributor model number.
For information regarding the licensing of emerging technologies, licensees should consult the NRC’s web page at: www.nrc.gov/materials/miau/med-use-toolkit.html.
Type A broad scope licensees are exempted under 12VAC5-470 from selected requirements in 12VAC5-1680 regarding emerging technologies. However, broad scope licensees should ensure that the quantity of radioactive material needed for the proposed use is authorized on their license or apply for an increase if it is not.
Broad scope licensees should refer to NRC’s IN 99-024, ‘Broad-Scope Licensees Responsibilities for Reviewing and Approving Unregistered Sealed Sources and Devices’.
Revision 4 January 14, 2022
Non-Medical Use of Radioactive Material
The applicant should check the ‘Other radioactive material’ box and provide a detailed description for items that need to be listed (e.g., depleted uranium for linear accelerator shielding, survey meter calibrations with NIST traceable brachytherapy sources, dosimetry system constancy check source).
Sources that are authorized by 12VAC5-481-1830, ‘Authorization for calibration and reference sources’, should not be listed.
If applicable, the applicant should request authorization to possess depleted uranium (i.e., uranium depleted in uranium-235) in quantities sufficient to include shielding material in both the device(s) and source containers used for source exchange.
The applicant should review the manufacturer’s specifications for each device specified in the license request to determine:
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(1) if depleted uranium is used to shield the source(s) within the device; and
(2) the total quantity of depleted uranium present in the device (in kilograms).
The applicant should also consult the manufacturer’s specifications or the source supplier to determine if depleted uranium is contained in shielding source containers used during source exchange, as well as the total quantity of depleted uranium in such containers (in kilograms).
Note: When determining both individual radionuclide and total quantities, all materials to be possessed at any one time under the license should be included:
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materials in use or possessed,
material used for shielding, and
materials classified as waste awaiting disposal or held for decay-in-storage.
When requesting possession limits for materials where a source exchange is anticipated (i.e., remote afterloader), the applicant should request the maximum activity per source and total activity requested.
For example, a remote afterloader possession limit should be requested as “not to exceed 10 curies per source and 20 curies total”.
Item 7.2: Recordkeeping for Decommissioning and Financial Assurance
Rule: 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-510, 12VAC5-481-1161, 12VAC5-481-1680
Criteria: A licensee authorized to possess licensed material in excess of the limits specified in 12VAC5-481-450 C must meet the requirements for decommissioning financial assurance.
All licensees are required to maintain, in an identified location, records of information important to decommissioning of the facility until the site, or any area, is released for unrestricted use.
Licensees must transfer records important to decommissioning either to the new licensee before licensed activities are transferred or assigned in accordance with 12VAC5-481-500 or to VDH before the license is terminated.
Discussion
VDH wants to ensure that decommissioning will be carried out with minimum impact on public and occupational health and safety and the environment.
There are two parts to the rule: financial assurance that applies to SOME licensees, and recordkeeping that applies to ALL licensees.
The requirements for financial assurance are specific to the types and quantities of radioactive material authorized on a license.
Most medical use applicants and licensees do not need to take any action to comply with the financial assurance requirements because either their total inventory of licensed material does not exceed the limits in 12VAC5-481-450 C or because the half-life of the unsealed radioactive material used does not exceed 120 days.
Applicants requesting licensed material with a half-life in excess of 120 days should determine whether financial assurance is necessary.
In addition, applicants requesting more than one radionuclide must use the sum-of-the-ratios method to determine if financial assurance is needed. See Appendix E for additional information.
Revision 4 January 14, 2022
Applications for authorization to possess and use unsealed radioactive material with a half-life exceeding 120 days
must be accompanied by a decommissioning funding plan or certification of financial assurance when the trigger quantities given in 12VAC5-481-450 C are exceeded.
Acceptable methods of providing financial assurance include trust funds, escrow accounts, government funds, certificates of deposit, deposits of government securities, surety bonds, letters of credit, lines of credit, insurance policies, parent company guarantees, self guarantees, external sinking funds, statements of intent, special arrangements with government entities, and standby trust funds.
NRC NUREG-1757, Volume 3, ‘Consolidated NMSS Decommissioning Guidance: Financial Assurance, Recordkeeping, and Timeliness’, contains acceptable wording for each mechanism authorized by the regulation to guarantee or secure funds.
VDH will authorize sealed source possession exceeding the limits given in 12VAC5-481-450 C without requiring decommissioning financial assurance, for the purpose of normal sealed source exchange, for no more than 30 days.
Table 4 shows examples of the limits for selected sealed sources.
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Table 4: Minimum Sealed Source Inventory Quantity Requiring Financial Assurance
Radionuclide: Cesium-137 (Cs-137), Activity in GBq: 3.7 x 10^6, Activity in Curies: 100,000
Radionuclide: Cobalt-60 (Co-60), Activity in GBq: 3.7 x 10^5, Activity in Curies: 10,000
Radionuclide: Strontium-90 (Sr-90), Activity in GBq: 3.7 x 10^4, Activity in Curies: 1,000
The same regulation also requires that licensees maintain records important to decommissioning in an identified location.
Licensees using sealed sources authorized by 12VAC5-481, Part VII ‘Use of Radionuclides in the Healing Arts’, generally use licensed material in a manner that would preclude releases into the environment, would not cause the activation of adjacent materials, and would not contaminate work areas.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
The licensee’s most recent leak test should demonstrate that there has been no leakage from the sealed sources while the sealed sources were in the licensee’s possession. However, any leakage of the sealed source in excess of the regulatory limits would warrant further VDH review of decommissioning procedures on a case-by-case basis.
Reference: Copies of NRC Information Notices and NUREGs including NUREG-1757, Volume 3, ‘Consolidated NMSS Decommissioning Guidance: Financial Assurance, Recordkeeping, and Timeliness’, can be accessed at NRC’s web site at: http://www.nrc.gov.
Item 7.3: Sealed Sources and Devices
Rule:
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12 VAC 5-481-440, 12VAC 5-481-450, 12VAC 5-481-1830
Criteria:
In accordance with 12VAC 5-481-440, applicants must provide the manufacturer’s name and model number for each requested sealed source and device (except for calibration and reference sources authorized by 12VAC 5-481-1830).
Licensees will be authorized to possess and use only those sealed sources and devices specifically approved or registered by NRC or another Agreement State.
Discussion:
The NRC or another Agreement State performs a safety evaluation of sealed sources and devices before authorizing a manufacturer to distribute the sources or devices to specific licensees. The safety evaluation is documented in a Sealed Source and Device Registration Certificate (SSDR).
Applicants must provide the manufacturer’s name and model number for each requested sealed source and device so that VDH can verify that they have been evaluated in an SSDR or specifically approved on a license.
Applicants should include all possible new sources they might use, in order to minimize the need for license amendments if they change model or vendor.
Additional Guidance:
An applicant should consult with the proposed supplier or manufacturer to ensure that requested sources and devices are compatible with each other and that they conform to the SSDR designations registered with NRC or another Agreement State.
Licensees may not make any changes to the sealed source, device, or source-device combination that would alter the description or specifications from those indicated in the respective SSDR certificates without obtaining VDH’s prior permission in a license amendment.
To ensure that sealed sources and devices are used in ways that comply with the registration certificates, applicants should obtain copies of the certificates and discuss them with the manufacturer.
SSDR Certificates contain sections on "Conditions of Normal Use" and "Limitation and Other Considerations of Use." These sections may include limitations derived from conditions imposed by the manufacturer or distributor, by particular conditions of use that would reduce radiation safety of the device, or by circumstances unique to the sealed source or device. For example, working life of the device or appropriate temperature and other environmental conditions are specified.
Except as specifically approved by VDH, licensees are required to use gauges according to their respective SSDR certificates. Applicants should obtain a copy of the certificate and review it with the manufacturer, distributor, or agency to ensure understanding and compliance with the SSDR requirements.
In addition, many sealed sources must have a National Institute of Standards and Technology (NIST) traceable calibration prior to use. Refer to Item 9.17 for additional information on calibration of therapy sealed sources.
Reference:
Copies of NRC Information Notices and NUREGs including NUREG-1556, Vol. 3, Rev. 1, ‘Consolidated Guidance about Materials Licensees: Applications for Sealed Source and Device Evaluation and Registration’, can be accessed at NRC’s web site: http://www.nrc.gov.
Note: If necessary and the manufacturer cannot supply the certificate, SSDR certificates are also available by calling the agency at (804) 864-8150.
Item 7.4: Disposition of Material and Termination of License
Rule:
-
12VAC5-481-100, 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-510, 12VAC5-481-570, 12VAC5-481-571, 12VAC5-481-1161, 12VAC5-481-1690
Criteria:
The licensee must do the following:
-
Notify the agency, in writing, within 60 days of:
[a.] The expiration of its license;[/a.]
[a.] A decision to permanently cease licensed activity at the entire site or in any separate building or outdoor area if it contains residual radioactivity making it unsuitable for release according to VDH requirements;[/a.]
[a.] No principal activities have been conducted at the entire site under the license for a period of 24 months;[/a.]
[a.] No principal activities have been conducted for a period of 24 months in any separate building or outdoor area if it contains residual radioactivity making it unsuitable for release according to VDH requirements.[/a.]
Submit a decommissioning plan, if required by 12VAC5-481-510;
Decommission, as required by 12VAC5-481-510 & 12VAC5-481-1161;
Submit to the agency a completed VDH form ‘Certificate of Disposition of Materials’ (Appendix C) and demonstrate that the premises are suitable for release for unrestricted use (e.g., results of final survey);
Before a license is terminated, send the records important to decommissioning to the agency as required by 12VAC5-481-571. If licensed activities are transferred or assigned in accordance with 12VAC5-481-500, transfer records important to decommissioning to the new licensee.
Discussion:
Useful guidance and other aids related to decommissioning are:
-
NUREG-1757, Volume 2, ‘Consolidated NMSS Decommissioning Guidance: Characterization, Survey, and Determination of Radiological Criteria’, contains the current regulatory guidance concerning decommissioning of facilities and termination of licenses.
NUREG-1757, Volume 2, includes a table (Table H.1) of acceptable license termination screening values of common beta/gamma radionuclides for building surface contamination. NUREG-1757, Volume 2, also contains methods for conducting site-specific dose assessment for facilities with contamination levels above those in the table.
‘Multi-Agency Radiation Survey and Site Investigation Manual (MARSSIM)’, Revision 1, should be reviewed by licensees who have large facilities to decommission. This document may be accessed at the U.S. Environmental Protection Agency’s website: http://www.epa.gov.
An acceptable computer code for calculating screening values to demonstrate compliance with the unrestricted dose limits is D and D, Version 2.1.0, (McFadden and others).
Licensees must use the VDH Form, ‘Certificate of Disposition of Materials’ (Appendix C) when submitting for termination of a license.
McFadden, K., D.A. Brosseau, W.A. Beyeler, and C.D. Updegraff, ‘Residual Radioactive Contamination from Decommissioning - User’s Manual D and D Version 2.1,’ NUREG/CR-5512, Volume 2, U.S. Nuclear Regulatory Commission, Washington, D.C.
Facilities and Equipment
Rule:
-
12VAC5-481-450
Criteria:
Facilities and equipment must be adequate to protect health and minimize danger to life or property.
Discussion:
12VAC5-481-450 A states that an application will be approved if, among other things, the applicant’s proposed equipment and facilities are adequate to protect health and minimize danger to life or property.
Facility and equipment requirements depend on the scope of the applicant’s operations (e.g., planned use of the material, the types of radioactive emissions, the quantity and form of radioactive materials possessed, etc.).
Applicants should focus particularly on operations using large quantities of radioactive materials; preparation steps involving liquids, gases, and volatile radioactive materials; and the use of alpha-emitters, high-energy photon-emitters, and high-energy beta-emitters.
Item 8.1: Facility Diagram
Rule:
-
12VAC5-481-10, 12VAC5-481-440, 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-630, 12VAC5-481-640, 12VAC5-481-720, 12VAC5-481-730, 12VAC5-481-780, 12VAC5-481-790, 12VAC5-481-850, 12VAC5-481-860, 12VAC5-481-990, 12VAC5-481-1680, 12VAC5-481-1690, 12VAC5-481-1870, 12VAC5-481-1900, 12VAC5-481-1920, 12VAC5-481-1950, 12VAC5-481-2010, 12VAC5-481-2020, 12VAC5-481-2040, 12VAC5-481-2060
Criteria:
Discussion:
Applicants must describe the proposed facilities and equipment as required by 12VAC5-481-440, 12VAC5-481-450, and 12VAC5-481-500.
The facility diagram should include the room or rooms and adjacent areas where radioactive material is prepared, used, administered, and stored that is sufficient to demonstrate that the facilities and equipment are adequate to protect health and minimize danger to life or property.
For types of use permitted by 12VAC5-481-1900 and 12VAC5-481-1920, applicants should provide room numbers for areas in which radioactive materials are used or prepared for use (i.e., ‘hot labs’). When information regarding an area or room is provided, adjacent areas and rooms, including those above and below, should be described.
For types of use permitted by 12VAC5-481-1950 and 12VAC5-481-2010, applicants should provide the above information and in addition they should provide the locations where sources are stored.
Describe the rooms where patients will be housed if they cannot be released under 12VAC5-481-1870. The discussion should include a description of shielding, if applicable.
For types of use permitted by 12VAC5-481-2020, the applicant should provide the room numbers of use.
For types of use permitted by 12VAC5-481-2040, the applicant should provide all of the information discussed above and the shielding calculations for the facility as described in the diagram.
When preparing applications for use under 12VAC5-481-2060, applicants should review the above to determine the type of information appropriate to evaluate the adequacy of the facilities.
Licensees are required by 12VAC5-481-1680 to obtain a license amendment before adding to or changing an area of use identified in the application or on the license, except for areas of use where radioactive material is used only in accordance with 12VAC5-481-1900 and 12VAC5-481-1920.
Licensees are required by 12VAC5-481-1690 to notify VDH within 30 days following changes in areas of use for 12VAC5-481-1900 and 12VAC5-481-1920 radioactive material.
Regulatory requirements, the principle of ALARA, good medical care, and access control should be considered when determining the location of the therapy patient’s room or a therapy treatment room.
Figure 1: Facility Diagram for Nuclear Medicine Suite
The applicant should demonstrate that the limits specified in 12VAC5-481-720 will not be exceeded. If the calculations demonstrate that these limits cannot be met, indicate any further steps that will be taken to limit exposure to individual members of the public. Options to Reduce Exposure:
-
Adding shielding to the barrier in question, with corresponding modification of the facility description if necessary.
Requesting prior VDH authorization to operate up to an annual dose limit for an individual member of the public of 5 mSv (0.5 rem) and demonstrating that the requirements of 12VAC5-481-720 will be met.
The applicant must demonstrate the need for and the expected duration of operations that will result in an individual dose in excess of the limits specified in 12VAC5-481-720.
A program to assess and control dose within the 5 mSv (0.5 rem) annual limit and procedures to be followed to maintain the dose ALARA must be developed.
Applicants who wish to perform studies with PET radiopharmaceuticals are reminded that rooms in which patients will rest (e.g., ‘quiet rooms’) may require additional shielding to achieve the public dose limits.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
This document provides guidance and regulatory requirements for the use of radioactive materials in medical settings, including licensing, safety measures, and equipment calibration.
EXECUTIVE SUMMARY
This section summarizes the key points and regulatory expectations for licensees involved in medical radioactive material use.
Introduction and Purpose
The purpose of this guidance is to ensure safe and compliant use of radioactive materials in medical applications, including therapy, diagnostics, and storage.
Description of VAREGS
VAREGS (Virginia Radioactive Equipment and Gamma Source) is the regulatory framework established by the Virginia Department of Health (VDH) to oversee the safe handling, storage, and use of radioactive materials in medical facilities.
Application Process and Guidance
Applicants must submit detailed plans including room diagrams, shielding calculations, and administrative procedures. The following sections outline specific requirements:
Room and Shielding Requirements
-
Drawings should be to scale, indicating the scale used;
Location, room numbers, and principal use of each room or area where radioactive material is prepared, used, or stored;
Location, room numbers, and principal use of each adjacent room (e.g., office, file, toilet, closet, hallway), including areas above, beside, and below therapy treatment rooms; indicate whether the room is a restricted or unrestricted area as defined in 12VAC5-481-10;
Provide shielding calculations, including type, thickness, and density of shielding materials, to enable independent verification. Include details about portable shields used (e.g., dimensions, location, source storage safe).
Indicate addresses for multiple storage locations on diagrams.
Portable Shielding and Equipment Use
Applicants proposing portable shielding should describe alternative equipment and administrative procedures for evaluation and approval. They must commit to configuration management to maintain doses within regulatory limits. For teletherapy units, restrictions on primary beam use may be necessary if shielding is inadequate. Mechanical or electrical stops should be used to limit movement or rotation of units, with example responses provided for guidance:
-
“For the primary beam directed toward the integral beam absorber, electrical or mechanical stops are set so that the primary beam must be centered (within plus or minus 2 degrees) on the integral beam absorber and, in that configuration, the attenuated primary beam may be rotated 360 degrees pointing toward the floor, east wall, ceiling, and west wall.”
“For the primary beam directed away from the integral beam absorber, electrical or mechanical stops permit the unattenuated primary beam to be directed in a 95-degree arc from 5 degrees toward the west wall to vertically down toward the floor to 90 degrees toward the east wall.”
Many applicants can adapt these examples to their specific setups, such as vertical units or rotational units without beam absorbers.
Facility Diagrams and Shielding Calculations
Provide detailed, scaled drawings showing:]
-
Location, room numbers, and principal use of each room or area where radioactive material is prepared, used, or stored;
Location, room numbers, and principal use of adjacent rooms, including areas above, beside, and below therapy rooms; specify restricted or unrestricted areas;
Shielding calculations with details on materials, thickness, and density; include descriptions of portable shields (e.g., dimensions, shielding of patient rooms);
Addresses for multiple storage locations on diagrams.
In addition, for teletherapy and GSR facilities, applicants should specify primary beam directions and, for isocentric units, the plane of beam rotation.
References from NCRP reports and NRC guidance are recommended to assist in preparing responses, including NCRP Reports 49, 102, 40, and NRC NUREGs 6276 and 6324.
Item 8.2: Radiation Monitoring Instrumentation
Rule: 12VAC5-481-450, 12VAC5-481-630, 12VAC5-481-750, 12VAC5-481-1000, 12VAC5-481-1710, 12VAC5-481-1810, 12VAC5-481-2070
Criteria: All licensees shall possess calibrated radiation detection and measuring instruments, including:
-
Survey and monitoring instruments;
Quantitative measuring instruments needed to monitor containment and contamination;
Discussion: The radiation protection program must include survey instrument calibration (12VAC5-481-750). Instruments used to measure radiation levels, contamination, and radioactivity must be calibrated and available when radioactive materials are in use. Instruments should be sensitive enough to detect low-energy or low-activity seeds (e.g., I-125, Pd-103). It is generally unnecessary to possess a survey meter solely for diagnostic procedures, but one should be available for emergencies or malfunctions.
Surveys are necessary to verify source integrity and ensure dose rates are within limits. Calibration must be performed by authorized personnel, such as licensed individuals or those with a valid license from VDH, NRC, or another Agreement State. An alternative is to develop procedures ensuring calibration or propose other methods. Appendix I provides guidance on instrumentation and calibration procedures.
Item 8.3: Dose Calibrator and Other Equipment for Measuring Unsealed Radioactive Material
Rule: 12VAC5-481-450, 12VAC5-481-1710, 12VAC5-481-1730, 12VAC5-481-1800, 12VAC5-481-1820, 12VAC5-481-2070
Criteria: 12VAC5-481-1800 and 12VAC5-481-1820 specify requirements for use, possession, calibration, and checking of instruments like dose calibrators.
Discussion: For licensees preparing patient dosages, dosage measurement is required if they prepare their own doses or split unit doses. If only receiving pre-measured unit doses from licensed providers, measurement may rely on provider labels. If direct measurement is performed, all instruments must be calibrated per standards (e.g., ANSI) and be accurate and reliable.
Activity determination for other than unit doses involves direct measurement, calculations, or volumetric methods, with inherent technical challenges such as geometry dependence and lack of industry standards. For beta emitters like P-32, volumetric and calculation methods may be more accurate due to assay inaccuracies caused by geometry variations. Proper shielding to minimize bremsstrahlung is essential, especially with high activity sources.
Item 8.4: Dosimetry Equipment - Calibration and Use
Rule: 12VAC5-481-450, 12VAC5-481-1710, 12VAC5-481-1730, 12VAC5-481-2010, 12VAC5-481-2040, 12VAC5-481-2070
Criteria: These regulations include record-keeping and verification requirements for dosimetry equipment used to measure source activity or output. Licensees must select equipment that accurately measures source output, especially for new or specialized sources. For manual brachytherapy and low-dose-rate remote afterloaders, activity or output can be determined by manufacturer or accredited calibration labs listed on the AAPM website.
Discussion: Licensees must possess calibrated dosimetry systems (e.g., Farmer chambers, electrometers, well chambers) for calibration of sealed sources used in therapy. These systems and sources must be traceable to NIST or accredited laboratories. Records of calibrations must be maintained for the duration of the license.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
sources and devices used for therapy in accordance with published protocols accepted by nationally recognized bodies (e.g., ANSI). (Note: The medical physicist who performs calibrations for sources in 12VAC5-481-2010 need not be an authorized medical physicist except for calculating the activity of Sr-90 sources.) The licensee’s AMP must calculate the activity of each strontium-90 source that is used to determine the treatment times for ophthalmic treatments.
In addition, the licensee must perform spot-check measurements of sealed sources and devices used for therapy in accordance with written procedures established by the AMP (12VAC5-481-2040). The calibration procedures described by AAPM Task Group No. 21 and Reports 41, 46, 51, 54, 59, 61, and 67 or any published protocol approved by a nationally recognized body, as applicable, may be used. The calibration procedures should address, in part:
-
The method used to determine the exposure rate (or activity) under specific criteria (i.e., distances used for the measurement, whether the measurement is an ‘in air’ measurement or done using a phantom configuration of the chamber with respect to the source(s) and device, scatter factors used to compute the exposure rate, etc.).
Full calibrations, as described in greater detail in Item 9.17, must be performed before first medical use, whenever spot-check measurements (if required) indicate that the output differs by more than 5% from the output obtained at the last full calibration corrected mathematically for decay, following replacement of the sources or reinstallation of the unit in a new location not previously described in the license, following any repairs of the unit that include removal of sealed sources or major repair of the components associated with the source exposure assembly, and at intervals as defined in 12VAC5-481-2040.
Manual brachytherapy sources must be calibrated only initially and prior to use (12VAC5-481-2010).
References:
Copies of AAPM Task Group No. 21, ‘A Protocol for the Determination of Absorbed Dose from High-Energy Photon and Electron Beams’, AAPM Task Group No. 40, ‘Comprehensive QA for Radiation Oncology’, AAPM Report No. 54, ‘Stereotactic Radiosurgery’, AAPM Task Group No. 56, ‘Code of Practice for Brachytherapy Physics’, may be obtained from the American Association of Physicists in Medicine, One Physics Ellipse, College Park, MD 20740-3843 or by ordering electronically from http://www.aapm.org.
Revision 4 January 14, 2022
Item 8.5: Other Equipment and Facilities
Rule:
12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-630, 12VAC5-481-840, 12VAC5-481-1870, 12VAC5-481-1890, 12VAC5-481-1970, 12VAC5-481-2010, 12VAC5-481-2040
Criteria:
Facilities and equipment must be adequate to protect health and minimize danger to life or property.
Discussion:
The applicant must describe, in Item 8.5 of the application, other equipment and facilities available for safe use and storage of radioactive material listed in Item 7.1 of the application (e.g., fume hoods, xenon traps, emergency response equipment, area monitors, remote handling tools, source transport containers, patient viewing and intercom systems, interlock systems). This description should be identified as an attachment.
Applicants who use PET radiopharmaceuticals should describe any additional shielding material being used (e.g., PET specific syringe shields or vial shields). The applicant must describe additional facilities and equipment for the radiopharmaceutical therapy program to safely receive, use, store, and dispose of radioactive material.
The applicant should focus on facilities to be used for radioactive drug therapy administration and patient accommodations (i.e., private room with private bath).
I-131 sodium iodide is the most widely used source of radiopharmaceutical therapy. If the radionuclide is administered in volatile liquid form, it is important to place the patient dosage in a closed environment (i.e., a fume hood).
Also note there are hazards associated with volatile iodine in pill form; applicants should consider this in establishing their radiological controls.
When patients are treated with I-131 sodium iodide, sources of contamination include airborne I-131, urine, perspiration, saliva, and other secretions. If release limits in 12VAC5-481-1870 might be exceeded, provide a room with a private bath as described in Item 8.1 of this document.
To facilitate decontamination of the patient’s room, floors, toilet areas, sink areas, countertops, and other permeable surfaces, the licensee should consider covering areas with disposable materials having plastic on one side and an absorbent material on the other.
In addition, items handled by the patient may be covered with plastic.
If the radiopharmaceutical administered is secreted in perspiration or saliva, or may by some other means be present as a source of surface contamination, then it may be helpful to place removable covers on telephone handsets, faucet and toilet handles, television remote controls, door handles, and nurse call buttons.
P-32
is effectively shielded by a plastic syringe. After P-32 has been administered to a patient, there is no external radiation hazard; therefore, isolation of patients who have administrations of P-32 is not required.
P-32 administered in colloidal form can contaminate bandages and dressings; therefore, waste containers labeled for disposal of radioactive wastes should be readily available.
Teletherapy, GSR, and HDR Facilities
The licensee shall require any individual entering the treatment room to ensure, through the use of appropriate radiation monitors, that radiation levels have returned to ambient levels.
A beam-on radiation monitor permanently mounted in each therapy treatment room that is equipped with an emergency power supply separate from the power supply for the therapy unit meets the requirements of 12VAC5-481-2040.
In addition, the beam-on monitors traditionally installed in therapy treatment rooms can provide a visible indication (e.g., flashing light) of an exposed or partially exposed source.
The applicant shall describe the system, required by 12VAC5-481-2040, used to view and communicate with the patient continuously while the patient is in the treatment room.
If a shielded viewing window will be used, the thickness, density, and type of material used shall be specified.
If a closed-circuit television system (or some other electronic system) will be used to view the patient, the backup system or procedure to be used in case the electronic system malfunctions shall be specified, or the applicant must commit to suspending all treatments until the electronic system is repaired and functioning again.
The communication system must allow the patient to communicate with the unit operator in the event of medical difficulties.
An open microphone system is recommended to allow communication without requiring the patient to move to activate controls.
The applicant must also provide adequate equipment and controls to maintain exposures of radiation to workers ALARA and within regulatory limits.
12VAC5-481-2040, in part, requires that each door leading into the treatment room be provided with an electrical interlock system to control the on-off mechanism of the therapy unit.
The interlock system must cause the source(s) to be shielded if the door to the treatment room is opened when the source is exposed.
The interlock system must also prevent the operator from initiating a treatment cycle unless the treatment room entrance door is closed.
Additionally, the interlock must be wired so that the source(s) cannot be exposed after interlock interruption until the treatment room door is closed and the source(s) on-off control is reset at the console.
Due to the unique characteristics of pulsed dose-rate remote afterloaders (PDR) and the lack of constant surveillance of their operation, a more sophisticated alarm system is essential to ensure the patient is protected during treatment.
In addition to the above, it is necessary, under 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-840, and 12VAC5-481-2040, to ensure the following:
-
The PDR device control console is not accessible to unauthorized personnel during treatment;
A primary care provider checks the patient to ensure that the patient’s device has not been moved, kinked, dislodged, or disconnected;
A more sophisticated interlock/warning system is normally installed for PDR devices. This system should perform the following functions or possess the following characteristics:
- The signal from the PDR device and the signal from the room radiation monitor should be connected in such a manner that an audible alarm sounds if the room monitor indicates the presence of radiation and the device indicates a ‘safe’ or retracted position;
- The alarm circuit should also be wired in such a manner that an audible alarm is generated for any device internal error condition that could indicate the unintended extension of the source. This would constitute a circuit that generates the audible alarm when either the ‘source retracted and radiation present’ or appropriate internal error condition(s) exist;
- The ‘source safe and radiation present’ signal should also be self-testing. If a ‘source not safe’ input is received without a corresponding ‘radiation present’ signal, the circuit should generate an interlock/warning circuit failure signal that will cause the source to retract. Reset this circuit manually before attempting to continue treatment;
- The audible alarm should be sufficiently loud to be clearly heard by the facility’s responsible device/patient monitoring staff at all times; and
- No provisions for bypassing this alarm circuit or for permanently silencing the alarm should be made to the circuit as long as the room radiation monitor is indicating the presence of radiation.
Controls that disable this alarm circuit or provide for silencing the alarm for periods in excess of 1 minute should be prohibited.
If the alarm circuit is inoperative for any reason, licensees shall prohibit further treatment of patients with the device until the circuit has been repaired and tested.
If the alarm circuit fails during the course of a patient treatment, the treatment in progress may continue as long as continuous surveillance of the device is provided during each treatment cycle or fraction.
Applicants may submit information on alternatives to fixed shielding as part of their facility description. This information must demonstrate that the shielding will remain in place during the course of patient treatment.
For patient rooms where low dose-rate (LDR) remote afterloader use is planned, neither a viewing nor an intercom system is required. However, the applicant should describe how the patient and device will be monitored during treatment to ensure that the sources and catheter guide tube are not disturbed during treatment and to provide for prompt detection of any operational problems with the LDR device during treatment.
Note:
For manual brachytherapy facilities, provide a description of the emergency response equipment.
For teletherapy, GSR, and remote afterloader facilities, provide a description of the following:
-
Warning systems and restricted area controls (e.g., locks, signs, warning lights and alarms, interlock systems) for each therapy treatment room;
Area radiation monitoring equipment;
Viewing and intercom systems (except for LDR units);
Steps that will be taken to ensure that no two units can be operated simultaneously, if other radiation-producing equipment (e.g., linear accelerator, X-ray machine) are in the treatment room;
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Ensure that whenever the device is not in use or is unattended, the console keys will be inaccessible to unauthorized persons.
• Emergency response equipment.
Item 9: Radiation Protection Program
Rule: 12VAC5-481-450, 12VAC5-481-490, 12VAC5-481-500, 12VAC5-481-630, 12VAC5-481-990, 12VAC5-481-1690, 12VAC5-481-1700, 12VAC5-481-2070
Criteria: 12VAC5-481-630 states that each licensee must develop, document, and implement a radiation protection program commensurate with the scope of the licensed activity. The program must be sufficient to ensure compliance with the provisions of 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part IV ‘Standards For Protection Against Radiation’.
The licensee is responsible for the conduct of all licensed activities and the acts and omissions of individuals handling licensed material.
12VAC5-481-490 provides that VDH may incorporate into radioactive material licenses, at the time of issuance or thereafter, additional requirements and conditions that it deems appropriate or necessary to, in part, protect health or to minimize danger to life and property.
12VAC5-481-630 and 12VAC5-481-1700 describe the licensee management’s authorities and responsibilities for the radiation protection program.
12VAC5-481-1700 sets forth four circumstances in which the licensee may revise its radiation protection program without VDH approval.
Discussion:
Licensees must abide by all applicable rules; develop, implement, and maintain procedures when required; and/or provide requested information about the proposed radiation protection program during the licensing process.
The applicant should consider the following functional areas (as applicable to the type of medical program):
-
Audit program;
Occupational dose;
Public dose;
Minimization of contamination;
Operating and emergency procedures;
Material receipt and accountability;
Ordering and receiving;
Opening packages;
Sealed source inventory;
Use records;
Leak tests;
Area surveys;
Procedures for administrations requiring a written directive;
Safe use of unsealed licensed material;
Installation, maintenance, adjustment, repair, and inspection of therapy devices containing sealed sources;
Spill procedures;
Emergency response for sealed sources or devices containing sealed sources;
Release of patients or human research subjects;
Safety procedures for patients that are hospitalized;
Procedures for device calibration, safety checks, operation, and inspection;
Mobile medical service;
Transportation;
Medical event response and notification;
Waste management.
Item 9.1: Audit Program
Rule: 12VAC5-481-630, 12VAC5-481-990
Criteria: Licensees must annually review the content and implementation of the radiation protection program. The review should ensure the following:
-
Compliance with VDH and applicable DOT regulations and the terms and conditions of the license;
Occupational doses and doses to members of the public are ALARA (12VAC5-481-630);
Records of audits and other reviews of radiation protection program content are maintained for 3 years after the record is made.
Discussion:
Appendix K contains a suggested medical licensee audit that is specific to medical use and is acceptable to the agency.
All areas indicated in Appendix K may not be applicable to every licensee and may not need to be addressed during each audit.
Currently, the agency’s emphasis in inspections is to perform actual observations of work in progress.
As a part of their audit programs, applicants should consider performing unannounced audits of authorized and supervised users to determine if, for example, operating and emergency procedures are available, are being followed, etc.
It is essential that once identified, problems be corrected comprehensively and in a timely manner; NRC Information Notice (IN) 96-28, "Suggested Guidance Relating to Development and Implementation of Corrective Action", provides guidance on this subject.
The agency will review the licensee's audit results and determine if corrective actions are thorough, timely, and sufficient to prevent recurrence.
If violations are identified by the licensee and these steps are taken, the agency can exercise discretion and may elect not to cite a violation.
The agency’s goal is to encourage prompt identification and comprehensive correction of violations and deficiencies.
With regard to audit records, 12VAC5-481-990 requires licensees to maintain records of audits and other reviews of program content and implementation.
The agency has found audit records that contain the following information to be acceptable: date of audit, name of person(s) who conducted audit, person(s) contacted by the auditor(s), areas audited, audit findings, corrective actions, and follow-up.
References:
Copies of NRC Information Notices including: NRC’s IN 96-28, ‘Suggested Guidance Relating to Development and Implementation of Corrective Action’, can be accessed at NRC’s web site, http://www.nrc.gov.
Item 9.2: Occupational Dose
Rule: 12VAC5-481-10, 12VAC5-481-630, 12VAC5-481-640, 12VAC5-481-650, 12VAC5-481-670, 12VAC5-481-700, 12VAC5-481-710, 12VAC5-481-750, 12VAC5-481-760, 12VAC5-481-770, 12VAC5-481-1040, 12VAC5-481-1710, 12VAC5-481-2070, 12VAC5-481-2280
Criteria: Applicants must do either of the following:
-
Provide dosimetry processed and evaluated by a National Voluntary Laboratory Accreditation Program (NVLAP) approved processor that is exchanged at a frequency recommended by the processor. OR
Maintain, for inspection by the agency, documentation demonstrating that unmonitored individuals are not likely to receive, in one year, a radiation dose in excess of 10 percent of the allowable limits as shown in Table 5.
Table 5: Occupational Dose Limits for Adults
Occupational Dose Limits for Adults (12VAC5-481-640)
-
Body Location: Total Effective Dose Equivalent (TEDE): 0.05 Sv (5 Rem)
Dose to the skin of the whole body or any extremity*: 0.5 Sv (50 Rem)
Dose to lens of the eyes: 0.15 Sv (15 Rem)
Table 6: Investigational Levels
Part of Body | Investigational Level I (mrem per year) | Investigational Level II (mrem per year)
Whole body; head; trunk including male gonads; arms above the elbow; or legs above the knee | 500 (5 mSv) | 1500 (15 mSv)
Hands; elbows; arms below the elbow; feet; knee; leg below the knee; or skin | 5000 (50 mSv) | 15,000 (150 mSv)
Lens of the eye | 1500 (15 mSv) | 4500 (45 mSv)
Discussion:
The radiation protection program that licensees are required to develop, document, and implement in accordance with 12VAC5-481-630, must include provisions for monitoring occupational dose.
The licensee must evaluate the exposure of all occupational workers (e.g., nurses, technologists) to determine if monitoring is required to demonstrate compliance with 12VAC5-481-760.
Licensees must consider the internal and external dose and the occupational workers’ assigned duties when evaluating the need to monitor occupational radiation exposure.
Review of dosimetry histories for workers previously engaged in similar duties may be helpful in assessing potential doses.
When evaluating dose from aerosols, licensees may take credit for the reduction of dose resulting from the use of aerosol traps.
Licensees may vent aerosols directly to the atmosphere as long as the effluent concentration is within 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part IV ‘Standards For Protection Against Radiation’ limits.
Appendix L provides a procedure for monitoring external occupational exposure.
If external dose monitoring is necessary, the applicant should describe the type of personnel dosimetry, such as film badges, optically stimulated luminescence dosimeters (OSL), and thermoluminescent dosimeters (TLDs), that personnel will use.
If occupational workers handle licensed material, the licensee should evaluate the need to provide extremity monitors, which are required if workers are likely to receive a dose in excess of 0.05 Sv (5 rem) shallow-dose equivalent (SDE), in addition to whole-body badges.
Additionally, applicants should ensure that their personnel dosimetry program contains provisions that personnel monitoring devices be worn so that the part of the body likely to receive the greatest dose will be monitored.
Some licensees use self-reading dosimeters in lieu of processed dosimetry. This is acceptable if the regulatory requirements are met.
See American National Standards Institute (ANSI) N322, ‘Inspection and Test Specifications for Direct and Indirect Reading Quartz Fiber Pocket Dosimeters’, for more information.
If pocket dosimeters are used to monitor personnel exposures, applicants should state the useful range of the dosimeters, along with the procedures and frequency for their calibration and maintenance as required by 12VAC5-481-750.
When personnel monitoring is needed, most licensees use either OSLs or TLDs that are supplied by a processor holding current personnel dosimetry accreditation from the National Voluntary Laboratory Accreditation Program (NVLAP).
Under 12VAC5-481-750, licensees must verify that the processor is accredited by NVLAP for the type of radiation for which monitoring will be performed.
Consult the NVLAP accredited processor for its recommendations for exchange frequency and proper use.
It may be necessary to assess the intake of radioactivity for occupationally exposed individuals in accordance with 12VAC5-481-650, 12VAC5-481-670, and 12VAC5-481-760.
If internal dose monitoring is necessary, the applicant must measure the following:
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Concentrations of radioactive material in air in work areas;
Quantities of radionuclides in the body;
Quantities of radionuclides excreted from the body;
Or combinations of these measurements.
The applicant should describe in its procedures the criteria used to determine the type of bioassay and the frequencies at which bioassay (both in vivo and in vitro) will be performed to evaluate intakes.
The criteria also should describe how tables of investigational levels are derived, including the methodology used by the evaluated internal dose assessments (i.e., the empirical models used to interpret the raw bioassay data).
The bioassay procedures should provide for baseline, routine, emergency, and follow-up bioassays.
If a commercial bioassay service will be used, the applicant must ensure that the service is licensed to perform these activities by VDH, NRC, or another Agreement State.
NRC’s RG 8.9, Revision 1, ‘Acceptable Concepts, Models, Equations, and Assumptions for a Bioassay Program’, and NUREG/CR-4884, ‘Interpretation of Bioassay Measurements’, outline acceptable criteria that applicants may use in developing their bioassay programs.
NRC Regulatory Issue Summary (RIS) 2002-06, “Evaluating Occupational Dose for Individuals Exposed to NRC-Licensed Material and Medical X-Rays”, provides guidance for evaluating occupational dose when some exposure is due to X-rays and dosimeters are used to measure exposure behind lead aprons and elsewhere.
Note: The definition of “Shallow dose equivalent (Hs)” in 12VAC5-481-10 changes the area for averaging dose to skin from 1 square centimeter to 10 square centimeters (see NRC Regulatory Issue Summary 2002-10, “Revision of the Skin Dose Limit in 10 CFR Part 20”).
12VAC5-481-650 describes the requirements for summing external and internal doses.
Applicants must ensure that their occupational monitoring procedures include criteria for summing external and internal doses.
References:
• National Institute of Standards and Technology (NIST) Publication 810, ‘National Voluntary Laboratory Accreditation Program Directory’, is published annually and is
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Available for purchase from the Government Printing Office and on the Internet at http://ts.nist.gov/ts/htdocs/210/214/scopes/programs.htm.
Copies of ANSI N322 may be obtained from the American National Standards Institute, 1430 Broadway, New York, NY 10018, or ordered electronically from http://www.ansi.org.
NUREG/CR-4884, ‘Interpretation of Bioassay Measurements’ and NRC Regulatory Guide 8.9, Revision 1, ‘Acceptable Concepts, Models, Equations, and Assumptions for a Bioassay Program’ can be accessed at NRC’s web site, http://www.nrc.gov.
NRC Regulatory Issue Summary 2002-06, ‘Evaluating Occupational Dose for Individuals Exposed to NRC-Licensed Material and Medical X-Rays’ can be accessed at NRC’s web site, http://www.nrc.gov.
NRC Regulatory Issue Summary 2002-10, ‘Revision of the Skin Dose Limit in 10 CFR Part 20’ can be accessed at NRC’s web site, http://www.nrc.gov.
Application Process and Guidance
Item 9.3: Public Dose Rule
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[a.] 12VAC5-481-10, 12VAC5-481-720, 12VAC5-481-730, 12VAC5-481-840, 12VAC5-481-1050, 12VAC5-481-1110, 12VAC5-481-1870
Criteria:
• Ensure that licensed material will be used, transported, and stored in such a way that members of the public will not receive more than 1 mSv (100 mrem) in one year, and the dose in any unrestricted area will not exceed 0.02 mSv (2 mrem) in any one hour from licensed operations;
• Ensure air emissions of radioactive materials to the environment will not result in exposures to individual members of the public in excess of 0.1 mSv (10 mrem) (TEDE) in one year from these emissions; and
• Control and maintain constant surveillance of licensed material that is not in storage and secure stored licensed material from unauthorized access, removal, or use.
Discussion:
Members of the public include persons who are not radiation workers. This includes workers who work or may be near locations where licensed material is used or stored and employees whose assigned duties do not include the use of licensed materials and who work in the vicinity where it is used or stored.
Public dose is controlled, in part, by ensuring that licensed material is secure (e.g., located in a locked area) to prevent unauthorized access or use by individuals coming into the area. Some medical use devices containing licensed material are usually restricted by controlling access to the keys needed to operate the devices and/or to keys to the locked storage area. Only authorized users (AUs) and personnel using radioactive material under their supervision should have access to these keys.
The definition of “Public dose” in 12VAC5-481-10 does not include doses received due to exposure to patients released in accordance with 12VAC5-481-1870.
Dose to members of the public in waiting rooms was addressed in the NRC Information Notice (IN) 94-09.
The provisions of 12VAC5-481-720 should not be applied to radiation received by a member of the general public from patients released under 12VAC5-481-1870.
If a patient is released pursuant to 12VAC5-481-1870, licensees are not required to limit the radiation dose to members of the public (e.g., visitors in a waiting room) from a patient to 0.02 mSv (2 mrem) in any one hour.
Patient waiting rooms need only be controlled for those patients not meeting the release criteria in 12VAC5-481-1870.
12VAC5-481-720 allows licensees to permit visitors to a patient who cannot be released under 12VAC5-481-1870 to receive a dose greater than 1 mSv (0.1 rem) provided the dose does not exceed 5 mSv (0.5 rem) and the authorized user has determined before the visit that it is appropriate.
NRC Regulatory Issue Summary 2005-24 ‘Control of Radiation Dose to Visitors of Hospital Patients’ provides guidance to licensees on methods that may be used to estimate and control radiation doses to visitors of hospitalized patients who have been administered radioactive material.
The licensee must control emissions of radioactive material to air such that the individual member of the public likely to receive the highest total effective dose equivalent (TEDE) does not exceed the constraint level of 0.10 mSv (10 mrem) per year from those emissions. If exceeded, the licensee must report this in accordance with 12VAC5-481-1110 and take prompt actions to ensure against recurrence.
Public dose is also affected by the choice of storage and use locations and conditions. Licensed material may produce a radiation field and must be located so that the public dose in an unrestricted area (e.g., an office or the exterior surface of an outside wall) does not exceed 1 mSv (100 mrem) in a year or 0.02 mSv (2 mrem) in any one hour.
Licensees should use the concepts of time, distance, and shielding when choosing storage and use locations.
Decreasing the time, increasing the distance, and using shielding (e.g., brick, concrete, lead, or other solid walls) will reduce the radiation exposure.
Licensees can determine the radiation levels adjacent to licensed material either by direct measurement, calculations, or a combination of direct measurements and calculations using some or all of the following:
• typical known radiation levels provided by the manufacturer;
• the ‘inverse square’ law to evaluate the effect of distance on radiation levels;
• occupancy factor to account for the actual presence of the member of the public; and
• limits on the use of licensed material.
If, after making an initial evaluation, a licensee changes the conditions used for the evaluation (e.g., the location of licensed material within a designated room, the type or frequency of licensed material use, or the occupancy of adjacent areas), the licensee must perform a new evaluation to ensure that the public dose limits are not exceeded and take corrective action, as needed.
Item 9.4: Minimization of Contamination Rule
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[a.] 12VAC5-481-450, 12VAC5-481-1840
Criteria:
Applicants for new licenses must describe in the application how facility design and procedures for operation will minimize, to the extent practicable, contamination of the facility and the environment, facilitate eventual decommissioning, and minimize, to the extent practicable, the generation of radioactive waste.
Discussion:
All applicants for new licenses need to consider the importance of designing and operating their facilities to minimize the amount of radioactive contamination generated at the site during its operating lifetime and to minimize the generation of radioactive waste during decontamination. This is especially important for licensed activities involving unsealed radioactive material.
As described in Item 9.14, ‘Spill Procedures’, cleanup procedures should be implemented for contamination events.
Recommended limits for acceptable levels of surface contamination in restricted and unrestricted areas are provided in Appendix R, Tables 13 and 14.
Sealed sources and devices that are approved by the NRC or another Agreement State and located and used according to their Sealed Source Device Registration certificates (SSDR) usually pose little risk of contamination.
Leak tests performed as specified in the SSDR Certificate should identify defective sources.
Leaking sources must be immediately withdrawn from use and stored, repaired, or disposed of according to VDH requirements.
These steps minimize the spread of contamination and reduce radioactive waste associated with decontamination efforts.
Other efforts to minimize radioactive waste do not apply to programs using only sealed sources and devices that have not leaked.
Item 9.5: Operating and Emergency Procedures Rule
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[a.] 12VAC5-481-500, 12VAC5-481-630, 12VAC5-481-750, 12VAC5-481-780, 12VAC5-481-790, 12VAC5-481-840, 12VAC5-481-900, 12VAC5-481-910, 12VAC5-481-1090, 12VAC5-481-1100, 12VAC5-481-1110, 12VAC5-481-1150, 12VAC5-481-1710, 12VAC5-481-1730, 12VAC5-481-1860, 12VAC5-481-1870, 12VAC5-481-1890, 12VAC5-481-1960, 12VAC5-481-1970, 12VAC5-481-2010, 12VAC5-481-2040, 12VAC5-481-2080, 12VAC5-481-2260, 12VAC5-481-3700
Criteria:
This section summarizes operating and emergency procedures. Many of these procedures are covered in greater detail in other sections of this document.
The licensee shall develop, implement, and maintain specific operating and emergency procedures containing the following elements:
Instructions for opening packages containing licensed material;
Using licensed material, operating therapy treatment devices, and performing routine maintenance on devices containing sealed sources, according to the manufacturer’s written recommendations and instructions and in accordance with regulatory requirements;
Instructions for conducting area radiation level and contamination surveys;
Instructions for administering licensed material in accordance with the written directive (WD);
Steps to take, and whom to contact (e.g., RSO, local officials), when the following has occurred:
(a) leaking or damaged source,
(b) device malfunction and/or damage,
(c) licensed material spills,
(d) theft or loss of licensed material,
(e) releases of xenon-133,
(f) a medical event, or
(g) any other incidents involving licensed material.
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Provide a current copy of the operating procedures at each location of use (or, if this is not practicable, post a notice describing the procedures and stating where they may be examined).
When developing the procedures described above, the licensee is reminded that 12VAC5-481-630 requires that the licensee use, to the extent practical, procedures and engineering controls based on sound radiation protection principles to achieve occupational doses and doses to members of the public that are ALARA.
In addition, when receiving and using radioactive material, the licensee is reminded that it must be licensed to possess the radioactive material and that the radioactive material must be secured (or controlled) and accounted for at all times.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
to be performed is due to the possible exposure of the hands and face to relatively intense beta radiation.
Procedures for emergency surgery or autopsy can be found in Section 5.3 of NCRP Report No. 37, ‘Precautions In The Management of Patients Who Have Received Therapeutic Amounts of Radionuclides’.
Appendix N also provides procedures for responding to emergency surgery or death of a therapy patient.
Applicants must develop emergency procedures that address a spectrum of incidents (e.g., major spills, leaking source, medical events, interlock failure, stuck source, etc.).
After its occurrence becomes known to the licensee, VDH must be notified when licensed material in excess of 10 times the quantity specified in 12VAC5-481-3700 is lost or stolen.
The RSO must be proactive in evaluating whether VDH notification is required for any incident involving licensed material.
Refer to the rule references (12VAC5-481-1090, 12VAC5-481-1100, 12VAC5-481-1110, 12VAC5-481-1150, and 12VAC5-481-2080) for a description of when notifications are required.
Reference: Copies of NCRP Report No. 37, “Precautions In The Management of Patients Who Have Received Therapeutic Amounts of Radionuclides”, NCRP Report No. 105, “Radiation Protection for Medical and Allied Health Personnel”, and NCRP Report No. 107, “Implementation of the Principle of As Low As Reasonably Achievable (ALARA) for Medical and Dental Personnel”, may be obtained from the National Council on Radiation Protection and Measurements, 7910 Woodmont Avenue, Suite 800, Bethesda, MD 20814-3095, or ordered electronically at http://www.ncrp.com.
Item 9.6: Material Receipt and Accountability
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Rule: 12VAC5-481-100, 12VAC5-481-500, 12VAC5-481-570, 12VAC5-481-571, 12VAC5-481-840, 12VAC5-481-900, 12VAC5-481-1090, 12VAC5-481-1710, 12VAC5-481-1840, 12VAC5-481-2070
Criteria:
Licensees must do the following:
Maintain records of receipt, transfer, and disposal of licensed material and
Conduct physical inventories at intervals not to exceed 6 months (or some other interval justified by the applicant) to account for all sealed sources.
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Physical inventories of sealed sources at intervals not to exceed 6 months;
Ordering and receiving licensed material;
Package opening;
Disposal records; and
Use records.
‘Cradle to Grave’ Accountability refers to maintaining the radioactive material from the moment it becomes a part of your organization (whether through creation there, delivered to the company, etc.) through performing the quarterly inventories (ensuring the material’s location, etc.) until it leaves your organization (through shipment, disposal on/off site, etc.).
Maintain inventory records that contain the following types of information:
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Radionuclide and amount (in units of Bq or curies) of radioactive material in each sealed source;
Manufacturer's name, model number, and serial number of each sealed source;
Manufacturer's name, model number, and serial number of each device containing depleted uranium or radioactive material;
Location of each sealed source and device;
Date of the inventory; and
Name of individual performing inventory; and
For materials transferred or disposed of, the date of the transfer or disposal, name and license number of the recipient, description of the affected radioactive material (e.g., radionuclide, activity, manufacturer’s (or distributor’s) name and model number, serial number).
Item 9.7: Ordering and Receiving
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Rule: 12VAC5-481-100, 12VAC5-481-500, 12VAC5-481-570, 12VAC5-481-571, 12VAC5-481-840, 12VAC5-481-900, 12VAC5-481-3091
Criteria:
Item 9.8: Opening Packages
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Rule: 12VAC5-481-750, 12VAC5-481-900, 12VAC5-481-1000, 12VAC5-481-3091
Criteria:
Item 9.9: Leak Tests
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Rule: 12VAC5-481-740, 12VAC5-481-750, 12VAC5-481-1010, 12VAC5-481-1150, 12VAC5-481-1840, 12VAC5-481-2070, 12VAC5-481-2080
Criteria:
Item 9.10: Area Surveys
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Rule: 12VAC5-481-10, 12VAC5-481-630, 12VAC5-481-640, 12VAC5-481-720, 12VAC5-481-730, 12VAC5-481-750, 12VAC5-481-840, 12VAC5-481-1000, 12VAC5-481-1050, 12VAC5-481-1710, 12VAC5-481-1860, 12VAC5-481-2070
Criteria:
Licensees are required to make surveys of potential radiological hazards in their workplace. For example, licensees must perform surveys to:
Ensure that radioactive material will be used, transported, and stored in such a way that members of the public will not receive more than 1 mSv (100 mrem) in one year and that the dose in any unrestricted area will not exceed 0.02 mSv (2 mrem) in any one hour from licensed operations;
Ensure that radioactive material will be used, transported, and stored in such a way that occupational doses to individuals will not exceed the limits specified in 12VAC5-481-640;
Control and maintain constant surveillance over radioactive material that is not in storage and secure radioactive material from unauthorized access or removal; and
Ensure that licensed material will be used, transported, and stored in such a way that the air emissions do not exceed the constraint value in 12VAC5-481-630.
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Facilities (restricted and unrestricted areas);
Equipment;
Incoming and outgoing radioactive packages; and
Personnel (during use, transfer, or disposal of licensed material).
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Surveys for radioactive contamination that could be present on surfaces of floors, walls, laboratory furniture, and equipment;
Measurements of radioactive material concentrations in air for areas where radiopharmaceuticals are handled or processed in unsealed form and where operations could cause workers to inhale radioactive material (e.g., radioiodine) or where radioactive material is or could be released to unrestricted areas;
Bioassays to determine the kinds, quantities, or concentrations, and in some cases, the location of radioactive material in the human body. Radioiodine uptake in a worker’s thyroid gland is commonly measured by external counting using a specialized thyroid detection probe;
Surveys of external radiation exposure levels in both restricted and unrestricted areas; and
Surveys of radiopharmaceutical packages entering (e.g., from suppliers) and departing (e.g., returned radiopharmaceuticals to the supplier).
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
Radioactive materials, as well as the specific protective facilities, equipment, and procedures that are designed to protect workers and the public from external and internal exposure. Also, the frequency of the survey depends on the type of survey. Appendix R contains procedures with suggested survey frequencies for ambient radiation level and contamination surveys.
For example, licensees are required to perform daily surveys in all areas where a written directive (WD) is required for preparation and administration of radiopharmaceuticals (i.e., diagnostic activities exceeding 30 μCi of I-131 and all therapy treatments); when the licensee administers radiopharmaceuticals requiring a WD in a patient’s room, the licensee is not required to perform a survey if the patient is not released. However, the licensee should perform adequate surveys of patients’ rooms after patient release and prior to release of the room for unrestricted use.
Licensees should be cognizant of the requirement to perform surveys to demonstrate the public limits are not exceeded.
Revision 4 January 14, 2022
Because therapy sealed sources (including applicators and catheters) may become dislodged during implantation or after surgery, and inadvertently lost or removed, the following surveys shall be performed:
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Immediately after implanting sources in a patient or a human research subject, the licensee shall make a survey to locate and account for all sources that have not been implanted;
Immediately after removing the last temporary implant source from a patient or human research subject, the license shall make a survey of the patient or human research subject with a radiation detection survey instrument to confirm that all sources have been removed.
In addition, licensees should also consider surveying the following:
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The therapy patient’s bed linens before removing them from the patient’s room;
The operating room and the patient’s room after source implantation (e.g., radiation level and/or visual check);
All trash exiting the patient’s room; and
Areas of public access in and around the patient’s room.
The licensee must also perform surveys to ensure that radiation levels around a patient’s room after source implantation are within the regulatory requirements (e.g., less than 0.02 mSv (2 mrem) in any one hour in any unrestricted area).
Not all instruments can measure a given type of radiation (e.g., alpha, beta, and gamma). The presence of other radiation may interfere with a detector’s ability to measure the radiation of interest. The energy of the radiation may not be high enough to penetrate some detector windows and be counted.
The correct selection, calibration, and use of radiation detection instruments are important aspects of any radiation safety program. Additionally, applicants are reminded that probe movement speeds and surface-to-probe distances greatly affect ambient exposure rate survey results.
Item 9.11: Procedures for Administration of Radioactive Material Requiring a Written Directive
Rule: 12VAC5-481-1710, 12VAC5-481-1720, 12VAC5-481-1730, 12VAC5-481-2070 Criteria: 12VAC5-481-1720 sets forth the requirements for Written Directives (WDs). 12VAC5-481-1730 requires medical use licensees to develop, maintain, and implement written procedures to provide high confidence that licensed material is administered as directed by authorized users. Discussion: The procedures do not need to be submitted to VDH. This gives licensees the flexibility to revise the procedures to enhance effectiveness without obtaining VDH approval. Appendix S provides guidance on developing the procedures. Procedures will be reviewed by the agency during inspection.Item 9.12: Safe Use of Unsealed Licensed Material
Rule: 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-630, 12VAC5-481-640, 12VAC5-481-720, 12VAC5-481-730, 12VAC5-481-840, 12VAC5-481-1000, 12VAC5-481-1710, 12VAC5-481-1850, 12VAC5-481-1860, 12VAC5-481-1960, 12VAC5-481-1970 Criteria: Before using radioactive material, the licensee must develop and implement a radiation protection program that includes safe use of unsealed radioactive material. Discussion: The radiation protection program that licensees are required to develop, document, and implement in accordance with 12VAC5-481-630 must include provisions for safe use of radioactive material. Licensees are responsible for developing, documenting, and implementing procedures to ensure the security and safe use of all radioactive material from the time it arrives at their facilities until it is used, transferred, and/or disposed.The written procedures should provide reasonable assurance that only appropriately trained personnel will handle and use radioactive material without undue hazard to themselves, other workers, or members of the public.
In addition, licensees must develop, implement, and maintain procedures for protective measures to be taken by occupational workers to maintain their doses ALARA. Protective measures may include:
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Use of syringe shields and/or vial shields;
Wearing laboratory coats and gloves when handling unsealed radioactive material;
Monitoring hands after handling unsealed radioactive material.
Appendix T contains procedures for safe use of unsealed radioactive material.
Item 9.13: Installation, Maintenance, Adjustment, Repair, and Inspection of Therapy Devices Containing Sealed Sources
Rule: 12VAC5-481-440, 12VAC5-481-500, 12VAC5-481-630, 12VAC5-481-2040, 12VAC5-481-2070 Criteria: In accordance with 12VAC5-481-2040, licensees must ensure that therapy devices containing sealed sources are installed, maintained, adjusted, repaired, and inspected by persons specifically licensed to conduct these activities.The above activities should be conducted according to the manufacturers’ written recommendations and instructions and according to the Sealed Source Device Registration certificate.
In addition, 12VAC5-481-2040 requires that teletherapy and GSR units be fully inspected and serviced during source replacement or at intervals not to exceed 5 years, whichever comes first, to ensure that the source exposure mechanism functions properly.
Maintenance is necessary to ensure that the device functions as designed and source integrity is not compromised. Discussion: Maintenance and repair includes installation, replacement, and relocation or removal of the sealed source(s) or therapy unit that contains a sealed source(s). Maintenance and repair also includes any adjustment involving any mechanism on the therapy device, treatment console, or interlocks that could expose the source(s), reduce the shielding around the source(s), affect the source drive controls, or compromise the radiation safety of the unit or the source(s).
VDH requires that maintenance and repair (as defined above) be performed only by persons specifically licensed by VDH, NRC, or an other Agreement State to perform such services.
Most licensee employees do not perform maintenance and repair because they do not have the specialized equipment and technical expertise to perform these activities.
Applicants requesting authorization to possess and use Low Dose Rate remote afterloaders should review 12VAC5-481-2040 before responding to this item.
12VAC5-481-2040 allows for an AMP to perform certain service activities with regard to LDR remote afterloader units.
Item 9.14: Spill Procedures
Rule: 12VAC5-481-100, 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-570, 12VAC5-481-630, 12VAC5-481-670, 12VAC5-481-1000, 12VAC5-481-1100, 12VAC5-481-1110, 12VAC5-481-1710, 12VAC5-481-2260, 12VAC5-481-2070 Criteria: Before using radioactive material, the licensee must develop, document, and implement a radiation protection program that includes proper response to spills of radioactive material. Discussion: The radiation protection program that licensees are required to develop, document, and implement in accordance with 12VAC5-481-630 must include provisions for responding to spills or other contamination events in order to prevent the spread of radioactive material.Appendix N contains emergency response procedures, including spill procedures.
Spill procedures should address all types and forms of radioactive material used (e.g., unsealed and gases) and should be posted in restricted areas where radioactive materials are used or stored.
The instructions should specifically state the names and telephone numbers of persons to be notified (e.g., RSO, staff, state and local authorities, and VDH, when applicable).
Additionally, the instructions should contain procedures for evacuation of the area, containment of spills and other releases, appropriate methods for re-entering, and for decontaminating facilities (when necessary).
Note: The names and telephone numbers of the person to be notified of a spill or contamination event do not need to be included in the submitted Spill Procedures. However, these names and telephone numbers should be included in the posted spill procedures at your facility.
The Virginia Department of Health Radioactive Materials Program office number is (804) 864-8150 during regular business hours (7:45 a.m. to 4:30 p.m.). For spills requiring immediate notification after normal business hours, use Virginia Department of Emergency Management’s 24-hour emergency telephone number: 1-800-468-8892.
Identify the emergency as radiological.
Item 9.15: Emergency Response for Sealed Sources or Devices Containing Sealed Sources
Rule: 12VAC5-481-100, 12VAC5-481-450, 12VAC5-481-500, 12VAC5-481-630, 12VAC5-481-1090, 12VAC5-481-1100, 12VAC5-481-1110, 12VAC5-481-1710, 12VAC5-481-2010, 12VAC5-481-2040, 12VAC5-481-2070, 12VAC5-481-2080, 12VAC5-481-2260 Criteria: Before handling sealed sources or using devices containing sealed sources, the applicant must develop, document, and implement written procedures for emergency response.VDH requires that written procedures shall be developed, implemented, and maintained for responding to an abnormal situation involving manual brachytherapy, a remote afterloader unit, a teletherapy unit, or a gamma stereotactic radiosurgery unit.
The procedures must be submitted to VDH with your application and should include as appropriate:
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Steps to take if brachytherapy seeds are lost in an operating room;
Steps to take if a brachytherapy seed is breached;
Instructions for responding to equipment failures and the names of the individuals responsible for implementing corrective actions;
The process for restricting access to and posting of the treatment area to minimize the risk of inadvertent exposure; and
The names and telephone numbers of AUs, AMPs, and the RSO to be contacted if the unit or console operates abnormally.
Revision 4 January 14, 2022
For 12VAC5-481-2040 modalities, a copy of these procedures must be physically located at the therapy unit console. The instructions must inform the operator of procedures to be followed if the operator is unable to place the source(s) in the shielded position or remove the patient from the radiation field with controls from outside the treatment room.
Model procedures for responding to manual brachytherapy emergencies are provided in Appendix J. Discussion: The radiation protection program that licensees are required to develop, document, and implement in accordance with 12VAC5-481-630 must include provisions for responding to incidents involving sealed sources or devices containing sealed sources.
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REVISION 4 JANUARY 14, 2022
must address all types of radioactive material and devices used and should be posted in restricted areas where sealed sources are used or stored. The instructions must specifically state the names and telephone numbers of persons to be notified (e.g., RSO, staff, state and local authorities, and VDH, when applicable). Additionally, the instructions must contain procedures for evacuation and security of the involved area(s), source recovery, area re-entry, and decontamination of facilities (when necessary). All equipment necessary for complying with emergency procedures shall be available near each treatment room; for example, these may include remote handling tools, t-bars, Allen keys, and shielded containers. The applicant must establish and follow written procedures for emergencies that may occur (e.g., a manual brachytherapy source becomes dislodged, a therapy source fails to retract or return to the shielded position, or a GSR couch fails to retract). A copy of the manufacturer’s recommendations and instructions should be given to each individual performing therapy treatments or operating the therapy device. Practice drills, using non-radioactive (dummy) sources (when possible), must be practiced annually or more frequently, as needed. The drills should include dry runs of emergency procedures that cover stuck or dislodged sources and applicators (if applicable), and emergency procedures for removing the patient from the radiation field. Team practice may also be important for adequate emergency coordination for such maneuvers as removing a patient from a malfunctioning GSR unit and manual movement of the patient treatment table. These procedures, designed to minimize radiation exposure to patients, workers, and the general public should address the following points, as applicable to the type of medical use:
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• When the procedures are to be implemented such as any circumstance in which the source becomes dislodged, cannot be retracted to a fully shielded position, or the patient cannot be removed from the beam of radiation.
• The actions specified for emergency source recovery or shielding that primarily consider minimizing exposure to the patient and health care personnel while maximizing safety of the patient.
• Process for identifying and decontaminating equipment if a brachytherapy source ruptures.
• The step-by-step actions for single or multiple failures that specify the individual(s) responsible for implementing the actions. The procedures should clearly specify which steps are to be taken under different scenarios. The procedure should specify situations in which surgical intervention may be necessary and the steps that should be taken in that event.
• Location of emergency source recovery equipment and specification of what equipment may be necessary for various scenarios. Emergency equipment should include shielded storage containers, remote handling tools, and if appropriate, supplies necessary to surgically remove applicators or sources from the patient and tools necessary for removal of the patient from the device.
• Giving first consideration to minimizing exposure to the patient, usually by removing the patient from the room (rather than using tools to attempt to return the source to the off position). Note: If the first step of the emergency procedures for therapy units specifies pressing the emergency bar on the therapy unit console, the applicant is advised that this action may cause the source to return to the off position but may also cut power to the entire therapy unit or to the gantry or the couch.
• Instructing the staff to act quickly and calmly and to avoid the primary beam of radiation or areas contaminated with radioactive material.
• Specifying who is to be notified.
• Requirements to restrict access to (lock, as necessary) and post the treatment area with appropriate warning signs as soon as the patient and staff are out of the treatment room.
Item 9.16: Release of Patients or Human Research Subjects
Rule: 12VAC5-481-1710, 12VAC5-481-1870, 12VAC5-481-2070
Criteria: Licensees may release from confinement patients or human research subjects (patients) who have been administered radioactive material if the TEDE to any other individual from exposure to the released patient is not likely to exceed 5 mSv (0.5 rem). Licensees must provide radiation safety instructions to patients released (or their parent or guardian) in accordance with 12VAC5-481-1870.
Discussion: 12VAC5-481-1870 requires that the licensee provide the released individual (patient) with instructions, including written instructions, on actions recommended to maintain doses to other individuals ALARA if the TEDE to any other individual is likely to exceed 1 mSv (0.1 rem). If the dose to a breast-feeding infant or a child could exceed 1 mSv (0.1 rem), assuming there was no interruption of breast-feeding, the instructions also shall include:
-
• Guidance on the interruption or discontinuation of breast-feeding; and
• Information on the potential consequences of failure to follow the guidance.
This implies that the licensee will confirm whether a patient is breast-feeding before releasing the patient. In addition, 12VAC5-481-1870 and 12VAC5-481-2070 require that the licensee maintain a record of the basis for authorizing the release of an individual for 3 years after the release date, if the TEDE is calculated by:
-
• Using the retained activity rather than the activity administered;
• Using an occupancy factor less than 0.25 at 1 meter;
• Using the biological or effective half-life; or
• Considering the shielding by tissue.
In 12VAC5-481-1870 and 12VAC5-481-2070, the licensee is required to maintain a record for 3 years after the date of release of the instructions that were provided to a breast-feeding woman if the radiation dose to the infant or child from continued breast-feeding could result in a TEDE exceeding 5 mSv (0.5 rem).
Appendix U provides reference to NRC Regulatory Guide 8.39 containing guidance to the applicant for determining when:
-
• The licensee may authorize the release of a patient who has been administered radiopharmaceuticals or who has been treated with implants containing radioactive material; and
• Instructions to the patient required by 12VAC5-481-1870.
Guidance on recordkeeping requirements in 12VAC5-481-1870 and 12VAC5-481-2070 are also detailed within Regulatory Guide 8.39. The Regulatory Guide lists activities for commonly used radionuclides and the corresponding dose rates with which a patient may be released in compliance with the dose limits in 12VAC5-481-1870.
Item 9.17: Mobile Medical Service
Rule: 12VAC5-481-10, 12VAC5-481-100, 12VAC5-481-570, 12VAC5-481-571, 12VAC5-481-590, 12VAC5-481-630, 12VAC5-481-1680, 12VAC5-481-1870, 12VAC5-481-1880, 12VAC5-481-2040, 12VAC5-481-2070, 12VAC5-481-2980, 12VAC5-481-3000, 12VAC5-481-3010, 12VAC5-481-3020, 12VAC5-481-3030
Criteria: In addition to the requirements in 12VAC5-481-1880, mobile medical service licensees must comply with all other applicable regulations.
Discussion: Applicants for licensure of mobile medical services should review this guide for information to be submitted as part of their applications; many of the requirements in these sections are relevant to use of radioactive material by mobile medical service providers with details being dependent upon the scope of such programs. “Temporary job site” means a location, other than specific location(s) of use authorized on the license, where mobile medical services are conducted. Mobile medical service licensees may transport licensed material and equipment into a client’s building or may bring patients into the mobile coach/van. In either case, the coach/van should be located on the client’s property that is under the client’s control. Self-contained mobile medical service involves a mobile treatment or administration facility that provides ready-to-deliver mobile medical services on arrival at a client’s site. Companies providing transportation only will not be licensed for medical use under 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radio nuclides in the Healing Arts’.
Before using a remote afterloader for this type of service, the device should be installed in an appropriately shielded treatment room. The general types of services provided as mobile medical services are:
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• Mobile medical services (radioactive material, trained personnel, and facility) that provide the device/facility (e.g., in-coach/van use) and treatment of (or administration to) patients at the client site. These mobile medical service providers are responsible for all aspects of radioactive material use and authorized patient treatments (or administrations); and
• Mobile medical service providers (radioactive material and trained personnel) that provide the transportation to and use of the radioactive material within the client’s facility. These mobile medical service providers are also responsible for all aspects of radioactive material use and authorized patient treatments (or administrations).
Mobile medical service licensees must ensure that the criteria in 12VAC5-481-1870 are met before releasing patients in their facilities. Refer to Appendix V for additional guidance on information to provide in applications.
Note: NRC licensees and other Agreement State licensees that request reciprocity for activities conducted in the Commonwealth of Virginia are subject to the general license provisions described in 12VAC5-481-590. This general license authorizes persons holding a specific license from the NRC or an other Agreement State to conduct the same activity in the Commonwealth of Virginia if the specific license issued by the NRC or an other Agreement State does not limit the authorized activity to specific locations or installations.
Item 9.18: Transportation Rule
Rule: 12VAC5-481-100, 12VAC5-481-570, 12VAC5-481-571, 12VAC5-481-630, 12VAC5-481-2970, 12VAC5-481-2980, 12VAC5-481-3000, 12VAC5-481-3010, 12VAC5-481-3020, 12VAC5-481-3030, 12VAC5-481-3070, 12VAC5-481-3080, 12VAC5-481-3130, 49 CFR Parts 171-178
Criteria: Applicants who will prepare for shipment, ship, or transport radioactive materials, including radioactive waste, must develop, implement, and maintain safety programs for the transport of radioactive material to ensure compliance with VDH and DOT regulations.
Discussion: Most packages of radioactive material for medical use contain quantities of radioactive material that require use of Type A packages. Additionally, many packages shipped by medical licensees (e.g., unused radiopharmaceutical dosages) frequently meet the “Limited Quantity” criteria described in 49 CFR 173.421 and are therefore excepted from certain DOT requirements, provided certain other less restrictive requirements are met (e.g., activity in the package is less than the limited quantity and the radiation level on the surface of the package does not exceed 0.005 mSv per hour (0.5 mrem per hour)).
The general license in 12VAC5-481-3000, ‘General license: NRC-approved package’, provides the authorization used by most licensees to transport or to deliver to a carrier for transport radioactive material in a package for which a license, certificate of compliance, or other approval has been issued by NRC. This general license is subject to certain conditions. 12VAC5-481-2980 sets forth the requirements for transportation of radioactive material. 12VAC5-481-2970 exempts any physician licensed by a state to dispense drugs in the practice of medicine, who is also licensed under 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’, or the equivalent NRC or another Agreement State regulations from
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
the requirements in 12VAC5-481-2980. This exemption applies to transport by the physician of radioactive material for use in the practice of medicine.
Some medical use licensees (e.g., teletherapy or gamma stereotactic radiosurgery) may need to ship licensed material in Type B packages. 12VAC5-481-3000, 12VAC5-481-3010, 12VAC5-481-3020 and 12VAC5-481-3030 set forth the Type B package requirements for transporting or delivering the package to a carrier for transport.
These include registration as a user of the package and having a VDH-approved quality assurance (QA) plan. For information about these QA plans, see the NRC’s Revision 1 of RG 7.10, *Establishing Quality Assurance Programs for Packaging Used in the Transport of Radioactive Material*. To obtain this document visit the NRC’s website located at www.nrc.gov.
For further information about registering as a user of a package or submitting a QA program for review, contact NRC’s Spent Fuel Project Office by calling NRC toll-free at (800) 368-5642, extension 415-8500. For information about associated fees, contact NRC’s OCFO by calling NRC toll-free at (800) 368-5642, extension 415-7544.
Most medical use licensees that ship radioactive material have chosen to transfer possession of radioactive materials to a manufacturer (or service licensee) with a VDH, NRC, or another Agreement State license, who then acts as the shipper.
The manufacturer (or service licensee), who is subject to the provisions of 12VAC5-481-3000 or 12VAC5-481-3030, as appropriate, then becomes responsible for proper packaging of the radioactive materials and compliance with VDH and DOT regulations.
Licensees who do this must ensure that the manufacturer (or service licensee):
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Is authorized to possess the radioactive material at temporary job sites (e.g., the licensee’s facilities);
Actually takes possession of the radioactive material under its license.
Additionally, for Type B package shipments, the licensee should verify and the manufacturer (or service licensee) must:
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Use an approved Type B package;
Register with NRC as a user of the Type B package;
Possess a VDH-approved QA plan; and
Be authorized to possess the material at temporary job sites (e.g., the licensee’s facilities).
For each shipment, it must be clear who possesses the radioactive material and who is responsible for proper packaging of the radioactive materials and compliance with VDH and DOT regulations.
During an inspection, VDH uses the provisions of 12VAC5-481-2980 to examine and enforce various DOT requirements applicable to medical use licensees.
Appendix W lists major DOT regulations that apply to medical licensees.
Note: Before making shipments of radioactive materials on its own in a Type B package, a licensee must have registered with NRC as a user of the package and obtained VDH’s concurrence.
Transportation issues will be reviewed during inspection.
References: *A Review of Department of Transportation Regulations for Transportation of Radioactive Materials* can be obtained by calling DOT’s Office of Hazardous Material Initiatives and Training at (202) 366-4425.
Item 9.19: Sealed Source Inventory Rule
12VAC5-481-100, 12VAC5-481-571, 12VAC5-481-840, 12VAC5-481-1840, 12VAC5-481-2010, 12VAC5-481-2070
Criteria:
VDH requires the licensee in possession of a sealed source or brachytherapy source to conduct a semi-annual physical inventory of all such sources in its possession. Inventory records must be maintained for 3 years.
Discussion:
According to 12VAC5-481-1840, the licensee must conduct a semi-annual physical inventory of all sealed sources and brachytherapy sources in its possession.
Individual GSR sources are exempt from this physical inventory requirement, as stated in 12VAC5-481-1840. However, the licensee must maintain records of GSR source receipt, transfer, and disposal, under 12VAC5-481-100 and 12VAC5-481-571, to indicate the current inventory of sources at the licensee’s facility.
The licensee shall retain each inventory record in accordance with 12VAC5-481-2070.
In addition, 12VAC5-481-2010 and 12VAC5-481-2070 require the licensee to make a record of brachytherapy source accountability when removing and returning brachytherapy sources from the storage location.
Maintain inventory records that contain the following types of information:
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Radionuclide and amount (in units of Bq or curies) of radioactive material in each sealed source;
Manufacturer's name, model number, and serial number of each sealed source;
Manufacturer's name, model number, and serial number of each device containing depleted uranium or radioactive material;
Location of each sealed source and device;
Date of the inventory;
Name of individual performing inventory; and
For materials transferred or disposed of, the date of the transfer or disposal, name and license number of the recipient, description of the affected radioactive material (e.g., radionuclide, activity, manufacturer’s (or distributor’s) name and model number, serial number).
Item 9.20: Records of Dosages and Use of Brachytherapy Sources Rule:
12VAC5-481-100, 12VAC5-481-480, 12VAC5-481-1930, 12VAC5-481-2070
Criteria:
Licensees must record the use of licensed material to reflect proper use and accountability. Records of use must be maintained for 3 years.
Discussion:
Licensees are required to make and maintain records of each dosage activity prior to medical use. The records must include:
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Radiopharmaceutical;
Patient’s or human research subject’s name or identification number (if one has been assigned);
Prescribed dosage, determined dosage, or a notation that the total activity is less than 1.1 MBq (30 μCi);
Date and time of dosage determination; and
Name of the individual who determined the dosage.
Dosage determination for unit dosages may be made either by direct measurement or by a decay correction based on the determination (e.g., measurement) made by the manufacturer or preparer licensed under 12VAC5-481-480, or equivalent NRC or another Agreement State requirements.
If molybdenum concentration is measured under 12VAC5-481-1930, records of molybdenum concentration must be made and must include, for each measured elution of technetium-99m:
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Ratio of the measurements expressed as kBq (μCi) of molybdenum-99 per MBq (mCi) of technetium-99m;
Date and time of the measurement; and
Name of the individual who made the measurement.
If the licensee uses manual brachytherapy sources, the following records of use must be kept:
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When temporary implant brachytherapy sources are removed from storage, a record will include the number and activity of sources removed, the time and date they were removed from storage, the location of use, and the name of the individual who removed them from storage;
When temporary implant brachytherapy sources are returned to storage, a record will include the number and activity of sources returned, the time and date they were returned to storage, and the name of the individual who returned them to storage; and
For permanent implants, a record will be made and will include the number and activity of sources removed from storage, the date they were removed from storage, the name of the individual who removed them from storage, the number and activity of sources not implanted, the date they were returned to storage, the name of the individual who returned them to storage, and the number and activity of sources permanently implanted in the patient or human research subject.
Item 9.21: Safety Procedures for Treatments Where Patients are Hospitalized Rule:
12VAC5-481-630, 12VAC5-481-750, 12VAC5-481-840, 12VAC5-481-860, 12VAC5-481-1000, 12VAC5-481-1870, 12VAC5-481-1970, 12VAC5-481-2010, 12VAC5-481-2040, 12VAC5-481-2070
Criteria:
Applicants must develop and implement procedures to ensure that access to therapy treatment rooms, and exposure rates from therapy treatments, are limited to maintain doses to occupational workers and members of the public ALARA.
Discussion:
12VAC5-481-1970, 12VAC5-481-2010, and 12VAC5-481-2040 require the licensee to take certain safety precautions regarding radiopharmaceutical therapy, manual brachytherapy, or remote afterloader brachytherapy involving patients hospitalized in accordance with 12VAC5-481-1870.
This section does not include teletherapy or GSR outpatient treatments.
The precautions described below are to ensure compliance with the exposure limits in 12VAC5-481, *Virginia Radiation Protection Regulations*, Part IV *Standards For Protection Against Radiation*.
12VAC5-481-2010 and 12VAC5-481-2040 require licensees to perform a radiation survey of the patient (and the remote afterloader unit) immediately after removing the last temporary implant source from the patient and prior to releasing the patient from licensee control.
This is done to confirm that all sources have been removed and accounted for. A record of the patient survey must be maintained for 3 years.
12VAC5-481-2040 requires that when sources are placed within the patient’s body, licensed activities be limited to treatments that allow for expeditious removal of a decoupled or jammed source.
In addition, applicants must take the following steps for patients who cannot be released under 12VAC5-481-1870:
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Provide a private room with a private sanitary facility for patients treated with a radiopharmaceutical therapy dosage (Note: 12VAC5-481-1970 allows for a room shared with another radiopharmaceutical therapy patient);
Provide a private room for patients implanted with brachytherapy sources (Note: 12VAC5-481-2010 allows for a room shared with another brachytherapy patient);
Visibly post a ‘Radioactive Materials’ sign on the patient’s door and note on the door or in the patient’s chart stating where and how long visitors may stay in the patient’s room (12VAC5-481-1970 and 12VAC5-481-2010);
Either monitor material and items removed from the patient’s room (e.g., patient linens, surgical dressings) with a radiation detection survey instrument set on its most sensitive scale with no interposed shielding to determine that their radioactivity cannot be distinguished from the natural background radiation level or handle them as radioactive waste (12VAC5-481-750 and 12VAC5-481-1970); and
Notify the RSO, or his/her designee, and AU as soon as possible if the patient has a medical emergency or dies (12VAC5-481-1970, 12VAC5-481-2010, and 12VAC5-481-2040).
12VAC5-481-750 requires licensees to perform adequate surveys to evaluate the extent of radiation levels. Therefore, licensees must evaluate the exposure rates around patients who are hospitalized in accordance with 12VAC5-481-1870 following the dosage administration or implant (e.g., measured exposure rates, combination of measured and calculated exposure rates).
12VAC5-481-840 requires licensees to secure radioactive material in storage from unauthorized access or removal. Therefore, licensees must ensure that access to rooms where patients are hospitalized, in accordance with 12VAC5-481-1870, is limited to authorized personnel.
Access control and appropriate training of authorized personnel may prevent unauthorized removal of radioactive material and unnecessary personnel exposures.
In order to control exposures to individuals in accordance with 12VAC5-481, *Virginia Radiation Protection Regulations*, Part IV *Standards For Protection Against Radiation*, the licensee should consider briefing patients on radiation safety procedures for confinement to bed, visitor control, identification of potential problems, notification of medical staff in the event of problems, and other items as applicable and consistent with good medical care. [Note: NRC Regulatory Issue]
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Summary 2005 -24 ‘Control of Radiation Dose to Visitors of Hospital Patients’ provides guidance to licensees on methods that may be used to estimate and control radiation doses to visitors of hospitalized patients who have been administered radioactive material.
Introduction and Purpose
Item 9.22: Recordkeeping Rule: 12VAC5-481-100, 12VAC5-481-571, 12VAC5-481-910, 12VAC5-481-2070
Criteria: Licensees must maintain records as provided in 12VAC5-481-100; 12VAC5-481-571; and 12VAC5-481-2070.
Discussion: The licensee must maintain certain records to comply with 12VAC5-481 ‘Virginia Radiation Protection Regulations’, the conditions of the license, and commitments made in the license application and correspondence with VDH.
Operating procedures should identify which individuals in the organization are responsible for maintaining which records.
A table of recordkeeping requirements appears in Appendix Y.
Application Process and Guidance
Item 9.23: Reporting Rule
Rule: 12VAC5-481-740, 12VAC5-481-1090, 12VAC5-481-1100, 12VAC5-481-1110, 12VAC5-481-1150, 12VAC5-481-2080
Criteria: Licensees are required to report to VDH via telephone, written report, or both for a medical event, or in the event that the safety or security of radioactive material may be compromised.
The specific events that require reporting are explained in 12VAC5-481-740, 12VAC5-481-1090, 12VAC5-481-1100, 12VAC5-481-1110, 12VAC5-481-1150, and in 12VAC5-481-2080.
The timing and type of report are specified within these parts.
Discussion: VDH requires licensees to report incidents that might compromise the health and safety of patients, health care providers, or the public.
Therefore, 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part III ‘Licensing of Radioactive Material’, Part IV ‘Standards for Protection Against Radiation’ and Part VII ‘Use of Radionuclides in the Healing Arts’ include provisions that describe reporting requirements associated with the medical use of radioactive material.
A table of reporting requirements appears in Appendix Z.
Item 10: Waste Management
Rule: 12VAC5-481-100, 12VAC5-481-430, 12VAC5-481-450, 12VAC5-481-570, 12VAC5-481-571, 12VAC5-481-630, 12VAC5-481-720, 12VAC5-481-750, 12VAC5-481-880, 12VAC5-481-910, 12VAC5-481-920, 12VAC5-481-930, 12VAC5-481-940, 12VAC5-481-950, 12VAC5-481-960, 12VAC5-481-970, 12VAC5-481-971, 12VAC5-481-980, 12VAC5-481-990, 12VAC5-481-1000, 12VAC5-481-1050, 12VAC5-481-1060, 12VAC5-481-1090, 12VAC5-481-1100, 12VAC5-481-1710, 12VAC5-481-1870, 12VAC5-481-1890, 12VAC5-481-2070, 12VAC5-481-2980, 12VAC5-481-3690, 49 CFR Parts 170 through 189
Criteria: Radioactive materials must be disposed of in accordance with VDH requirements by:
Appropriate records must be maintained.
Discussion: The radiation protection program that licensees are required to develop, document, and implement in accordance with 12VAC5-481-630 must include provisions for waste disposal of radioactive material.
Appendix X contains procedures for decay-in-storage and generator or other radioactive material return to authorized recipients.
12VAC5-481-910 requires that licensees dispose of radioactive material only by means specified therein.
For radioactive material transferred to a land disposal facility, the licensee must comply with the specific requirements in 12VAC5-481-960.
Applicants are reminded to take into account the following information when they develop procedures (as applicable):
• If applicants propose to treat or dispose of radioactive material by incineration, they must receive specific approval from VDH. Contact VDH for guidance on treatment or disposal of material by incineration in accordance with 12VAC5-481-940.
• Applicants that wish to use waste volume reduction operations (e.g., compactors) must provide a detailed description (as outlined below), along with their response to Item 8.1 ‘Facilities Diagram’:
General Guidance for Waste Disposal Under 12VAC5-481-880 and 12VAC5-481-1890: all radioactivity labels must be removed or obliterated from empty or adequately decayed containers and packages prior to disposal as non-radioactive waste.
If waste is compacted, all labels that are visible in the compacted mass must be defaced or removed.
In accordance with 12VAC5-481-1890, radiation labels do not require removal or obliteration if the label is on materials that are within containers that will be managed as biomedical waste after they have been released from the licensee.
Remind employees that non-radioactive waste such as leftover reagents, boxes, and packing material should not be mixed with radioactive waste.
Occasionally, licensees should review all practices to limit waste generation.
Review all new procedures to ensure that waste is handled in a manner consistent with established procedures.
Licensees are cautioned that, on several occasions, incinerator and sanitary landfill operators have returned waste shipments that have triggered their portal monitors.
NRC Information Notice 99-33, ‘Management of Wastes Contaminated with Radioactive Materials’ describes this issue in greater detail.
In many cases, the waste is from patients who have been released under 12VAC5-481-1870.
Licensees should review state and local ordinances for disposal of waste at these facilities to ensure that their waste is acceptable.
VDH requires that licensees who transport radioactive material (including radioactive waste) outside the site of usage where transport is on public highways, or who deliver it for transport, comply with the applicable regulations of DOT in 49 CFR Parts 170 through 189.
In all cases, consider the impact of various available disposal routes, including occupational and public exposure to radiation, other hazards associated with the material and routes of disposal (e.g., toxicity, carcinogenicity, pathogenicity, flammability), and expense.
Decay-In-Storage
For radionuclides of radioactive material with a half-life of less than 120 days, licensees may dispose of waste in ordinary trash as long as the following criteria are followed:
Returning Sources
Because of the nature of the material contained in brachytherapy, teletherapy, and GSR sources, the only option for disposal is transfer to an authorized recipient as specified in 12VAC5-481-910.
Authorized recipients are the original manufacturer of the sealed source, a waste broker licensed by VDH, NRC, or another Agreement State to accept radioactive waste from other persons, or another specific licensee authorized to possess the radioactive material (i.e., their license specifically authorizes possession of the same radionuclide, form, and use).
Medical licensees are often the first to come into contact with plutonium-powered pacemakers or the first to be contacted by nursing homes and funeral homes when a patient implanted with a pacemaker dies.
If the pacemaker was not originally implanted by your facility, you should contact the hospital where the pacemaker was implanted to arrange for explanation and notify VDH.
The licensee (e.g., the implanting hospital) is responsible for the follow-up, explanation, and return of the pacemaker to the manufacturer for proper disposal.
NRC Information Notice 98-12, ‘Licensees Responsibilities Regarding Reporting and Follow-up Requirements for Nuclear-Powered Pacemakers’.
Before transferring radioactive material, a licensee must verify that the recipient is authorized to receive the material using one of the methods described in 12VAC5-481-570.
Records of the transfer must be maintained as required by 12VAC5-481-100 and 12VAC5-481-571.
Licensees should promptly dispose of unused sealed sources to minimize potential problems such as access by unauthorized individuals, use for inappropriate purposes, and improper disposal.
Because of the difficulties and costs associated with disposal of sealed sources,
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Applicants should preplan the disposal. Applicants may want to consider contractual arrangements with the source supplier as part of a purchase agreement.
Note: NRC INs can be accessed at the NRC website: www.nrc.gov in the ‘electronic reading room’.
Item 11: License Fees
For a listing of application fees, please see 12VAC5-490.
On VD H Form, ‘Application for Radioactive Material for Medical Use’, enter the fee category and the amount.
Item 12: Certification
Individuals acting in a private capacity are required to sign and date VDH Form, ‘Application for Radioactive Material for Medical Use’.
Otherwise, senior representatives of the corporation or legal entity filing the application should sign and date VDH Form, ‘Application for Radioactive Material for Medical Use’.
Representatives signing an application must be authorized to make binding commitments and sign official documents on behalf of the applicant.
The agency will return all unsigned applications for proper signature.
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It is a violation of 12VAC5-481-30, to make a willful false statement or representation on applications or correspondence.
When the application references commitments, those items become part of the licensing conditions and regulatory requirements.
Revision 4 January 14, 2022
Appendix A: VDH Form, ‘Application for Radioactive Material License for Medical Use’
The Application Form is located at:
Attachment A: Medical Applicant’s Checklist
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Yes / No Item Material Needed
Application Used the correct form (New for new licensees or Renewal for renewing licensees)
Application Checked at least one box and filled in all the required information, as needed, for all Items
Item 5.1 Checked box(es) and attached training information for the Radiation Safety Officer
Item 5.2 Checked box(es) and attached training information for the Associate Radiation Safety Officer
Item 5.3 Checked box(es) and attached training information for Authorized User(s)
Item 5.4 Checked box and, if needed, attached training information for the Authorized Nuclear Pharmacist
Item 5.5 Checked box and, if needed, attached training information for the Authorized Medical Physicist or Ophthalmologic Physicist
Item 6 Checked box or attached alternate procedures
Item 8.1 Attached facility diagram
Item 8.2 Checked box(es) and attached description of instrumentation and, if needed, alternate calibration procedure
Item 8.3 Checked box and/or attached description of instrumentation
Item 8.4 Checked box and/or attached alternate procedure
Item 8.5 Checked box AND attached description of equipment and facilities (i.e.; L-block, lead bricks, etc.)
Item 9.2 Checked box(es) and, if needed, attached alternate procedure
Item 9.4 Checked box and/or attached alternate procedure
Item 9.6 Checked box and/or attached alternate procedure
Item 9.7 Checked box and attached procedure for ordering and receiving
Item 9.9 Checked box(es) or attached alternate procedure
Item 9.10 Checked box and/or attached procedure
Item 9.11 Checked box and, if needed, attached procedure
Item 9.12 Checked box and, if needed, attached procedure
Item 9.13 Checked box and, if needed, attached procedure and training information
Item 9.14 Checked box and, if needed, attached procedure
Item 9.15 Checked box and, if needed, attached procedure
Item 9.16 Checked box and, if needed, attached procedure
Item 9.17 Checked box and, if needed, attached procedure
Item 10 Checked box and, if needed, attached procedure
Appendix B: RESERVED
Appendix C: VDH Form, ‘Certificate of Disposition of Materials’
Virginia Department of Health Radioactive Materials Program (804) 864-8150
CERTIFICATE OF DISPOSITION OF MATERIALS
Completion of this form is required to complete termination of a Radioactive Material License as outlined in 12VAC5-481-500.
Failure to provide information will result in this request for termination of a specific license not being processed.
Instructions - Complete all items. Retain one copy and submit original to Virginia Department of Health, Radioactive Materials Program, 109 Governor Street, Room 730, Richmond, VA 23219.
CONTACT INFORMATION
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Item 1 Name and Mailing Address of Applicant:
Item 2 Virginia Radioactive Material License Number
Item 3 Contact Person - Name
Contact Person - Telephone Number (Include area code)
TERMINATION AND DISPOSITION INFORMATION
The following information is provided in accordance with 12VAC5-481-510.
(Check all that apply)
-
Item 4 All use of radioactive material authorized under the above referenced license has been terminated.
Item 5 Radioactive contamination has been removed to the levels outlined in 12VAC5-481-1161 B.
Item 6 All radioactive material previously procured and/or possessed under the authorization granted by the above referenced license has been disposed of as follows. (Check all that apply)
Transferred to: Name, Address, Who is (are) authorized to possess such material under Licensed Number:
Decayed, surveyed and disposed of as non-radioactive waste.
No radioactive material has ever been procured and/or possessed by the licensee under the authorization granted by the above referenced license.
Other (Attach additional pages)
-
Name:
Address:
Contact Person Telephone Number: ( ) - x
CERTIFICATION
(To be completed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 10. The undersigned, on behalf of the licensee, hereby certifies that licensable quantities of radioactive material under the jurisdiction of the Virginia Department of Health are not possessed by the licensee.
It is therefore requested that the above referenced radioactive material license be terminated.
SIGNATURE - Applicant or Authorized Individual
Date signed
Print Name and Title of above signatory
Appendix D: Information Needed for Transfer of Control
Control: Control of a license is in the hands of the person or persons who are empowered to decide when and how that license will be used.
That control is to be found in the person or persons who, because of ownership or authority explicitly delegated by the owners, possess the power to determine corporate policy and thus the direction of the activities under the license.
Transferee: A transferee is an entity that proposes to purchase or otherwise gain control of a VDH-licensed operation.
Transferor: A transferor is a VDH licensee selling or otherwise giving up control of a licensed operation.
Licensees must provide full information and obtain VDH’s prior written consent before transferring control of the license.
Provide the following information concerning changes of control by the applicant (transferor and/or transferee, as appropriate). If any items are not applicable, so state.
-
1. Provide a complete description of the transaction (transfer of stocks or assets, or merger). Indicate whether the name has changed and include the new name. Include the name and telephone number of a licensee contact whom VDH may contact if more information is needed.
2. Describe any changes in personnel or duties that relate to the licensed program. Include training and experience for new personnel.
3. Describe any changes in the organization, location, facilities, equipment, radiation safety program, use, waste management, or other procedures that relate to the licensed program.
4. Describe the status of the licensee’s facilities, equipment, and radiation safety program, including any known contamination and whether decontamination will occur prior to transfer. Include the status of calibrations, leak tests, area surveys, wipe tests, training, quality control, and related records.
5. If current decommissioning funding plans (DFP) will be changed as a result of the transfer, the revised DFP should be submitted. If other financial assurance documents will be changed as a result of the transfer, confirm that all financial assurance instruments associated with the license will be held in the transferee’s name before the license is transferred, and as required, the licensee must, within 30 days, submit all financial instruments reflecting such changes.
6. Confirm that all records concerning the safe and effective decommissioning of the facility will be transferred to the transferee or to VDH, as appropriate. These records include documentation of surveys of ambient radiation levels and fixed and/or removable contamination, including methods and sensitivity.
7. Confirm that both transferor and transferee agree to transferring control of the licensed material and activity, and the conditions of transfer, and that the transferee has been made aware of any open inspection items and its responsibility for possible resulting enforcement actions.
8. Confirm that the transferee will abide by all constraints, conditions, requirements and commitments of the transferor or that the transferee will submit a complete description of the proposed licensed program. Licensees should refer to NRC Information Notice 89-25, Revision 1, “Unauthorized Transfer of Ownership or Control of Licensed Activities”, available on the NRC’s webpage at http://www.nrc.gov
Appendix E: Guidance on Financial Assurance Determination
Determining Need for Financial Assurance for Decommissioning
The half-lives of unsealed radioactive material traditionally used by medical licensees have been less than 120 days.
Therefore, most medical use applicants need only consider licensed material in sealed sources to evaluate the need for financial assurance.
Use Table 7 to determine if financial assurance is required for the sealed sources listed.
If requesting sealed sources other than those listed or any other unsealed radioactive material with a half-life greater than 120 days, refer to 12VAC5-481-450 C for possession limits requiring financial assurance.
The sum of the fractions procedure is also depicted in Table 7 and must be used to determine the need for financial assurance for both sealed and unsealed radioactive material.
If the sum of the fractions is greater than 1, the applicant will need to submit financial assurance (12VAC5-481-450 C).
NRC NUREG-1757, Vol. 3, ‘Consolidated NMSS Decommissioning Guidance: Financial Assurance, Recordkeeping, and Timeliness’, contains acceptable wording for each mechanism authorized by the regulation to guarantee or secure funds.
Table 7: Worksheet for Determining Need for Financial Assurance for Sealed Sources
-
Step Number
Description
Cobalt-60
Cesium-137
Strontium-90
1. Activity possessed, in Curies*
2. Activity requiring financial assurance, in Curies
3. Divide data in Step 1 by data in Step 2 for each isotope = fraction
4. Add the fractions determined in Step 3
5. If the sum of the fractions is greater than 1, the applicant will need to submit financial assurance
*This table uses only conventional units. The conversion to the International System of units (SI) is: 1 Curie = 37 gigabecquerels.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance on the responsibilities and procedures for the safe use of radioactive materials in medical settings, ensuring compliance with applicable regulations and license conditions.
Description of VAREGS
VAREGS refers to the Virginia Radioactive Materials Management System, which is used for tracking and managing radioactive materials within the state of Virginia. It ensures proper inventory control, safety, and regulatory compliance.
Application Process and Guidance
Applicants seeking authorization for medical use of radioactive materials must adhere to the procedures outlined below or develop alternative Radiation Safety Officer (RSO) duties that meet the requirements of 12VAC5-481-1700.
RSO Duties and Responsibilities
-
Stopping unsafe activities involving licensed material;
Ensure that radiation exposures are kept as low as reasonably achievable (ALARA);
Oversee all activities involving radioactive material, including monitoring and surveying all areas in which radioactive material is used or stored;
Ensure that up-to-date radiation protection procedures are developed, distributed, and implemented;
Maintain an inventory of all radioactive material as required;
Ensure possession, use, and storage of licensed material are consistent with license limitations, rules, SSDR certificates, and manufacturer’s instructions;
Oversee receipt, opening, and delivery of all packages of radioactive material arriving at the facility, including radiation surveys, packaging, and labeling;
Ensure personnel installing, relocating, maintaining, or repairing devices containing sealed sources are trained and authorized by VDH, NRC, or another Agreement State license;
Conduct annual refresher training for personnel, aligned with their duties;
Maintain documentation demonstrating personnel are unlikely to receive more than 10% of the allowable dose limits annually, or ensure personnel monitoring devices are provided;
Use and exchange personnel monitoring devices as needed, maintaining records of results;
Properly secure licensed material and/or keep it under constant supervision;
Support development and implementation of security programs for radioactive material if possessing Category 1 or 2 quantities, in accordance with 12VAC5-481-451;
Maintain documentation demonstrating that the total effective dose to the individual likely to receive the highest dose does not exceed public dose limits;
Notify proper authorities of incidents such as loss, theft, damage, or malfunction of sealed sources, excess breakthrough values, or fire;
Serve as a point of contact during routine operations, emergencies, or incidents;
Investigate and report medical and precursor events, identifying causes and corrective actions;
Perform annual audits of the radiation protection program, documenting findings and corrective actions;
Communicate audit results and corrective actions to all personnel using licensed material;
Develop, implement, and document corrective actions for rule violations, program weaknesses, incidents, and accidents;
Investigate personnel exposures exceeding limits, and submit reports to VDH and other authorities as required;
Ensure proper transportation of licensed material according to VDH and DOT requirements;
Supervise radioactive waste disposal, including effluent monitoring and recordkeeping;
Oversee inventory and leak testing of sealed sources;
Oversee calibration of radiation survey instruments;
Supervise decontamination operations;
Maintain current copies of regulations, licenses, and procedures, and amend licenses as needed;
Ensure timely submission of license amendments and renewals;
Assign tasks to ARSOs if applicable.
ARSO Duties and Responsibilities
Under 12VAC5-481-1700, the licensee, through the RSO, shall ensure radiation safety activities are performed per approved procedures and regulations.
The licensee may appoint associate radiation safety officers (ARSOs) to support the RSO, with specific duties restricted to their listed use types. The RSO retains overall responsibility.
ARSOs must meet the same training and experience requirements as the RSO for their assigned sections and report to the RSO. Examples include:
-
A moderate-sized program: the RSO oversees the entire program; a single ARSO oversees specific sections and reports to the RSO.
A larger, single-campus program: the RSO manages the entire program; two ARSOs oversee different sections, both reporting to the RSO.
A large, multi-campus program: the RSO manages the entire program; ARSOs oversee smaller campuses, reporting to the RSO.
Before assigning duties to an ARSO in a different section, the license must be amended, and the individual must meet training and experience requirements. ARSOs can qualify to be named RSO on other licenses based on their training and experience.
Model Delegation of Authority Memo
To: Radiation Safety Officer
From: Chief Executive Officer
Subject: Delegation of Authority
Date: ( )
You, _______________________________, have been appointed Radiation Safety Officer and are responsible for ensuring the safe use of radiation. Your responsibilities include managing the radiation protection program, identifying problems, initiating corrective actions, verifying their implementation, stopping unsafe activities, and ensuring compliance with regulations.
You are delegated the authority necessary to fulfill these responsibilities, including prohibiting use by unqualified employees and shutting down operations if justified.
Notify management if staff do not cooperate or address safety issues. You may raise issues with the Virginia Department of Health at any time.
Estimated hours per week conducting radiation protection activities: _____ [Signature block]
Signature of Management Representative
Date: ___________________
Printed Name
Title: ____________________
Acceptance of Responsibilities
I accept the above responsibilities, ____________________________.
Name of Radiation Safety Officer: ____________________________
Signature: ____________________________
Date: ____________________________
Model Correspondence Delegation
[date]
Virginia Department of Health Radioactive Materials Program
109 Governor Street, Room 730
Richmond, Virginia 23219
To Radioactive Material Program Director:
As [job title] of [name of licensee], I have delegated authority for all matters pertaining to our Radioactive Material License to [name of designee].
[Name of designee] has management approval to sign and submit amendment requests to the Virginia Department of Health on behalf of [name of licensee].
I understand that license renewals must still be signed by a senior management representative.
[This document must be signed by a management representative with independent authority to reassign duties and provide support.]
Signature: ____________________________
Title: ____________________________
Date: ____________________________
Appendix G: Documentation of Training and Experience for Authorized User (AU), Radiation Safety Officer (RSO), Authorized Nuclear Pharmacist (ANP), Authorized Medical Physicist (AMP), or Ophthalmologic Physicist]
93 Documentation of Training and Experience to Identify Individuals on a License as AU, RSO, ARSO, AMP, or ANP
A. Experienced AUs, AMPs, Ophthalmologic Physicists, ANPs, RSO, ARSO
An applicant or licensee adding an experienced AU, AMP, Ophthalmologic Physicist, ANP, RSO, or ARSO to its medical use license only needs to provide evidence that the individual is listed on a valid license or permit issued by VDH, NRC, or another Agreement State, or a permit issued by an NRC master materials licensee, broad-scope licensee, or similar authority.
The individual must be authorized for the same types of use(s) requested and meet recent training criteria per 12VAC5-1790.
When adding an experienced ANP, evidence may include listing on an NRC or Agreement State commercial nuclear pharmacy license or identification as an ANP by a licensed commercial nuclear pharmacy. [END OF DOCUMENT]
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
Introduction and Purpose
Description of VAREGS
Applications for AU, AMP, Ophthalmologic Physicist, ANP, RSO, or ARSO Recognition Applicants should submit the appropriate completed Training, Experience and Preceptor VDH form to show that the individuals meet the correct training and experience criteria in 12VAC5-481, Part VII.
For the applicant's convenience, the forms have been separated into eight separate forms. The forms may be found on our website: http://www.vdh.virginia.gov/radiological-health/radiological-health/materials/forms-postings/.
There are two primary training and experience routes to qualify an individual as a new AU, AMP, ANP, RSO, or ARSO:
-
The first is by means of certification by a recognized board listed on the NRC Web site as provided. Preceptor attestations do not need to be submitted for individuals with a recognized board certification. Board certifications recognized by the NRC can be found at the following website: https://www.nrc.gov/materials/miau/med-use-toolkit/spec-board-cert.html.
The second route is by meeting the structured educational program, supervised work experience, and preceptor attestation requirements in 12VAC5-481, Part VII.
In some cases, there may be additional training and experience routes for recognized AUs, ANPs, AMPs, RSOs, or ARSOs to seek additional authorizations.
Recentness of Training
The required training and experience, including board certification, described in 12VAC5-481, Part VII must be obtained within the 7 years preceding the date of the application, or the individual must document having had related continuing education, retraining, and experience since obtaining the required training and experience.
Examples of acceptable continuing education and experience for physicians include the following:
-
Successful completion of classroom and laboratory review courses that include radiation safety practices relative to the proposed type of authorized medical use,
Practical and laboratory experience with patient procedures using radioactive material for the same use(s) for which the applicant is requesting authorization,
Practical and laboratory experience under the supervision of an AU at the same or another licensed facility that is authorized for the same use(s) for which the applicant is requesting authorization,
For therapy devices, experience with the therapy unit and/or comparable linear accelerator experience and completion of an in-service review of operating and emergency procedures relative to the therapy unit to be used by the applicant.
Appendix H: Training Programs
Procedures for describing the training programs appear below. Applicants may either adopt these procedures or develop an alternative program to meet VDH requirements.
These procedures include examples of topics to be chosen from for training, based on the experience, duties, and previous training of trainees. The topics chosen will depend on the purpose of the training, the audience, and the background knowledge of the audience.
These procedures also may be useful to identify topics for annual refresher training. Refresher training should include topics with which the individual is not involved frequently and require reaffirmation. Topics for refresher training need not include a review of procedures or basic knowledge that the trainee routinely uses.
Guidance on requirements for training and experience for AMPs and AUs who engage in certain specialized practices is also included.
Training Program for Medical Uses of Radionuclides, Sealed Sources, and Medical Devices Containing Sealed Sources
Personnel will receive instruction before assuming duties with, or in the vicinity of, radioactive materials, during annual refresher training and whenever there is a significant change in duties, regulations, terms of the license, or type of radioactive material or therapy device used.
Records of worker training will be maintained for at least 3 years. The training records will include the date of the instruction or training and the name(s) of the attendee(s) and instructor(s).
Training for Individuals Involved in the Usage of Radioactive Material
Training for professional staff (e.g., AU, AMP, ANP, RSO, ARSO, nurse, dosimetrist, technologist, therapist) may contain the following elements for those who provide or are involved in the care of patients during diagnostic or therapeutic procedures, commensurate with their duties:
-
Basic radiation biology, e.g., interaction of ionizing radiation with cells and tissues (12VAC5-481-2270);
Basic radiation protection to include concepts of time, distance, and shielding (12VAC5-481-2270);
Concept of maintaining exposure ALARA (12VAC5-481-630, 12VAC5-481-2270);
Risk estimates, including comparison with other health risks (12VAC5-481-2270);
Posting requirements (12VAC5-481-860);
Proper use of personnel dosimetry (when applicable) (12VAC5-481-760);
Access control procedures (12VAC5-481-780, 12VAC5-481-790, 12VAC5-481-840);
Proper use of radiation shielding, if used;
Patient release procedures (12VAC5-481-1870);
Instruction in procedures for notification of the RSO and AU, when responding to patient emergencies or death, to ensure that radiation protection issues are identified and addressed in a timely manner (12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040);
Occupational dose limits and their significance (12VAC5-481-640);
Dose limits to the embryo/fetus, including instruction on declaration of pregnancy (12VAC5-481-710);
Worker’s right to be informed of occupational radiation exposure (12VAC5-481-2280);
Each individual’s obligation to report unsafe conditions to the RSO (12VAC5-481-2270);
Where copies of the applicable rules, the VDH license, and its application are posted or made available for examination (12VAC5-481-2260);
Proper recordkeeping required by VDH rules (12VAC5-481-100, 12VAC5-481-571, 12VAC5-481-2070);
Appropriate surveys to be conducted, including surveys of all material leaving radioactive material areas (12VAC5-481-750, 12VAC5-481-1860);
Proper use of required survey instruments (12VAC5-481-750, 12VAC5-481-1810);
Decontamination and release of facilities and equipment (12VAC5-481-510, 12VAC5-481-1161);
Dose to individual members of the public (12VAC5-481-720);
Licensee’s operating procedures (e.g., survey requirements, instrument calibration, waste management, sealed source leak testing) (12VAC5-481-1710);
HAZMAT Training for preparing shipments of radioactive material, when applicable (49 CFR Part 172);
Security for Category 1 or Category 2 sources or aggregated quantities of material, when applicable (12VAC5-481-451).
Training for the Staff Directly Involved in Administration to or Care of Patients Administered Therapeutic Quantities of Radioactive Material (Including Greater than 30 microcuries of I-131), or Therapeutic Treatment Planning
In addition to the topics identified above, the following topics may be included in instruction for staff involved in the therapy treatment of patients (e.g., nursing, RSO, AMP, AU, and dosimetrist) in the following topics, commensurate with their duties:
-
Leak testing of sealed sources (12VAC5-481-740, 12VAC5-481-1840);
Emergency procedures (including emergency response drills) [12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040];
Operating instructions (12VAC5-481-1710, 12VAC5-481-2010, 12VAC5-481-2040);
Computerized treatment planning system (12VAC5-481-2040);
Dosimetry protocol (12VAC5-481-2040);
Detailed pretreatment quality assurance checks (12VAC5-481-1710, 12VAC5-481-2040);
Safe handling (when applicable) of the patient’s dishes, linens, excretions (saliva, urine, feces), and surgical dressings that are potentially contaminated or that may contain radioactive sources (12VAC5-481-1960, 12VAC5-481-2010);
Patient control procedures (12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040);
Visitor control procedures, such as visitors’ stay times and safe lines in radiation control areas (patient’s room) [12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040];
Licensee’s WD Procedures, to ensure that each administration is in accordance with the WD, patient identity is verified, and where applicable, attention is paid to correct positioning of sources and applicators to ensure that treatment is to the correct site (or, for GSR, correct positioning of the helmet) [12VAC5-481-1730];
Proper use of safety devices and shielding to include safe handling and shielding of dislodged sources (or, in the case of remote afterloaders, disconnected sources) [12VAC5-481-2010, 12VAC5-481-2040];
Size and appearance of different types of sources and applicators (12VAC5-481-2010, 12VAC5-481-2040);
Previous incidents, events, and/or accidents (12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040);
For remote afterloaders, teletherapy units, and GSR units; initial training provided by the device manufacturer or by individuals certified by the device manufacturer that is device model-specific and includes:
- Design, use, and function of the device, including safety systems and interpretation of various error codes and conditions, displays, indicators, and alarms;
- Hands-on training in actual operation of the device under the direct supervision of an experienced user including ‘dry runs’ (using dummy sources) of routine patient setup and treatment and implementation of the licensee’s emergency procedures;
- A method of determining each trainee’s competency to use the device for each type of proposed use, such as practical examinations.
Additional Training for Authorized Medical Physicists and Ophthalmic Physicists
Applicants for licenses to include AMPs or Ophthalmic Physicists who plan to engage in certain tasks requiring special training should be sure to address the sections of 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part VII ‘Use of Radionuclides in the Healing Arts’ listed in 12VAC5-481-1760.
Note, for example, that additional training requirements apply to AMP planning tasks such as manual brachytherapy, remote afterloader therapy, teletherapy, GSR therapy, and the use of the treatment planning system that applicants contemplate using.
Medical physicists must also have training for the type(s) of use for which authorization is sought that includes hands-on device operation, safety procedures, clinical use, and the operation of a treatment planning system, as required in 12VAC5-481-1760.
Additional Training for Therapy Authorized Users
Applicants for licenses should carefully consider the type of radiation therapy that is contemplated. In addition to the training and experience requirements of 12VAC5-481-1980, 12VAC5-481-1990, 12VAC5-481-2000, 12VAC5-481-2001, 12VAC5-481-2010, and 12VAC5-481-2040, attention should be focused on the additional training and experience required for treatment planning and quality control system, and clinical procedures.
Refer to the training and experience requirements associated with specialized uses discussed in 12VAC5-481-1980, 12VAC5-481-2010, and 12VAC5-481-2040.
Training for Ancillary Staff
For the purposes of this section, ancillary staff includes personnel engaged in janitorial and/housekeeping duties, dietary, laboratory, security, and life-safety services.
The training program for ancillary staff who perform duties that are likely to result in a dose in excess of 1 mSv (100 mrem) will include instruction commensurate with potential radiological health protection problems present in the workplace. [END OF DOCUMENT]
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Description of VAREGS
Application Process and Guidance
Appendices
Restricted areas may be applied to ancillary personnel unless escorted by trained personnel. Topics of instruction may include the following:
-
Storage, transfer, or use of radiation and/or radioactive material (12VAC5-481-2270);
Potential biological effects associated with exposure to radiation and/or radioactive material, precautions or procedures to minimize exposure, and the purposes and functions of protective devices (e.g., basic radiation protection concepts of time, distance, and shielding) [12VAC5-481-2270];
The applicable provisions of 12VAC5-481 ‘Virginia Radiation Protection Regulations’ and licenses for the protection of personnel from exposure to radiation and/or radioactive material (e.g., posting and labeling of radioactive material) [12VAC5-481-2270];
Responsibility to report promptly to the licensee any condition that may lead to or cause a violation of 12VAC5-481 ‘Virginia Radiation Protection Regulations’ and/or the license or unnecessary exposure to radiation and/or radioactive material (e.g., notification of the RSO regarding radiation protection issues) [12VAC5-481-2270];
Appropriate response to warnings made in the event of any unusual occurrence or malfunction that may involve exposure to radiation and/or radioactive material (12VAC5-481-2270); and
Radiation exposure reports that workers may request (12VAC5-481-2280).
98 Appendix I Radiation Monitoring Instrument Specifications and Model Survey Instrument Calibration Program
99 Model procedures for describing the specifications for monitoring instruments and a program for calibration of survey instruments appear below. Applicants may either adopt these model procedures or adopt alternative procedures.
Facilities and Equipment
• To reduce doses received by individuals not calibrating instruments, calibrations should be conducted in an isolated area of the facility or at times when no one else is present.
• Individuals conducting calibrations will wear assigned dosimetry, if required.
Equipment Selection
• Low-energy beta emitters, such as carbon-14 and sulfur-35, are difficult to detect with Geiger-Mueller (GM) probes. The detection efficiency generally is about 2% for low-energy beta emitters. The proper surveying method (e.g., speed and height above surface) is important to perform adequate surveys. Additionally, wipes should be taken and counted on a liquid scintillation counter to verify potential contamination.
• Medium- to high-energy beta emitters, such as P-32 and Ca-45, can be detected with a pancake GM. The efficiency ranges from 15% to 40%, depending on the beta energy.
• Low-energy gamma emitters, such as I-125, can be detected with a sodium iodide (NaI) probe or a thin window GM probe (pancake or thin end-window). If the sodium iodide probe possesses a thin window and thin crystal, the detection efficiency is approximately 20%. If a pancake or thin end-window GM probe is used, the detection efficiency is significantly lower and care should be taken to ensure that the GM probe is capable of detecting the trigger levels.
• Medium- to high-energy gamma emitters, such as I-131, can be detected with either GM or sodium iodide probes, depending on the required sensitivity. In general, the sensitivity of GM probes is much lower than for sodium iodide probes.
• The following table (except for items marked with a *) , extracted from ‘The Health Physics & Radiological Health Handbook’, Revised Edition, may be helpful in selecting instruments:
Table 8: Typical Survey Instruments Portable Instruments Used for Contamination and Ambient Radiation Surveys
-
Detectors
Radiation Energy Range
Efficiency
Exposure Rate Meters
Gamma, X-ray
mR-R
N/A
Count Rate Meters
GM
Alpha
All energies (dependent on window thickness)
Moderate
Beta
All energies (dependent on window thickness)
Moderate
Gamma
All energies < 1%
NaI Scintillator
Gamma
All energies (dependent on crystal thickness)
Moderate
Plastic Scintillator
Beta C-14 or higher (dependent on window thickness)
Moderate
Stationary Instruments Used to Measure Wipe, Bioassay, and Effluent Samples
Detectors
Radiation Energy Range
Efficiency
Liquid Scintillation Counter*
Alpha
All energies
High
Beta
All energies
High
Gamma
Moderate
Gamma Counter (NaI)*
Gamma
All energies
High
Gas Proportional
Alpha
All energies
High
Beta
All energies
Moderate
Gamma
All energies < 1%
Procedure for Calibrating Survey Instruments
This provides acceptable procedures for survey instrument calibrations. You may either adopt these model procedures or develop your own procedures to meet the requirements of 12VAC5-481-630 and 12VAC5-481-1810.
Detailed information about survey instrument calibration may be obtained by referring to ANSI N323A-1997, ‘Radiation Protection Instrumentation Test and Calibration, Portable Survey Instruments’. Copies may be obtained from the American National Standards Institute at 1430 Broadway, New York, NY 10018 or by ordering electronically from http://www.ansi.org.
Procedures for calibration of survey instruments:
-
Radiation survey instruments will be calibrated with a radioactive source in accordance with 12VAC5-481-1810. Electronic calibrations alone are not acceptable. Survey meters must be calibrated at least annually, before first use and after servicing or repairs that may affect calibration. Battery changes are not considered ‘servicing’.
Instruments used to monitor higher energies are most easily calibrated in known radiation fields produced by sources of gamma rays of approximately the same energies as those to be measured. An ideal calibration source would emit the applicable radiation (e.g., alpha, beta, or gamma) with an energy spectrum similar to that to be measured and have a suitably long half-life.
Use radioactive sealed source(s) that:
- Approximates a point source;
- Is a certified, NIST-traceable, standard source that has an activity or exposure rate is accurate to within 5%; if the activity or exposure rate is determined by measurement, document the method used to make the determination and traceability to NIST;
- Emit the type of radiation measured;
- Approximate the same energy (e.g., Cs-137, Co-60) as the environment in which the calibrated device will be employed; and
- Provide a radiation dose rate sufficient to reach the full scale (<1000 mR/hr) of the instrument calibrated.
Use the inverse square and radioactive decay laws, as appropriate, to correct for changes in exposure rate due to changes in distance or source decay.
A record must be made of each survey meter calibration and retained for 3 years after each record is made (12VAC5-481-1000 and 12VAC5-481-2070).
Before use, perform daily operational-calibration (with a dedicated check source) and battery checks.
Instrument readings should be within ± 10% of known radiation values at calibration points; however, readings within ± 20% are acceptable if a calibration chart or graph is prepared and made available with the instrument.
The kinds of scales frequently used on radiation survey meters are calibrated as follows:
Linear Readout Instruments must be calibrated at no fewer than two points on each scale. Calibration will be checked near the ends of each scale (at approximately 20% and 80%).
Logarithmic Readout Instruments must be calibrated at one point (the midpoint) on each decade.
Digital Readout Instruments with either manual or automatic scale switching for indicating exposure rates must be calibrated at no fewer than two points on each scale. Calibration will be checked near the ends of each scale (at approximately 20% and 80% of each scale).
Digital readout instruments without scale switching for indicating exposure rates must be calibrated at one point (the midpoint) on each decade.
Integrating instruments must be calibrated at two dose rates (at approximately 20% and 80% of the dose rate range).
-
A description of the instrument, including the manufacturer’s name, model number, serial number, and type of detector;
A description of the NIST-traceable calibration source, including the calibration procedure, exposure rate, distance at which it was measured and date of measurement;
For each calibration point, the calculated exposure rate, the indicated exposure rate, the calculated correction factor (the calculated exposure rate divided by the indicated exposure rate), and the scale selected on the instrument;
The exposure reading indicated with the instrument in the ‘battery check’ mode (if available on the instrument);
For instruments with external detectors, the angle between the radiation flux field and the detector (i.e., parallel or perpendicular);
For instruments with internal detectors, the angle between the radiation flux field and a specified surface of the instrument;
For detectors with removable shielding, an indication of whether the shielding was in place or removed during the calibration procedure;
The exposure rate from a check source, if used;
The name of the person who performed the calibration and the date it was performed.
-
The source that was used to calibrate the instrument;
The proper deflection in the battery check mode (unless this is clearly indicated on the instrument);
Special use conditions (e.g., an indication that a scale or decade was checked only for function but not calibrated);
The date of calibration and the next calibration due date;
The apparent exposure rate from the check source, if used.
Sodium iodide (thallium doped) [NaI(Tl)] uptake probes are commonly used for bioassays of personnel administering I-131. Refer to 12VAC5-481-3690 for the Annual Limits on Intake (ALIs) and Derived Air Concentrations (DACs) for occupational exposure to radionuclides.
Convert count rates (e.g., in cpm) to units of activity (dpm, µCi) when performing bioassays to determine thyroid burdens of radioiodines. Use the following procedure to calibrate probe for uptake measurements:
-
Frequency: perform calibrations annually, before first use and after repairs that affect calibrations;
Check the instrument’s counting efficiency using either a standard source of the same radionuclide as the source being tested or one with similar energy characteristics. Accuracy of standards will be within ± 5% of the stated value and traceable to a primary radiation standard such as those maintained by NIST.
Calculate efficiency of the instrument. For example: Eff = (activity in microcuries in std) / (cpm std - background in cpm) where:
Eff = efficiency
cpm = counts per minute
std = standard, and
bkg = background
Note: The absolute efficiency is dependent on the counting geometry. Applicants may elect to use the intrinsic efficiency, which no longer includes the solid angle subtended by the detector and has much less of a dependence on the counting geometry.
Operational and calibration checks, using a dedicated check source, should be conducted on each day the instrument is used. The date of the efficiency test will be attached to the instrument as a calibration sticker or tag and the following information should be included:
The date of the next efficiency due;
Results of efficiency calculation(s).
Calculating the Gamma Well Efficiency of Counting Equipment
Gamma well counting equipment is often used for assaying the wipe testing of packages, sealed sources, and areas where unsealed radioactive material is prepared, administered, or stored. Converting cpm to dpm using smear wipes is
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance on the proper procedures and safety measures for the medical use of radioactive materials, including calibration, handling, and emergency procedures.
Description of VAREGS
VAREGS (Radioactive Material Management System) is a comprehensive program designed to ensure safe and compliant use of radioactive materials in medical settings. It includes protocols for inventory, safety, and regulatory compliance.
Application Process and Guidance
Applicants may either adopt Appendix J or develop alternative procedures to meet the requirements of 12VAC5-481-630.
Lost Implant Seeds in the Operating Room
-
A calibrated and operable survey meter appropriate to the energy of the sources being used (i.e., low energy gamma detector), shielded container, and forceps shall be available in the operating room during seed implantation.
A representative of Radiation Oncology must be present during seed implantation.
Once a source is known to be missing, no one shall leave the operating room until further notice.
Ensure that all known radiation sources are shielded.
Survey the room, including personnel and equipment, with a survey meter. Persons who have been surveyed and are free of contamination may be released from the operating room.
If the missing source is not found, notify the Radiation Safety Officer immediately.
If the missing source is found, use forceps to pick up the source and place it into the shielded container.
Continue to survey the room to ensure that all sources have been found.
Rupture of a Manual Brachytherapy Source
-
Manual brachytherapy sources for permanent implants are contained in titanium tubes and are susceptible to damage through improper handling (e.g., stepping on a source, cutting a source, or bending it with forceps or tweezers). AAPM recommends reverse action tweezers be used to prevent damage or rupture of brachytherapy seeds.
A calibrated and operable survey meter appropriate to the energy of the sources being used (i.e., low energy gamma detector), shielded container, and forceps shall be available in the operating room during seed implantation.
If a source rupture is suspected, ensure that no one leaves the operating room.
Notify Radiation Safety Officer.
Shield all known sources of radiation. Use forceps to pick up source fragments and place in the shielded container.
Ensure that the patient and linens are not contaminated before removing the patient from the operating room. Note: contamination control and evaluation should not impede medical care.
Survey room including personnel and equipment, with a survey meter. Persons who have been surveyed and are free of contamination may be released from the operating room.
Decontaminate personnel and equipment as needed. Bag waste and hold for decay-in-storage.
Appendix K Suggested Medical Licensee Audit
Suggested Medical Licensee Audit Annual Radiation Protection Medical Licensee Audit
Note: All areas indicated in audit notes may not be applicable to every license and may not need to be addressed during each audit. For example, licensees do not need to address areas that do not apply to the licensee’s activities, and activities that have not occurred since the last audit need not be reviewed at the next audit.
Date of This Audit: _____________
Date of Last Audit: _____________
Next Audit Date: _____________
Auditor: _____________ (Signature)
Management Review: ________________________________
Date: ____________ (Signature)
License Information
-
A. License Number
B. Current Amendment Number
C. Are all of the tie-down documents on file?
D. Has the Legal Entity having control over licensed activities changed since the last audit? Are materials, uses, and locations of use confined to those specifically described in the license?
Audit History
-
A. Were previous audits conducted annually (12VAC5-481-630)?
B. Are records of previous audits being maintained for three years (12VAC5-481-990)?
C. Were any deficiencies identified during previous audit?
D. Were corrective actions taken? (Note: Look for repeated deficiencies.)
E. Any previous problem / deficiency not corrected or repeated?
F. What corrective actions from previous audits, if any, are still in progress?
Organization and Scope of Program
-
A. Radiation Safety Officer:
1. If the RSO position has changed, was license amended (12VAC5-481-1680)?
2. Does the new RSO meet the agency's training requirements (12VAC5-481-1750, 12VAC5-481-1780, 12VAC5-481-1790)?
3. If the scope of the program expanded, does the RSO have training in radiation safety, regulatory issues, and emergency procedures for the new use? (12VAC5-481-1790)
4. Is the RSO fulfilling all of his/her duties (12VAC5-481-1700)?
5. If the scope of the program expanded, have the RSO duties been updated to reflect the scope of the program?
6. Is the written agreement in place for new RSO (12VAC5-481-1700)?
7. Has VDH been notified about a temporary RSO and are written duties and responsibilities in place for the temporary RSO, if applicable?
-
1. If the ARSO was changed, was the license amended?
2. Does the new ARSO meet VDH training requirements?
3. If the scope of the program expanded, did the RSO assign duties for the expanded program and does the ARSO have training in radiation safety, regulatory issues, and emergency procedures for new uses?
4. Is the ARSO fulfilling all duties and tasks?
5. Is the written appointment in place for a new ARSO?
-
1. The isotope, the chemical forms, the quantity, and authorized use is listed (L/C).
2. Does the total amount of radioactive material possessed require financial assurance? If so, is financial assurance adequate? (12VAC 5-481-450 C)
3. Calibration, transmission, and reference sources [12VAC5-481-1830]:
a. Sealed sources manufactured and distributed by a person licensed pursuant to VDH (12VAC5-481-480), NRC, or another equivalent Agreement State regulations who is authorized to redistribute sealed sources that do not exceed 1.11GBq (30 mCi) each (12VAC5-481-1830).
b. Any radioactive material with a half-life not longer than 120 days in individual amounts not exceeding 0.555 GBq (15 mCi) [12VAC5-481-1830].
c. Any radioactive material with a half-life longer than 120 days in individual amounts not to exceed the smaller of 7.4 MBq (200 μCi) or 103 times the quantities in 12VAC5-481-3730.
d. Technetium-99m in amounts as needed? (12VAC5-481-1830)
-
a. Obtained from a manufacturer or preparer licensed under 12VAC5-481-480 J? OR
b. Prepared by a physician authorized user, an authorized nuclear pharmacist, or an individual under the supervision of an authorized nuclear pharmacist or physician authorized user? OR
c. Obtained and prepared for research in accordance with 12VAC5-481-1900, 12VAC5-481-1920, and 12VAC5-481-1950, as applicable?
Radiation Safety Program
-
A. Minor changes or revision to radiation safety program (12VAC5-481-1700)?
B. Records of changes maintained for 5 years (12VAC5-481-2070)?
C. Content and implementation reviewed annually by the licensee (12VAC5-481-630)?
D. Records of annual reviews maintained 3 years after the date on which they were made (12VAC5-481-990)?
Use by Authorized Individuals
-
Compliance is established by meeting at least one criterion under each category.
A. Authorized Nuclear Pharmacist [12VAC5-481-1770, 12VAC5-481-1780, 12VAC5-481-1790]
1. Certified by specialty board
2. Identified on VDH, NRC or another Agreement State license
3. Identified on a permit issued by a broad scope or master materials licensee.
4. Listed on current facility license.
5. Uses only material for which they are authorized
-
1. Certified by specialty board
2. Identified on VDH, NRC or another Agreement State license
3. Identified on permit issued by a broad scope or master materials licensee
4. Listed on current facility license
5. Uses only material for which they are authorized
-
1. Certified by specialty board
2. Identified on VDH, NRC or another Agreement State license
3. Identified on permit issued by broad scope or master materials licensee
4. Listed on current facility license
5. Uses only material for which they are authorized
-
1. Certified by specialty board
2. Identified on VDH, NRC or another Agreement State license
3. Identified on permit issued by a broad scope or master materials licensee
4. Listed on current facility license
5. Uses only material for which they are authorized
Mobile Medical Service
-
A. Operates services per 12VAC5-481-1880 and/or 12VAC5-481-2040?
B. Compliance with 12VAC5-481-720 has been evaluated and met?
C. Are all base locations listed on the license?
D. Letter signed by management of each client (12VAC5-481-1880)?
E. Licensed material was not delivered to client’s address (unless the client is licensed to receive radioactive materials) [12VAC5-481-1880]?
F. Dosage measuring instruments are checked for proper function before used at each address of use or on each day of use, whichever is more frequent (12VAC5-481-1880)?
G. Survey instruments are checked for proper operation before used at each address of use (12VAC5-481-1880)?
H. Survey of all areas of use prior to leaving each client address (12VAC5-481-1880)?
I. Adequate security maintained for mobile
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Description of VAREGS
Application Process and Guidance
Appendices
---Additional Technical Requirements and Audit Questions
J. Mobile Remote Afterloaders
Are the additional technical requirements for mobile remote afterloaders per 12VAC5-481-2040?
Amendments since Last Audit:
-
A. Any amendments since last audit (12VAC5-481-1680)?
B. Security related sensitive information was properly marked?
Notifications Since Last Audit:
-
A. Any notifications since last audit (12VAC5-481-1690)?
B. Appropriate documentation provided to the department for Authorized Nuclear Pharmacist (ANP), Authorized Medical Physicists (AMP), or Authorized User (AU) no later than 30 days after the individual starts work (12VAC5-481-1690)?
C. VDH notified within 30 days after:
-
• authorized user, authorized nuclear pharmacist, authorized medical physicist, or RSO stops work or changes name;
• licensee’s mailing address changes;
• licensee’s name changes without a transfer of control of the license; or
• licensee has added to or changed an area of use for 12VAC5-481-1900 or 12VAC5-481-1920 use (12VAC5-481-1690).
Training, Retraining, And Instructions to Workers
A. Have workers been provided with all required instructions (12VAC5-481-1710, 12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040, 12VAC5-481-2270)?
B. Is the individual worker’s understanding of current procedures and VDH rules adequate?
C. Training program implemented?
-
1. Operating procedures (12VAC5-481-1710, 12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040)?
2. Emergency procedures (12VAC5-481-1710, 12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040)?
3. Periodic training required and implemented (12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040)?
4. Were all workers who are likely to exceed 1.0 mSv (100 mrem) in a year instructed, and was refresher training provided (12VAC5-481-2270)?
5. Was each supervised user instructed in the licensee's written radiation protection procedures and administration of written directives, as appropriate (12VAC5-481-1710)?
6. Are initial and periodic training records maintained for each individual for three years (12VAC5-481-2070)?
7. HAZMAT Training, when applicable (49 CFR Part 172)?
8. Briefly describe training program:
D. Additional therapy device instructions/training:
-
1. Unit operation, inspection, associated equipment, survey instruments?
2. License conditions applicable to the use of the unit (L/C)?
3. Emergency drills (12VAC5-481-2040)?
E. Workers cognizant of requirements for:
-
1. Radiation Safety Program (12VAC5-481-630, 12VAC5-481-1700)?
2. Annual dose limits (12VAC5-481-640, 12VAC5-481-700, 12VAC5-481-710, 12VAC5-481-720)?
3. VDH Form, ‘Occupational Exposure Record Per Monitoring Period’
4. 10% monitoring threshold (12VAC5-481-760)?
5. Dose limits to embryo/fetus and declared pregnant worker (12VAC5-481-710)?
6. Extreme Danger/Grave Danger Posting (12VAC5-481-860)?
7. Procedures for opening packages (12VAC5-481-900, 12VAC5-481-3091). Note: NRC RIS 8.13 'Instructions Concerning Prenatal Radiation Exposure' is a useful reference.
8. Supervision of individuals by authorized user and/or authorized nuclear pharmacist in accordance with 12VAC5-481-1710?
F. Was training provided for workers involved with emerging technologies in accordance with the VDH license and tie-downs? ---
Manual Brachytherapy and Unsealed Therapy Training
A. Safety instruction to personnel provided include (12VAC5-481-1960):
-
1. Control of patient and visitors?
2. Routine visitation to patients in accordance with 12VAC5-481-720?
3. Contamination control and size/appearance of sources?
4. Safe handling and shielding instructions?
5. Waste control?
6. RSO and AU notification in emergency or patient death?
7. Records of training retained for three years (12VAC5-481-2070)?
Facilities
A. Facilities as described in license application (L/C)?
B. Therapy device facilities provided with electrical interlock system, viewing and intercom systems, radiation monitor, source retraction mechanism, and source indicator lights (12VAC5-481-780, 12VAC5-481-2040)?
C. Emergency source recovery equipment available (12VAC5-481-2010, 12VAC5-481-2040)?
D. Storage areas:
-
1. Materials secured from unauthorized removal or access (12VAC5-481-840)?
2. Licensee controls and maintains constant surveillance of licensed material not in-storage (12VAC5-481-840)?
3. Locations appropriately shielded to control public and occupational exposures?
E. Therapy unit operation:
-
1. Unit, console, console keys, and treatment room controlled adequately (12VAC5-481-840, 12VAC5-481-2040)?
2. Restricted to certain source orientations and/or gantry angles?
3. Ceases to operate in restricted orientation(s)?
4. Only one radiation device can be operated at a time within the treatment room (12VAC5-481-2040)?
Dose or Dosage Measuring Equipment
A. Possession, use, calibration, and check of instruments to measure activities of unsealed radionuclides (12VAC5-481-1800):
-
1. List type of equipment used:
2. Approved procedures for use of instrumentation followed?
3. Constancy, accuracy, linearity, and geometry dependence tests performed in accordance with nationally recognized standards or the manufacturer’s instructions?
4. Instrument repaired or replaced or dosages mathematically corrected, as required, when tests do not meet the performance objectives provided in the nationally recognized standard or manufacturer’s instructions (e.g., ±10%)?
5. Records maintained and include required information (12VAC5-481-2070)?
B. Determination of dosages of unsealed radioactive material (12VAC5-481-1820):
-
1. Each dosage determined and recorded prior to medical use (12VAC5-481-1820)?
2. Measurement of unit dosages made either by direct measurement or by decay correction (12VAC5-481-1820)?
3. For other than unit dosages, measurement made by direct measurement of radioactivity or by combination of radioactivity or volumetric measurement and calculation (12VAC5-481-1820)?
C. Licensee uses generators?
-
1. Each eluate after receipt tested for Mo-99 breakthrough (12VAC5-481-1930)?
2. No radiopharmaceuticals administered with Mo-99 concentrations over 0.15 μCi per mCi of Tc-99m (12VAC5-481-1930)?
3. Before first patient use of day, eluate tested for strontium (Sr)-82 and strontium-85 (Sr-85) when eluting rubidium (Rb)-82 (12VAC5-481-1930)?
4. No radiopharmaceuticals administered with Sr-82 concentrations over 0.02 kBq per MBq [0.02 μCi per mCi] of Rb-82 or Sr-85 concentrations over 0.2 kBq per MBq [0.2 μCi per mCi] of Rb-82 (12VAC5-481-1930)?
5. Each measurement that exceeds the limits in paragraph b or d above reported to VDH and distributor of the generator? (12VAC5-481-1930)?
6. Records maintained for 3 years (12VAC5-481-2070)?
D. Confirmation of source output or activity for manual brachytherapy sources?
E. Dosimetry Equipment (12VAC5-481-2040):
-
1. Calibrated system available for use (12VAC5-481-2040)?
2. Calibrated by NIST or an AAPM-accredited lab within previous 2 years and after servicing or calibrated by inter-comparison per 12VAC5-481-2040?
3. Calibrated within the previous 4 years (12VAC5-481-2040)?
4. Licensee has available for use a dosimetry system for spot-check measurements (12VAC5-481-2040)?
5. Record of each calibration, inter-comparison, and comparison maintained (12VAC5-481-2070)?
Radiation Protection and Control of Radioactive Material
A. Use of radiopharmaceuticals:-
1. Protective clothing worn?
2. Personnel routinely monitor their hands?
3. No eating/drinking in use/storage areas?
4. No food, drink, or personal effects kept in use/storage areas?
5. Proper dosimetry worn?
6. Radioactive waste disposed of in proper receptacles?
7. Syringe shields and vial shields used and are specific to the energy emitted?
8. Proper use of remote handling tools and radiation shields?
-
1. Leak test performed on sealed sources and brachytherapy sources (12VAC5-481-1840)?
2. Inventory of sealed sources and brachytherapy sources performed semiannually (12VAC5-481-1840)?
3. If applicable, transactions associated with nationally tracked sources entered into the NSTS, including annual reconciliation (12VAC5-481-451)?
4. Records maintained for three years (12VAC5-481-2070)?
-
A. Survey instruments used to show compliance with 12VAC5-481-450A and 12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part IV ‘Standards for Protection Against Radiation’:
1. Appropriate operable survey instruments possessed or available (12VAC5-481-1800)?
2. Calibrations (12VAC5-481-1810):
• a. Before first use, annually and after repairs?
• b. Within 20% on each scale or decade of interest?
3. Records maintained for three years (12VAC5-481-2070)?
-
1. Survey instruments appropriate and operable?
2. Daily in all areas where radiopharmaceuticals requiring a written directive are prepared or administered (except patient rooms) [12VAC5-481-1860]?
3. Weekly in all areas where radiopharmaceuticals or waste is stored?
4. Weekly wipes in all areas where radiopharmaceuticals are routinely prepared, administered, or stored?
5. Trigger levels established?
6. Corrective action taken and documented if trigger level exceeded?
7. Techniques can detect 0.1 mR/hr, 2000 dpm?
8. Surveys made to assure that the maximum radiation levels and average radiation levels from the surface of the main source safe with the sources(s) in the shielded position does not exceed the levels stated in the Sealed Source and Device Registry (12VAC5-481-2040) and records maintained (12VAC5-481-2070)?
• a. After new source installation?
• b. Following repairs to the source(s) shielding, the source(s) driving unit, or other electronic and mechanical mechanism that could expose the source, reduce the shielding around the source(s), or compromise the radiation safety of the unit or the source(s)?
-
A. Is licensed material used in a manner to keep doses below 1 mSv (100 mrem) in a year (12VAC5-481-720)?
B. Has a survey or evaluation been performed per 12VAC5-481-730?
C. Have there been any additions or changes to the storage, security, or use of surrounding areas that would necessitate a new survey or evaluation?
D. Do unrestricted area radiation levels exceed 0.02 mSv (2 mrem) in any one hour (12VAC5-481-720)?
E. Is licensed material used or stored in a manner that would prevent unauthorized access or removal (12VAC5-481-840)?
F. Records maintained (12VAC5-481-1050)?
-
A. Individuals released when TEDE less than 5 mSv (500 mrem) (12VAC5-481-1870)?
B. Instructions to the released individual, including breast-feeding women, include required information (12VAC5-481-1870)?
C. Release records maintained for three years (12VAC5-481-2070)?
D. Records of instructions given to breast-feeding women maintained, if required, for three years (12VAC5-481-2070)?
-
A. Safety precautions implemented to include patient facilities, posting, stay times, patient safety guidance, release, and contamination controls (12VAC5-481-1970)?
B. RSO and AU promptly notified if patient died or had a medical emergency (12VAC5-481-1970).
-
A. Safety precautions implemented to include patient facilities, posting, stay times, and emergency response equipment (12VAC5-481-2010)?
B. Survey immediately after implant (12VAC5-481-2010)?
C. Patients surveyed immediately after removing the last temporary implant source (12VAC5-481-2010)?
D. RSO and AU promptly notified if patient died or had a medical emergency (12VAC5-481-2010)?
E. Records maintained for three years (12VAC5-481-2070).
-
A. Disposal:
1. Decay-in-storage (12VAC5-481-1890)?
2. Procedures followed (12VAC5-481-1890)?
3. Labels removed or defaced (12VAC5-481-880, 12VAC5-481-1890)?
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
- Describe the purpose of the guidance document. Outline the scope and applicability for medical use of radioactive materials.
Description of VAREGS
- Provide an overview of VAREGS (Virginia Radioactive Materials Management System). Explain its role in licensing, recordkeeping, and compliance monitoring.
Application Process and Guidance
- Procedures for applying for a license to use radioactive materials.
- Steps for submitting required documentation. Guidance on compliance with regulations.
Appendices
- Additional resources and references.
- Sample forms and checklists. Regulatory references and contact information.
Records and Disposal Procedures
- Performed as required (L/C)?
- C. Improper/unauthorized disposals (12VAC5-481-910)?
- D. Records maintained (12VAC5-481-100, 12VAC5-481-571, 12VAC5-481-1000, 12VAC5-481-1060, 12VAC5-481-2070)?
- E. Effluents:
- Release to sanitary sewer (12VAC5-481-930)?
- a. Material is readily soluble or readily dispersible (12VAC5-481-930)?
- b. Monthly average release concentrations do not exceed 12VAC5-481-3690, Table III values?
- c. No more than 185 GBq (5.0 Ci) of H-3, 37 GBq (1.0 Ci) of C-14, and 37 GBq (1.0 Ci) of all other radionuclides combined released in a year (12VAC5-481-930)? d. Procedures to ensure representative sampling and analysis implemented (12VAC5-481-630)?
- License authorizes (12VAC5-481-940)?
- Air effluent less than 10 mrem constraint limit (12VAC5-481-630)?
- Protection from elements and fire?
- Sources transferred to authorized individuals (12VAC5-481-570, 12VAC5-481-910)?
Receipt and Transfer of Radioactive Material
- A. Describe how packages are received and by whom.
- B. Written package opening procedures established and followed (12VAC5-481-900, 12VAC5-481-3091)?
- C. All incoming packages with a DOT label monitored for radioactive contamination, unless exempted (gases and special form) [12VAC5-481-900]?
- D. Incoming packages surveyed (12VAC5-481-900)?
- E. Monitoring in (C) and (D) performed within time specified (12VAC5-481-900)?
- F. Transfer(s) performed per 12VAC5-481-570?
- G. All sources surveyed before shipment and transfer (12VAC5-481-750, 49 CFR 173.475(i))?
- H. Records of surveys and receipt/transfer maintained (12VAC5-481-100, 12VAC5-481-571, 12VAC5-481-1000)? I. Package receipt/distribution activities evaluated for compliance with 12VAC5-481-720?
Transportation [12VAC5-481-2980 and 49 CFR 171-189]
- A. Shipments are:
- Delivered to common carriers;
- Transported in own private vehicle;
- Both; No shipments since last audit.
- Licensee assumes shipping responsibility?
- Authorized packages used?
- Prepared and used?
Teletherapy and Gamma Stereotactic Radiosurgery Servicing
- A. Inspection and servicing performed following source replacement or at intervals not to exceed 5 years (12VAC5-481-2040)?
- B. Needed service arranged for as identified during the inspection?
- C. Service performed by persons specifically authorized to do so (12VAC5-481-2040)? D. Were security requirements implemented, if applicable (12VAC5-481-451)?
Full Calibration - Therapeutic Medical Devices
- A. Proper protocol(s) used (e.g., TG-51, AAPM 54, TG-56, TG-40, etc.)?
- B. Performed prior to first patient use (12VAC5-481-2040)?
- C. At intervals not to exceed one year for teletherapy, gamma stereotactic, and LDR remote afterloader; at intervals not exceeding one quarter for HDR, MDR, and PDR remote afterloaders (12VAC5-481-2040)?
- D. Whenever spot-checks indicate output differs from expected by ±5% (12VAC5-481-2040)?
- E. After source exchange, relocation, major repair or modification (12VAC5-481-2040)?
- F. Performed with properly calibrated instrument (12VAC5-481-2040)?
- G. Includes:
- 1. For teletherapy:
- Output measured within ±3% of expected for the range of field sizes, range of distances (12VAC5-481-2040)?
- Coincidence of radiation field and field light localizer (12VAC5-481-2040)?
- Uniformity of radiation field and beam angle dependence (12VAC5-481-2040)?
- Timer accuracy and linearity over the range of use (12VAC5-481-2040)?
- On-off error (12VAC5-481-2040)? Accuracy of all measuring and localization devices (12VAC5-481-2040)?
- Output measured within ±5% of expected (12VAC5-481-2040)?
- Output measured within ±3% of expected (12VAC5-481-2040)?
Periodic Spot Checks For Therapeutic Devices
- A. Performed at required frequency (12VAC5-481-2040)?
- B. Procedures established by authorized medical physicist (12VAC5-481-2040)?
- C. Procedures are being followed?
- D. Authorized medical physicist reviews results within 15 days (12VAC5-481-2040)?
- E. Performed with properly calibrated instrument (12VAC5-481-2040)?
- F. Output and safety spot checks include:
- 1. For teletherapy:
- Timer accuracy and linearity over the range of use (12VAC5-481-2040)?
- On-off error (12VAC5-481-2040)?
- Coincidence of radiation field and field light localizer (12VAC5-481-2040)?
- Accuracy of all measuring and localization devices (12VAC5-481-2040)?
- The output for one typical set of operating conditions (12VAC5-481-2040)?
- Difference between measured and expected output (12VAC5-481-2040)?
- Interlock systems (12VAC5-481-2040)?
- Beam stops (12VAC5-481-2040)?
- Source exposure indicator lights (12VAC5-481-2040)?
- Viewing and intercom systems (12VAC5-481-2040)?
- Treatment room doors, inside and out (12VAC5-481-2040)? Electrical treatment doors with power shut off (12VAC5-481-2040)?
- Interlock systems (12VAC5-481-2040)?
- Treatment table retraction mechanism (12VAC5-481-2040)?
Installation, Maintenance, and Repair of Therapy Devices
- A. Only authorized individuals perform installations, maintenance, adjustment, repair, and inspections (12VAC5-481-2040)?
- Name of organization/individual: . License verified? B. Records maintained for three years (12VAC5-481-2070)?
Emergency and Operating Procedures For Therapy Devices
- A. Instructions on location of emergency procedures and emergency response telephone numbers are posted at the device console (12VAC5-481-2040)?
- B. Copy of the entire procedures physically located at the device console (12VAC5-481-2040)?
- C. Procedures include:
- Instructions for responding to equipment failures and the names of the individuals responsible for implementing corrective actions (12VAC5-481-2040)?
- The process for restricting access to and posting of the treatment area to minimize the risk of inadvertent exposure (12VAC5-481-2040)? The names and telephone numbers of the authorized users, the authorized medical physicist, and the RSO to be contacted if the unit or console operates abnormally (12VAC5-481-2040)?
- 1. Physically present during initiation of patient treatment with remote afterloaders for MDR and PDR, an appropriately trained physician under the supervision of the authorized user may be physically present instead of the AU (12VAC5-481-2040)?
Personnel Radiation Protection
- A. Exposure evaluation performed (12VAC5-481-750)? B. ALARA program implemented (12VAC5-481-630)?
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance on the safe and compliant use of radioactive materials in medical settings, including procedures for dosimetry, recordkeeping, security, and incident reporting.
Description of VAREGS
VAREGS refers to the Virginia Radiation Emergency and General Safety regulations, which outline requirements for radiation safety, monitoring, and security in medical and other applications.
Application Process and Guidance
Applicants must adhere to the licensing and regulatory requirements specified in 12VAC5-481 and related sections, including procedures for dosimetry, security, and incident reporting.
C. External Dosimetry
-
1. Monitor workers per 12VAC5-481-760?
2. External exposures account for contributions from airborne activity (12VAC5-481-660)?
3. Dosimetry supplier exchange frequency.
4. Supplier is NVLAP-approved (12VAC5-481-750)?
5. Dosimeter exchanged as recommended by the supplier.
D. Internal Dosimetry
-
1. Monitor workers per 12VAC5-481-760?
2. Briefly describe program for monitoring and controlling internal exposures (12VAC5-481-810, 12VAC5-481-820)?
3. Monitoring/control program implemented (includes bioassays)?
4. Respiratory protection equipment (12VAC5-481-830)?
E. Review of Records and Reports
-
1. Reviewed by frequency.
2. Auditor reviewed personnel monitoring records for period to.
3. Prior dose determined for individuals likely to receive doses (12VAC5-481-680)?
4. Maximum exposures TEDE: Other.
5. Maximum CDEs: Organ(s).
6. Maximum CEDE.
7. Internal and external summed (12VAC5-481-650)?
8. Were occupational limits met (12VAC5-481-640)?
9. VDH forms or equivalent used (12VAC5-481-1020, 12VAC5-481-1030, 12VAC5-481-1040)?
[a.] VDH Form, ‘Occupational Exposure Record Per Monitoring Period’
F. Who performed any planned special exposures at this facility (number of people involved and doses received)
[12VAC5-481-680, 12VAC5-481-690, 12VAC5-481-1030, 12VAC5-481-1120]?G. Records of exposures, surveys, monitoring, and evaluations maintained (12VAC5-481-990, 12VAC5-481-1000, 12VAC5-481-1040)?
-
12VAC5-481-2060: Other Medical Uses of Byproduct Material or Radiation from Byproduct Material
Use specific 10 CFR 35.1000 licensing guidance and the above components, as applicable, to develop an audit of other medical uses licensed under 10 CFR 35.1000.
Security Program for Category 1 and Category 2 Materials [12VAC 5-481-451] (if applicable)
A. Is access to the material controlled so that only authorized individuals can gain access to the material? Are personnel who have not been authorized escorted?
B. Have all personnel who have unescorted access to the material been deemed trustworthy and reliable, been fingerprinted, and been authorized in writing for access to the material? Is the list of authorized personnel up to date?
C. Is a system in place so that any unauthorized access to the material will be detected immediately? Are weekly verification checks conducted for Category 2 quantities of radioactive material?
D. Are procedures in place to ensure that any unauthorized access will be assessed to determine whether further response is required? If there have been any such accesses, was the procedure followed?
E. Is the security plan current? Is contact information for the local law enforcement agency current?
F. Is the security system operable?
G. Does the security system have a dependable means of communication to notify assessment personnel? Do personnel have a dependable means of communication to notify response staff or local law enforcement?
H. Are all documents being retained as required?
I. Is all sensitive information secured and protected in accordance with the procedure? Does the procedure address all required information?
J. Have personnel with access to the material been trained on security procedures, including emergency response, notifications, and surveillance?
K. Are procedures in place to ensure the safe and secure transport of Category 1 and Category 2 radioactive sources or material? Were the procedures followed for preplanning, license verification, coordination, advance notification, physical protection, and reporting, as applicable?
L. Is the security program content and implementation reviewed annually with records maintained for 3 years?
Confirmatory Measurements
Detail location and results of confirmatory measurements.
123 Medical Events
A. Review a sampling of records for administrations requiring a WD.
The number of patient cases to be sampled should be representative of each treatment modality performed in the institution.
B. Conduct a review of each applicable program area (e.g., radiopharmaceutical therapy, high dose-rate brachytherapy, implant brachytherapy, teletherapy, and emerging technologies). If feasible, the persons conducting the review should not review their own work. If this is not possible, two people should work together as a team to conduct the review of that work.
C. Review the procedures to ensure that the procedures for administrations requiring a WD are effective.
D. Determine whether the administered radiopharmaceutical dosage or radiation dose was in accordance with the WD or treatment plan, as applicable. Determine if a medical event has occurred, and for permanent implant brachytherapy, that within 60 calendar days from the date the implant was performed, the total source strength administered outside of the treatment site was compared to the total source strength documented in the post-implantation portion of the written directive, unless a written justification of patient unavailability is documented.
When deviations from the WD are found, the cause of each deviation and the action required to prevent recurrence should be identified.
If medical events (criteria as in 12VAC5-481-2080) have occurred since the last audit, evaluate the incident(s) and procedures for implementing and administering written directives using the existing guidance.
A. Event date _____________ Information Source _________________________ B. Notifications-
1. Virginia Department of Health
2. The referring physician
3. Patient in writing/by telephone
4. If notifications did not occur, why not?
-
1. Submitted to the agency within 15 days?
D. Patient intervention that resulted in the total dose or dosage not being administered? Describe each intervention.
Notification and Reports
-
A. In compliance with 12VAC5-481-1090, 12VAC5-481-1100, 12VAC5-481-1110, 12VAC5-481-1150, and 12VAC5-481-2280 (reports to individuals; public and occupational doses monitored to show compliance with 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part IV ‘Standards for Protection Against Radiation’)?
B. In compliance with 12VAC5-481-1090 (theft or loss)?
C. In compliance with 12VAC5-481-1100 and/or 12VAC5-481-1100 (incidents)?
D. In compliance with 12VAC5-481-1100 and/or 12VAC5-481-1110 (overexposures and high radiation levels)?
E. Aware of the Radioactive Materials Program phone numbers
[Office: (804) 864-8150, 24-hour: (800) 468-8892]F. In compliance with 12VAC5-481-1110 (constraint on air emissions)?
Posting and Labeling
-
A. VDH Form, ‘Notice to Employees’ is posted (12VAC5-481-2260)?
B. 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part IV ‘Standards for Protection Against Radiation’ and Part X ‘Notices, Instructions and Reports to Workers’, license documents, operating procedures applicable to activities under the license or registration are posted or post a notice indicating where documents may be examined. (12VAC5-481-2260)?
C. Other posting and labeling per 12VAC5-481-850, 12VAC5-481-860 and/or 12VAC5-481-880 and not exempted by 12VAC5-481-870 or 12VAC5-481-890?
Recordkeeping for Decommissioning
-
A. Records of information important to the safe and effective decommissioning of the facility maintained in an independent and identifiable location until license termination (12VAC5-481-450 C)?
B. Records include all information outlined in 12VAC5-481-450 C?
Information Notices and Regulatory Issue Summaries
-
A. VDH Information Notices, etc., received?
B. Appropriate action in response to VDH Information Notices, etc.?
Special License Conditions or Issues
-
A. Special license conditions or issues to be reviewed:
B. Evaluation:
Performance-Based Review
-
A. Conduct performance-based reviews of radiation workers performing licensed activities:
to assess the capability of the radiation workers to maintain exposures ALARA;
to assess that radiation workers follow the operating procedures;
to assess the effectiveness of the operating procedures and compliance with the regulations, license conditions and the licensee commitments submitted in support of a license (and incorporated by “tie-down” conditions);
to ensure the safe and secure use of radioactive material;
to verify that radiation workers are cognizant of the emergency procedures and, if necessary, would be able to implement them and maintain exposures ALARA; and
to ensure that emergency procedures have been developed for all likely scenarios.
Audits and Findings
-
A. Summary of findings:
B. Corrective and preventive actions:
C. Amendment required?
Appendix L Procedures for an Occupational Dose Program
This procedure provides acceptable methods for an external occupational dose program and references for developing an internal occupational dose program.
Applicants may either adopt these procedures for an external occupational dose program or develop alternative procedures to meet the requirements of 12VAC5-481-630 and 12VAC5-481 ‘Virginia Radiation Protection Regulations’, Part IV ‘Standards for Protection Against Radiation’.
The procedure includes guidance as well as discussion of rule requirements that are to be reflected in the elements of an occupational dose program.
“Dosimetry” is broad term commonly applied to those methods used to measure or otherwise quantify radiation doses to individuals.
A dosimetry program is required for individuals likely to receive in 1 year a dose in excess of 10% of the applicable regulatory limits in 12VAC5-481-640.
The Total Effective Dose Equivalent (TEDE) is the sum of the deep-dose equivalent (external exposure) and the committed effective dose equivalent (internal exposure).
The definition of the terms TEDE, deep-dose equivalent (DDE), and committed effective dose equivalent (CEDE) can be found in 12VAC5-481-10.
To demonstrate that dosimetry is not required, the licensee needs to have available for inspection an evaluation to demonstrate that the workers are not likely to exceed 10% of the applicable annual limits (12VAC5-481-750).
If an individual is likely to receive more than 10% of the annual dose limits, VDH requires the licensee to monitor the dose, to maintain records of the dose, and, on at least an annual basis, to inform the worker of his/her dose.
The licensee must consider the dose that an individual may receive in the current year from all sources of employment where the individual's assigned duties involve exposure to sources of radiation.
The As Low As Reasonably Achievable ‘ALARA’ Program 12VAC5-481-630 states that “each licensee shall develop, document, and implement a radiation protection program commensurate with the scope and extent of licensed activities…” and, “the licensee shall use, to the extent practical, procedures and engineering controls based upon sound radiation protection principles to achieve occupational doses and doses to members of the public that are as low as is reasonably achievable (ALARA).”
Additionally, 12VAC5-481-630 requires that licensees periodically review the content of the radiation protection program and its implementation.
External Exposure
It is necessary to assess doses to radiation workers to demonstrate compliance with regulatory limits on radiation dose and to help demonstrate that doses are maintained at ALARA levels.
Providing for the safe use of radioactive materials and radiation is a management responsibility.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance on the requirements for radiation protection in the medical use of radioactive materials. It outlines dose limits, monitoring requirements, and procedures to ensure safety for workers and patients alike.
Description of VAREGS
VAREGS (Virginia Radiation Exposure and Safety Program) is designed to monitor and regulate occupational exposure to radiation, ensuring compliance with state regulations and promoting best practices in radiation safety.
Application Process and Guidance
The following sections detail the dose limits, monitoring procedures, investigational levels, and special considerations such as pregnancy and internal exposure. Adherence to these guidelines helps maintain radiation doses As Low As Reasonably Achievable (ALARA).
Radiation Dose Limits and Monitoring Requirements
There are three dose limits included in 12VAC5-481-640 that apply to external exposure:
-
Deep dose to the whole body (5 rem or 0.05 Sv)
Shallow dose to the skin or extremities (50 rem or 0.5 Sv)
Dose to the lens of the eye (15 rem or 0.15 Sv)
According to the definitions in 12VAC5-481-10, the deep dose exposure (DDE) to the whole body is considered to be at a tissue depth of 1 cm (1000 mg/cm²), shallow-dose equivalent to the skin or extremities at 0.007 cm (7 mg/cm²), and eye dose equivalent at 0.3 cm (300 mg/cm²). In evaluating the eye dose equivalent, it is acceptable to take credit for the shielding provided by protective lenses.
Monitoring an individual’s external radiation exposure is required by 12VAC5-481-760 if the external occupational dose is likely to exceed 10% of the dose limit appropriate for the individual (i.e., adult, minor, or the fetus of a declared pregnant woman). External radiation monitoring is also required for any individual entering a high or very high radiation area.
Use of Individual Monitoring Devices
The use of individual monitoring devices for external exposure is required for the following:
-
For adults who are likely to receive an annual dose in excess of any of the following:
[a.] 0.5 rem (0.005 Sv) DDE
[a.] 1.5 rem (0.015 Sv) eye dose equivalent
[a.] 5 rem (0.05 Sv) shallow-dose equivalent to the skin
[a.] 5 rem (0.05 Sv) shallow-dose equivalent to any extremity
For minors who are likely to receive an annual dose in excess of:
[a.] 0.1 rem (1.0 mSv) DDE
[a.] 0.15 rem (1.5 mSv) eye dose equivalent
[a.] 0.5 rem (5 mSv) shallow-dose equivalent to the skin
[a.] 0.5 rem (5 mSv) shallow-dose equivalent to any extremity
For declared pregnant women who are likely to receive an annual dose from occupational exposure in excess of 0.1 rem (1.0 mSv) DDE, although the dose limit applies to the entire gestation period.
For individuals entering a high or very high radiation area.
To demonstrate that monitoring of occupational exposure is not necessary for a group of radiation workers, it must be shown that doses will not exceed 10% of the applicable limits. In these cases, VDH does not require licensees to monitor radiation doses for this class of worker.
The following methods may be used to demonstrate that doses are expected to be within 10% of rule limits:
-
Prior Experience: Review of radiation dose histories for workers in a specific work area show that they are not likely to receive a dose in excess of 10% of the limits;
Area Surveys: Demonstrate through the conduct of appropriate radiation level surveys (e.g., using a survey meter or area thermoluminescent dosimeters (TLDs)) in the work area, combined with estimates of occupancy rates and calculations, that doses to workers are not likely to exceed 10% of the limits (exposures associated with reasonable ‘accident’ scenarios should also be evaluated);
The licensee performs a reasonable calculation based upon source strength, distance, shielding, and time spent in the work area, that shows that workers are not likely to receive a dose in excess of 10% of the limits.
External dose is determined by using individual monitoring devices, such as film badges, optically stimulated luminescence dosimeters (OSLs), or TLDs. These devices must be evaluated by a processor that is NVLAP (National Voluntary Laboratory Accreditation Program)-approved, as required by 12VAC5-481-750.
Acceptable exchange frequencies are determined by the dosimetry provider. The device for monitoring the whole body dose, eye dose, skin dose, or extremity dose shall be placed near the location expected to receive the highest dose during the year (12VAC5-481-640).
When the whole body is exposed fairly uniformly, the individual monitoring device is typically worn on the front of the upper torso. If the radiation dose is highly non-uniform, causing a specific part of the whole body (head, trunk, arms above the elbow, or legs above the knees) to receive a substantially higher dose than the rest of the whole body, the individual monitoring device shall be placed near that part of the whole body expected to receive the highest dose.
For example, if the dose rate to the head is expected to be higher than the dose rate to the trunk of the body, a monitoring device shall be located on or close to the head.
If, after the exposure is received, the licensee learns that the maximum dose to a part of the whole body, eye, skin, or extremity was substantially higher than the dose measured by the individual monitoring device, an evaluation shall be conducted to estimate the actual maximum dose.
An acceptable alternative approach for highly non-uniform radiation fields is to use more than one dosimeter to separately track doses to different parts of the whole body. At the end of the year, each of the doses for each location is summed. The deep-dose equivalent recorded is that of the dosimeter location receiving the highest dose.
Dose Evaluation and Recordkeeping
Because evaluation of dose is an important part of the radiation protection program, it is important that users return dosimeters on time. Licensees shall be vigorous in their effort to recover any missing dosimeters.
Delays in processing a dosimeter can result in the loss of the stored information. If an individual’s dosimeter is lost, the licensee needs to perform and document an evaluation of the dose the individual received and add it to the employee’s dose record.
Sometimes the most reliable method for estimating an individual’s dose is to use his/her recent dose history. In other cases, particularly if the individual does non-routine types of work, it may be better to use doses of co-workers as the basis for the dose estimate. It also may be possible to estimate doses by modeling and calculation (i.e., reconstruction) of scenarios leading to dose.
12VAC5-481-1040 requires that the recording for individual monitoring be done on VDH Form, ‘Occupational Exposure Record Per Monitoring Period’ or equivalent.
VDH Form, ‘Occupational Exposure Record Per Monitoring Period’ is used to record doses received for the calendar year. The monitoring year may be adjusted as necessary to permit a smooth transition from one monitoring year to another, as long as the year begins and ends in January, the change is made at the beginning of the year, and no day is omitted or duplicated in consecutive years.
Additionally, 12VAC5-481-2280 requires licensees to provide written annual occupational exposure reports to workers.
Investigational Levels - External Dose Monitoring
VDH emphasizes that the investigational levels in this program are not new dose limits but, as noted in ICRP Report 26, ‘Recommendations of the International Commission on Radiological Protection’, investigational levels serve as check points above which the results are considered sufficiently important to justify investigation.
In cases where a worker’s or a group of workers’ doses need to exceed an investigational level, a new, higher investigational level may be established for that individual or group on the basis that it is consistent with good ALARA practices.
Justification for new investigational levels should be documented.
When the cumulative annual exposure to a radiation worker exceeds Investigational Level I in Table 9 (i.e., 10% of the annual limit for occupational exposure), the RSO or the RSO’s designee should investigate the exposure and review the actions that might be taken to reduce the probability of recurrence.
When the cumulative annual exposure exceeds Investigational Level II in Table 9 (i.e., 30% of the annual limit for occupational exposure), the RSO or the RSO’s designee will investigate the exposure and review actions to be taken to reduce the probability of recurrence. Management should review the report of the actions to be taken to reduce the probability of occurrence.
Table 9: Investigational Levels
-
Part of Body: Whole body; head; trunk including male gonads; arms above the elbow; or legs above the knee
Investigational Level I (mrem per year): 500 (5 mSv)
Investigational Level II (mrem per year): 1,500 (15 mSv)
Part of Body: Hands; elbows; arms below the elbow; feet; knee; leg below the knee; or skin
Investigational Level I: 5,000 (50 mSv)
Investigational Level II: 15,000 (150 mSv)
Part of Body: Lens of the eye
Investigational Level I: 1,500 (15 mSv)
Investigational Level II: 4,500 (45 mSv)
Actions When Investigation Levels Are Reached
Review and record on VDH Form, ‘Occupational Exposure Record Per Monitoring Period’, or an equivalent form (e.g., dosimeter processor’s report) the results of personnel monitoring.
Take the actions listed below when the investigation levels listed in Table 9 are reached:
-
Personnel dose less than Investigational Level I: Except when deemed appropriate by the RSO or the RSO’s designee, no further action will be taken if an individual’s dose is less than Table 9 values for the Investigational Level I.
Personnel dose equal to or greater than Investigational Level I but less than Investigational Level II: When the dose of an individual whose dose equals or exceeds Investigational Level I, the RSO or the RSO’s designee will conduct a timely investigation and review the actions that might be taken to reduce the probability of recurrence, following the period when the dose was recorded. If the dose does not equal or exceed Investigational Level II, no action related specifically to the exposure is required unless deemed appropriate by the RSO or the RSO’s designee. Consider investigating the factors that led to the radiation exposure and the radiation doses and work habits of other individuals engaged in similar tasks to determine if improvements or additional safety measures are needed to reduce exposures. Evaluate in the context of the ALARA program, and record the results of investigations and evaluations.
Personnel dose equal to or greater than Investigational Level II: The RSO should investigate in a timely manner the causes of all personnel doses equaling or exceeding Investigational Level II. A consideration of actions should be taken by the RSO to reduce the probability of occurrence, and a report of the actions should be reviewed by the licensee’s management at its first meeting following completion of the investigation. Re-establish the Investigational Level II to a level above that listed in Table 9.
Declared Pregnancy and Dose to Embryo/Fetus
12VAC5-481-710 states that the licensee shall ensure that the dose to an embryo/fetus during the entire pregnancy, due to occupational exposure of a declared pregnant woman, does not exceed 0.5 rem (5 mSv).
The licensee shall make efforts to avoid substantial variation above a uniform monthly exposure rate to a declared pregnant woman.
The pregnancy is declared in writing and includes the worker’s estimated date of conception. The dose to the embryo/fetus shall be taken as the sum of:
-
The deep-dose equivalent to the declared pregnant woman; and
The dose to the embryo/fetus from radionuclides in the embryo/fetus and radionuclides in the declared pregnant woman.
References - Methods for calculating the radiation dose to the embryo/fetus can be found in NRC Regulatory Guide 8.36, ‘Radiation Dose to the Embryo/Fetus’.
Additional references include: NUREG/CR-5631, PNL-7445, Rev. 2, ‘Contribution of Maternal Radionuclide Burdens to Prenatal Radiation Doses’. To obtain these documents, contact NRC Region I or visit the NRC’s website at www.nrc.gov.
Internal Exposure
With respect to internal exposure, you are required to monitor occupational intake of radioactive material and assess the resulting dose if it appears likely that personnel will receive greater than 10% of the annual limit on intake (ALI) from intakes in one year.
12VAC5-481, ‘Virginia Radiation Protection Regulations’, Part IV, ‘Standards for Protection Against Radiation’, provides terms for radionuclide intakes by means of inhalation and ingestion (i.e., derived air concentration (DAC) and ALI).
End of Document
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Airborne radioactivity in μCi/ml that, if an occupational worker were to be continuously exposed to for 2,000 hours (1 year), would result in either a committed effective dose equivalent (CEDE) of 5 rem (0.05 Sv) to the whole body or a committed dose equivalent (CDE) of 50 rem (0.5 Sv) to any individual organ or tissue, with no consideration for the contribution of external dose.
The ALI and DAC for each radionuclide in a specific chemical form are listed in 12VAC5-481-3690.
For each class of each radionuclide, there are two ALIs, one for ingestion and one for inhalation. The ALI is the quantity of radioactive material that, if taken into the body of an adult worker by the corresponding route, would result in a CEDE of 5 rem (0.05 Sv) or a CDE of 50 rem (0.5 Sv) to any individual organ or tissue, again, with no consideration for the contribution of external dose.
The total effective dose equivalent concept makes it possible to combine both the internal and external doses in assessing the overall risk to the health of an individual.
12VAC5-481-3690, ALI and DAC numbers reflect the doses to all principal organs that are irradiated. The ALI and DAC were derived by multiplying a unit intake by the appropriate organ weighting factors (W_T), for the organs specifically targeted by the radionuclide compound, and then summing the organ-weighted doses to obtain a whole body risk-weighted ‘effective dose’.
Per 12VAC5-481-3690, when an ALI is defined by the stochastic dose limit, this value alone is given. When the ALI is determined by the non-stochastic dose limit to an organ, the organ or tissue to which the limit applies is shown, and the ALI for the stochastic limit is shown in parentheses.
The types and quantities of radioactive material manipulated at most medical facilities do not provide a reasonable possibility for an internal intake by workers. However, uses such as preparing radioiodine capsules from liquid solutions and opening and dispensing radioiodine from vials containing millicurie quantities require particular caution.
To monitor internal exposures from such operations, a routine bioassay program to periodically monitor workers should be established. If a licensee determines that a program for performing thyroid uptake bioassay measurements is necessary, a program should be established. The program should include:
-
adequate equipment to perform bioassay measurements,
procedures for calibrating the equipment, including factors necessary to convert counts per minute into becquerel or microcurie units,
the technical problems commonly associated with performing thyroid bioassays (e.g., statistical accuracy, attenuation by neck tissue),
the interval between bioassays,
action levels, and
the actions to be taken at those levels.
For guidance on developing bioassay programs and determination of internal occupational dose and summation of occupational dose, refer to NRC Regulatory Guide 8.9 Revision 1, ‘Acceptable Concepts, Models, Equations and Assumptions for a Bioassay Program’, NRC Regulatory Guide 8.34, ‘Monitoring Criteria and Methods to Calculate Occupational Radiation Doses’, and NUREG-1400, ‘Air Sampling in the Workplace’. These documents are available by contacting the NRC or from the NRC’s website: www.nrc.gov.
Recordkeeping
Records of measurement data, calculations of intakes, and methods for calculating dose must be maintained as required by 12VAC5-481-1000 and 12VAC5-481-1040.
For additional information on recordkeeping and reporting occupational exposure data, including intakes, refer to Revision 1 of NRC Regulatory Guide 8.7, ‘Instructions for Recording and Reporting Occupational Radiation Exposure Data’. This document is available by contacting the NRC or from the NRC’s website: www.nrc.gov.
Summation of External and Internal Doses
Pursuant to 12VAC5-481-640, the external and internal doses must be summed if required to monitor both under 12VAC5-481-760.
Two documents that contain helpful information regarding occupational doses are:
-
NRC Regulatory Issue Summary 2002-06, ‘Evaluating Occupational Dose for Individuals Exposed to NRC-Licensed Material and Medical X-Rays’
NRC Regulatory Issue Summary 2002-10, ‘Revision of Skin Dose Unit in 10 CFR Part 20’
Copies of NRC Regulatory Issue Summaries are available on the NRC web site in the Electronic Reading Room found at www.nrc.gov.
Appendix M RESERVED
Appendix N Emergency Procedures
Spill Procedures - Low and High Activity Unsealed Sources
These procedures provide acceptable responses to emergencies. Applicants may either adopt Appendix N or develop alternative procedures to meet the requirements of 12VAC5-481-630.
Spilled Gas Procedure
-
1. Notify persons in the room that a spill has occurred and ask them to leave the room.
2. Remove the patient from the room.
3. Close door to room.
4. Remain outside the room for __ ____ minutes (see below for clearance time calculation).
5. Report the incident to the RSO.
RSO WORK PHONE NUMBER EMERGENCY NUMBER
This spilled gas procedure shall be posted in the room(s) where gas is used.
Clearance Time Calculation
Because normal room ventilation is usually not sufficient to ensure timely clearance of spilled gas, the following calculations should be done to determine for how long a room should be cleared in case of a gas spill.
1. Collect the following data:
-
a. A, the highest activity of gas in a single container, in microcuries;
b. Measured airflow supply from each vent in the room (if different during heating and cooling seasons, use the lesser value), in milliliters per minute;
c. Q, the total room air exhaust determined by measuring, in milliliters per minute, the airflow to each exhaust vent in the room (the exhaust should be vented and not recirculated within the facility); this may be either the normal air exhaust or a specially installed gas exhaust system;
d. C, the maximum permissible air concentrations in restricted and unrestricted areas. For Xe-133, the maximum permissible values are 1 x 10^-5 μCi/ml in restricted areas and 3 x 10^-7 μCi/ml in unrestricted areas. For other gases, see 12VAC5-481-3690; and
e. V, the volume of the room in milliliters.
2. For each room in which radioactive gases are used, make the following calculation:
-
a. The airflow supply should be less than the airflow exhaust to ensure the room is at negative pressure.
b. The evacuation time:
Minor Spills of Liquids and Solids
-
1. Notify persons in the area that a spill has occurred.
2. Prevent the spread of contamination by covering the spill with absorbent paper.
3. Wearing gloves and protective clothing such as a lab coat and booties, clean up the spill using absorbent paper. Carefully fold the absorbent paper with the clean side out and place in a “Caution Radioactive Material” labeled bag for transfer to a radioactive waste container. Also put contaminated gloves and any other contaminated disposable material in the bag.
4. Survey the area with a low-range radiation detection survey instrument sufficiently sensitive to detect the radionuclide. Check for removable contamination to ensure contamination levels are below trigger levels. Check the area around the spill. Also check hands, clothing, and shoes for contamination.
5. Report the incident to the RSO.
6. Cooperate and follow the instructions of the RSO and the RSO staff (e.g., criteria for returning to the work area, investigation of root cause, provision of requested bioassay samples, decontamination techniques, surveys, requested documentation).
Major Spills of Liquids and Solids
-
1. Clear the area. Notify all persons not involved in the spill to vacate the room.
2. Prevent the spread of contamination by covering the spill with “Caution Radioactive Material” labeled absorbent paper, but do not attempt to clean it up. To prevent the spread of contamination, clearly indicate the boundaries of the spill and limit the movement of all personnel who may be contaminated.
3. Shield the source, if possible. Do this only if it can be done without further contamination or a significant increase in radiation exposure.
4. Close the room and lock or otherwise secure the area to prevent entry.
5. Notify the RSO immediately.
6. Survey all personnel who could possibly have been contaminated. Decontaminate personnel by removing contaminated clothing and flushing contaminated skin with lukewarm water, then washing with mild soap. If contamination remains, the RSO may consider inducing perspiration. Then wash the affected area again to remove any contamination that was released by the perspiration.
7. Cooperate and follow the instructions of the RSO and the RSO’s staff (e.g., criteria for returning to the work area, investigation of root cause, provision of requested bioassay samples, decontamination techniques, surveys, requested documentation).
The decision to implement a major spill procedure instead of a minor spill procedure depends on many incident-specific variables, such as the number of individuals affected, other hazards present, likelihood of contamination spread, types of surfaces contaminated, and radiotoxicity of the spilled material.
For some spills of radionuclides with half-lives shorter than 24 hours and in amounts less than five times the lowest ALI, an alternative spill procedure may be to restrict access pending complete decay.
RSO WORK PHONE NUMBER EMERGENCY NUMBER
Note: A report to VDH may be required pursuant to 12VAC5-481-1100. Use Table 10 as general guidance to determine whether a major spill procedure or a minor spill procedure will be implemented.
Estimate the amount of radioactivity spilled. Initiate a major or minor spill procedure, based on the following information: spills above these millicurie amounts are considered major and below these levels are considered minor.
Table 10. Relative Hazards of Common Medical Radionuclides
Major Spill Threshold *For radiopharmaceuticals where the primary emission is alpha, consider implementing major spill precautions.
Source: NUREG-1556, Vol 9, Rev 3, “Consolidated Guidance About Materials Licenses Program -Specific Guidance About Medical Use Licenses”
Spill Kit
Assemble a spill kit that contains the following items:
-
Disposable gloves and housekeeping gloves;
Disposable lab coats;
Disposable head coverings;
Disposable shoe covers;
Roll of absorbent paper with plastic backing;
Masking tape;
Plastic trash bags with twist ties;
“Radioactive Material” labeling tape;
Marking pen;
Pre-strung “Radioactive Material” labeling tags;
Contamination wipes;
Instructions for “Emergency Procedures”;
Clipboard with copy of Radioactive Spill Report Form;
Pencil; and
Appropriate survey instruments, including batteries.
Reminders to RSO
-
Supervise and confirm decontamination of personnel. If decontamination of personnel was not fully successful, consider inducing perspiration by covering the area with plastic. Then wash the affected area again to remove any contamination that was released by the perspiration.
Document decontamination results, including all surveys, location of surveys, and decontamination results.
Evaluate and determine personnel radiation exposure. Beta emitting radionuclides could have a potential for resulting in a shallow-dose exposure in excess of regulatory limits from μCi quantities of contamination.
Determine cause and needed corrective actions; consider need for bioassays if licensed material may have been ingested, inhaled, or absorbed through the skin.
If necessary, notify VDH.
Emergency Surgery of Patients Who Have Received Therapeutic Amounts of Radionuclides
The following procedures should be followed:
-
1. If emergency surgery is performed within the first 24 hours following the administration of I-131 sodium iodide, fluids (e.g., blood, urine) will be carefully removed and contained in a
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance on the safe handling, administration, and disposal of radioactive materials used in medical settings. It aims to ensure compliance with regulatory requirements and promote radiation safety for patients, personnel, and the environment.
Description of VAREGS
VAREGS (Veterinary and Radiological Emergency Guidance System) is a comprehensive program designed to assist medical and veterinary facilities in managing radioactive materials safely. It includes protocols for handling, emergency response, and personnel training.
Application Process and Guidance
Applicants seeking authorization to use radioactive materials must follow the procedures outlined below to ensure safety and compliance:
-
Authorize, through a designee (e.g., RSO), each order of radioactive materials and verify that the requested materials and quantities are within the license limits.
Establish and maintain a system for ordering and receiving radioactive material, including records that identify the AU or department, radionuclide, physical and/or chemical form, activity, and supplier.
Confirm that received materials were ordered through proper channels using the above records.
For deliveries during normal working hours, instruct carriers to deliver packages directly to a specified area.
For off-hours deliveries, inform security personnel or designated persons to accept delivery according to established procedures.
Sample Memorandum for Package Delivery
MEMO TO: Chief of Security
FROM: Radiation Safety Officer
SUBJECT: Receipt of Packages Containing Radioactive Material
The security guard on duty will accept delivery of radioactive material that arrives outside normal working hours. Packages will be taken immediately to the Nuclear Medicine department, Room [insert room number]. Unlock the door, place the package on top of the counter, and relock the door.
If the package appears to be damaged, immediately contact one of the individuals listed below. Ask the carrier to remain until it can be determined that neither the driver nor the vehicle is contaminated. If you have questions, contact the hospital Radiation Safety Officer at extension [insert extension].
-
Title: Name: After Hours Telephone Number
Radiation Safety Officer: [Name], [Phone Number]
Director of Nuclear Medicine: [Name], [Phone Number]
Nuclear Medicine Technologist Supervisor: [Name], [Phone Number]
Nuclear Medicine Technologist on Call: [Name], [Phone Number]
Nuclear Medicine Physician on Call: [Name], [Phone Number]
Model Procedure for Safely Opening Packages Containing Radioactive Material
This procedure provides acceptable methods for opening packages containing radioactive material. Applicants may adopt this model or develop an alternative meeting the requirements of 12VAC5-481-900. Special procedures are required for packages exceeding Type A quantity limits (e.g., 20 Ci Mo-99, 54 Ci Cs-137, 27 Ci Ir-192, 540 Ci I-125, 270 Ci Xe-133, 110 Ci Tc-99m). Such packages must be received promptly and monitored for radiation levels and contamination.
Check for external radiation levels and surface contamination within 3 hours of receipt (during working hours) or by the start of the next working day (after hours). Notify VDH and the carrier if contamination exceeds limits or radiation levels are above 200 mR/hr on contact.
Opening Procedure:
-
Put on gloves to prevent hand contamination.
Visually inspect the package for damage (wet, crushed). If damaged, stop and notify the RSO immediately.
Monitor external surfaces for contamination unless the package contains only gas or special form material.
Monitor external surfaces for radiation levels unless below Type A quantities.
Continue monitoring all known radioactive packages. If integrity is compromised, notify RSO.
Remove the packing slip.
Open the outer package following supplier instructions.
Open the inner package and verify contents against the packing slip.
Check the final source container for broken seals, loss of liquid, condensation, or discoloration. Notify RSO if issues are found.
If contamination is suspected, wipe the external surface of the source container, assay the wipe for removable radioactivity using a sensitive instrument (e.g., NaI(Tl) detector, liquid scintillation counter).
Ensure received material matches the order.
Monitor and survey packing materials before disposal. Treat contaminated materials as waste; otherwise, remove labels and discard.
Record receipt, survey, and wipe test results.
For packages under general license (12VAC5-481-430 G):
-
Inspect for damage; if damaged, notify RSO.
Verify material matches order.
Appendix Q: Leak Test Program
Procedures for leak testing are provided below. Applicants may adopt these or develop alternative methods. Training is required to ensure competency in performing leak tests and analyzing samples.
Training should cover:
-
Principles and practices of radiation protection
Radioactivity measurements, monitoring techniques, and instrument use
Mathematics and calculations for measuring radioactivity
Biological effects of radiation
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
Appropriate on-the-job training consists of the following:
-
observing authorized personnel collecting and analyzing leak test samples
collecting and analyzing leak test samples under the supervision and in the physical presence of an individual authorized to perform leak test and sample analysis
Facilities and Equipment
To ensure achieving the required sensitivity of measurements, leak tests should be analyzed in a low-background area.
Use a calibrated and operable radiation survey instrument to check leak test samples for gross contamination before they are analyzed.
Consider using a NaI(Tl) well counter system with a single or multichannel analyzer to analyze samples obtained from gamma-emitting sources (e.g., Cs-137).
Consider using a liquid scintillation or gas-flow proportional counting system to analyze samples obtained from beta-emitting sources (e.g., Sr-90).
Instrumentation used to analyze leak test samples must be capable of detecting 185 Bq (0.005 μCi) of radioactivity.
If the sensitivity of the counting system is unknown, determine the minimum detectable activity (MDA). The MDA may be determined using the following formula: Note: The MDA equation shown assumes that counting times for the background measurement and for the sample will be equal. MDA equations for non-equal counting times, as well as derivations of equations and discussions of limitations, can be found in “Decommissioning Health Physics --A Handbook for MARSSIM Users,” Eric W. Abelquist, published by Taylor & Francis Group, 2001.
Frequency for Conducting Leak Tests of Sealed Sources
Leak tests will be conducted at the frequency specified in the respective Sealed Source and Device registration certificate.
If a sealed source is not registered, leak tests should be conducted at 6 month intervals, unless a different interval is established during the licensing process.
Leak testing of sealed sources may be required by license condition.
Procedure for Performing Leak Testing and Analysis (on all sealed sources except individual radium-226 (Ra-226) sealed sources)
-
Follow the manufacturer’s instructions for performing the leak test.
For each source to be tested, list identifying information such as sealed source serial number, radionuclide, and activity.
Use a radiation survey meter to monitor exposure.
Use a separate wipe sample (e.g., cotton swab or filter paper) for each source.
Number each wipe to correlate identifying information for each source.
Wear gloves.
Obtain samples at the most accessible area where contamination would accumulate if the sealed source were leaking.
Procedure for Performing Gaseous Emanation Test for Individual Ra-226 Sealed Sources (ANSI/HPS N43.6-1997, “Sealed Radioactive Sources - Classification,” Appendix A, Section A.2.1.5)
-
For each source to be tested, list identifying information, such as sealed source serial number, manufacturer, model number, radionuclide, and activity.
Number each container to correlate information for each source.
Wear gloves.
Put each Ra-226 sealed source into a separate small, gas-tight container with activated carbon or two cotton filters.
-- Leave source in an airtight container for 24 hours.
-- Remove source.
-- Close container.
Measure immediately the activity of the Absorber. (See “Model Procedure for Analysis of Gaseous Emanation and Leak Test” below for (i) how to analyze the absorber, (ii) required records, (iii) leakage determination, and (iv) required response to a leaking source.)
If the wipe test reveals 37 Bq [1 nanocurie (nCi)] or greater of radon or daughter products:
-- Notify the RSO.
-- Immediately withdraw the sealed source from use and store it, dispose of it, or cause it to be repaired in accordance with the requirements.
-- File a report within 5 days of the leak test.
Procedure for Analysis of Leak Test and Gaseous Emanation
-
Select an instrument that is sensitive enough to detect 185 Bq [0.005 μCi] of the radionuclide and ensure that its calibration is current.
Measure the background count rate and record.
Check the instrument’s counting efficiency, using either a standard source of the same radionuclide as the source being tested or one with similar energy characteristics. Accuracy of standards should be within ± 5% of the stated value and traceable to a primary radiation standard, such as those maintained by NIST.
Calculate efficiency of the instrument. For example:
Appendix R: Procedure for Area Surveys
This procedure provides acceptable methods for area surveys. Applicants may either adopt these procedures or develop alternative procedures to meet the requirements of 12VAC5-481-630, 12VAC5-481-750, and 12VAC5-481-1860.
Ambient Radiation Level Surveys
-
Perform surveys of dose rates in locations where:
- Workers are exposed to radiation levels that might result in radiation doses in excess of 10% of the occupational dose limits;
- An individual is working in an environment with a dose rate of 2.5 mrem/hour or more (5 rem/year divided by 2,000 hours/year).
12VAC5-481-720 requires that the TEDE to an individual member of the public from the licensed operation does not exceed 1 mSv (0.1 rem) in a year, and that the dose in any unrestricted area from external sources does not exceed 0.02 mSv (0.002 rem) in any one hour.
Appropriate surveys will be conducted to assure that the requirements of 12VAC5-481-720 are met.
Perform radiation level surveys with a survey meter sufficiently sensitive to detect 0.1 milliroentgen (mR) per hour in the following areas, at the frequency specified:
-
Survey at the end of each day of use all radiopharmaceutical elution, preparation, assay, and administration areas (except patient rooms, which will be surveyed at the end of the therapy instead of on the day of administration) when using radiopharmaceuticals requiring a written directive (e.g., all therapy dosages and any iodine-131 dosage exceeding 30 μCi).
Survey weekly all radionuclide use, storage, and waste storage areas.
If diagnostic administrations are occasionally made in patients’ rooms (e.g., bone scan injections, Tc-99m heart agents), and special care is taken to remove all paraphernalia, those rooms need not be surveyed.
Survey monthly all laboratory areas where only small quantities of gamma-emitting radioactive material are used (< 200 μCi at a time).
Survey quarterly all sealed source and brachytherapy source storage areas.
Notify radiation safety or the RSO immediately of radiation levels that exceed trigger levels. Trigger levels for restricted and unrestricted areas are presented in Table 11.
Table 11. Ambient Dose Rate Trigger Levels
-
Type of Survey Area: Unrestricted — Trigger Level: 0.1 mR/hr
Type of Survey Area: Restricted — Trigger Level: 5.0 mR/hr
Contamination Surveys
Perform contamination surveys using instruments suitable for removable and fixed contamination to identify areas of contamination that might result in doses to workers or to the public.
Removable contamination can be detected and measured by conducting a wipe test of the surface, counted in an appropriate counting instrument, such as a liquid scintillation counter, a sodium iodide or germanium gamma counter, or a proportional alpha/beta counter.
Procedures for contamination surveys:
-
Contamination surveys are performed in areas where unsealed forms of materials are used:
- To evaluate radioactive contamination that could be present on surfaces of floors, walls, laboratory furniture, and equipment;
- After any spill or contamination event;
- When procedures or processes have changed;
- To evaluate contamination of users and the immediate work area, at the end of the day, when licensed material is used;
- In unrestricted areas at frequencies consistent with the types and quantities of materials in use, but not less frequently than monthly;
- In areas adjacent to restricted areas and in all areas through which licensed materials are transferred and temporarily stored before shipment, not less than monthly.
Use methods for conducting surveys for removable contamination that are sufficiently sensitive to detect contamination for those radionuclides in use and for which the most restrictive limits apply, as listed in Tables 11 and 12 for unrestricted areas (e.g., 200 dpm/100 cm² for isotopes of iodine-131 in unrestricted areas).
Removable contamination survey samples will be measured in a low-background area.
The following areas and frequencies will be followed:
- Removable contamination surveys weekly for radiopharmaceutical elution, preparation, assay, and administration areas. If diagnostic administrations are occasionally made in patients’ rooms (i.e., bone scan injections, Tc-99m heart agents, etc.), with special care taken to remove all paraphernalia, those rooms need not be surveyed.
- Removable contamination surveys monthly of laboratory areas where only small quantities of photon-emitting radioactive material are used (<200 microcurie at a time).
- Removable contamination surveys weekly for radionuclide storage and radionuclide waste storage areas.
A radioactive source with a known amount of activity will be used to convert sample measurements (usually in cpm) to dpm.
If contamination is found above the applicable limits, the area should be either decontaminated, shielded, or posted and restricted from use if it cannot be decontaminated.
Table 12. Surface Contamination Levels in Restricted Areas (dpm/100 cm²)
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance for the safe and effective use of radioactive materials in medical settings. It outlines procedures, safety levels, and regulatory requirements to ensure protection of personnel, patients, and the environment.
Description of VAREGS
VAREGS (Veterinary and Radiological Emergency Guidance System) is a framework designed to assist in the management of radiological emergencies involving medical and veterinary applications. It includes protocols for contamination control, dose management, and safety procedures.
Application Process and Guidance
Applicants planning to use radioactive materials must follow established procedures for developing, maintaining, and implementing written directives (WDs). These directives are essential for ensuring compliance with regulatory standards and safety protocols.
Surface Contamination Levels in Unrestricted Areas
-
Sm-153, Yb-169, Lu-177, Au-198: 2,000 Bq / 20,000 dpm
Table 13. Surface Contamination Levels in Unrestricted Areas (per 100 cm²)
Nuclide | Average | Maximum | Removable
U-nat, U-235, U-238, and associated decay products | 83.3 Bq / 5,000 dpm | 250 Bq / 15,000 dpm | 16.7 Bq / 1,000 dpm
Transuranics, I-125, I-129, Ra-226, Ra-228, Pa-231, Ac-227, Th-230 | 1.7 Bq / 100 dpm | 5.0 Bq / 300 dpm | 0.3 Bq / 20 dpm
I-126, I-131, I-133, Ra-223, Ra-224, Sr-90, U-232, Th-nat, Th-232 | 16.7 Bq / 1,000 dpm | 50.0 Bq / 3,000 dpm | 3.3 Bq / 200 dpm
Other alpha emitters | 8.33 Bq / 500 dpm | 25 Bq / 1,500 dpm | 1.67 Bq / 100 dpm
Beta-gamma emitters (excluding those noted above) | 83.3 Bq / 5,000 dpm | 250 Bq / 15,000 dpm | 16.7 Bq / 1,000 dpm
Note: When surface contamination by both alpha- and beta-gamma-emitting nuclides exists, limits for each should apply independently.
Disintegrations per minute (dpm) are determined by correcting counts per minute for background, efficiency, and geometric factors.
Average contaminant measurements should not be averaged over more than 1 m²; for smaller objects, the average should be derived individually.
Radiation levels from beta-gamma contamination should not exceed 0.2 millirad/h at 1 cm for average levels and 1.0 millirad/h at 1 cm for maximum levels, measured through not more than 7 mg/cm² of absorber.
Maximum contamination levels apply to areas of no more than 100 cm².
Removable radioactive material should be determined by wiping the surface with a filter or soft absorbent paper, applying moderate pressure, and measuring the activity on the wipe with an appropriate instrument.
For objects with less surface area, contamination levels should be proportionally reduced, and the entire surface wiped.
Establishing Alternate Trigger Levels for Restricted Areas
Guidance is provided for developing procedures for surveying and controlling contamination using action levels different from those in Tables 11 and 12. These alternate levels may be used without prior approval if:
-
Acceptable unrestricted area trigger levels are implemented (e.g., Table 10).
The action levels maintain occupational doses as low as reasonably achievable (ALARA).
All other regulatory requirements are met, including minimizing contamination and waste, facilitating decommissioning, and protecting the environment.
Alternate Survey Frequency
To determine survey frequency, multiply activity ranges for LOW, MEDIUM, and HIGH categories by the appropriate Modifying Factor to create new mCi ranges. For example, if 30 mCi of I-131 is used, the survey frequency for the hot laboratory would be daily, as I-131 falls into Group 2, with a high activity level and a modifying factor of 1. Table 14. Grouping of Radioisotopes for Alternate Survey Frequency
-
Group 1: Excludes radioisotopes traditionally used in medicine. (e.g., Co-60, Sr-90, I-125, I-126, I-131, I-133, Cs-134, Cs-137, Eu-152, Eu-154, Ir-192, Tl-204)
Group 2: Includes isotopes like C-14, F-18, Na-24, P-32, S-35, Cr-51, Fe-59, Co-57, Co-58, Se-75, Sr-85, Y-90, Mo-99, Tc-99, Rh-105, Pd-103, In-115m, Sn-113, Sm-153, Eu-152, Eu-155, Gd-153, Dy-165, Yb-175, Lu-177, Au-198, Hg-197, Tl-201.
Group 3: Includes H-3, O-15, Rb-87, Tc-99m, Rh-103m, In-113m, Xe-133, Cs-134m.
Table 15. Classification of Laboratories for Alternate Survey Frequency
Survey Frequency Category
Low: <0.1 mCi
Medium: 0.1 mCi to 1 mCi
High: >1 mCi
-
Low: Not less than once a month
Medium: Not less than once per week
High: Not less than once per normal working day
-
Simple storage x 100
Very simple wet operations (e.g., preparation of aliquots) x 10
Normal chemical operations (e.g., analysis, chemical preparations) x 1
Complex wet operations (e.g., multiple operations, complex glass apparatus) x 0.1
Simple dry operations (e.g., powders) and work with volatile compounds x 0.1
Exposure of non-occupational persons (including patients) x 0.1
Dry and dusty operations (e.g., grinding) x 0.01
Contents of Survey Records
Records should include:
-
A description or diagram of the surveyed area
A list of items and equipment surveyed
Specific locations on the survey diagram where wipe tests were taken
Ambient radiation levels with appropriate units
Contamination levels with appropriate units
Make and model number of instruments used
Background levels
Name of the person making the evaluation, recording results, and date
Record contamination levels observed and procedures for incidents involving contamination of individuals, including names, activities, doses, causes, steps taken, times, dates, and signatures.
Licensees must maintain survey records for 3 years after the record is made.
Appendix S: Model Procedure for Developing, Maintaining, and Implementing Written Directives
This model provides acceptable procedures for administrations requiring written directives. You may adopt this model or develop your own to meet the requirements of 12VAC5-481-1720 and 12VAC5-481-1730.
Written Directive Procedures
Guidance for licensees and applicants to develop, maintain, and implement procedures for administrations requiring WDs. This does not restrict other guidance but ensures high confidence that objectives in 12VAC5-481-1730 are met.
The WD must be prepared for any administration of I-131 sodium iodide greater than 1.11 MBq (30 μCi), any therapeutic dose of radiopharmaceutical, or any therapeutic dose of radioactive material. It must contain information per 12VAC5-481-1720 and be retained as per 12VAC5-481-2070.
Discussion
Radioactive material administration can be complex, involving multiple professionals (e.g., oncologists, dosimetrists, therapists). Clear instructions and communication are essential to ensure safety and compliance.
Personnel should seek guidance if unsure about procedures, and verification by at least one qualified person is recommended.
Procedures must be developed for each modality requiring a WD, including verification steps, dose calculations, and documentation of activity or dose.
Specific procedures for doses greater than 30 μCi of Na-131 include verifying patient identity, documenting dose details, and retaining records for 3 years.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This document provides guidance on the safe and effective use of radioactive materials in medical settings, including procedures for sealed sources, dose calculations, verification methods, and reporting requirements.
Description of VAREGS
VAREGS (Veterinary and Radiological Equipment Guidance System) is a framework designed to ensure compliance with regulatory standards for the use of radioactive materials in medical applications. It encompasses procedures for administration, verification, and documentation to promote safety and accuracy.
Application Process and Guidance
The following sections outline the procedures and requirements for licensees to ensure proper use, verification, and reporting of radioactive materials in medical treatments.
Verification Methods and Procedures
Verification methods include:
-
Measuring the activity in the dose calibrator,
Checking the serial number of the sealed sources behind an appropriate shield,
Using color-coded sealed sources,
Using clearly marked storage locations.
Additional Procedures for Sealed Therapeutic Sources and Devices Containing Sealed Therapeutic Sources:
-
Licensees are required under 12VAC5-481-1720 and 12VAC5-481-1730 to have a Written Directive (WD) for certain dose administrations and procedures requiring a WD.
Procedures for meeting these requirements are outlined below.
Complete the WD
Complete the WD in accordance with 12VAC5-481-1720. For temporary implants, before implantation, record the treatment site, radionuclide, and dose. After implantation but before completion of the procedure, record the radionuclide, treatment site, number of sources, total source strength, exposure time (or total dose), and date.
For permanent implants, before implantation, record the treatment site, radionuclide, and total source strength. After implantation but before the patient leaves the post-treatment recovery area, record the treatment site, number of sources implanted, total source strength, and date.
The WD may be maintained in the patient’s chart.
Dose Delivery Verification
To ensure the dose is delivered according to the WD, the AU (and the neurosurgeon for GSR therapy) must date and sign the treatment plan, indicating approval and providing sufficient information and direction.
Imaging and Position Verification
For sealed sources inserted into the patient’s body, radiographs or comparable images (e.g., computerized tomography) will be used to verify the position of dummy sources and calculate the administered dose before administration.
In some brachytherapy procedures, fixed geometry applicators (e.g., appliances or templates) may be used to establish source location and calculate exposure time or total dose, potentially eliminating the need for radiographs.
Dose Calculation Checks
Dose calculations will be checked before therapy administration by a qualified person, preferably one who did not perform the original calculations. Methods include:
-
Examining computer printouts for correct input data (source strength, positions),
Verifying correct data transfer into therapy consoles (channel numbers, source positions, treatment times),
Verifying manual calculations for arithmetic errors, data transfer, use of nomograms, and relevant data, and comparing manual and computer-generated doses.
Post-Implantation Recording
After implantation but before procedure completion, record on the WD:
-
Radionuclide,
Treatment site,
Number of sources,
Total source strength,
Exposure time or total dose.
For example, after permanent implant brachytherapy, the AU should record the actual number of sources and total source strength. The WD may be kept in the patient’s chart.
Acceptance Testing
Acceptance testing of treatment planning or dose calculation computer programs will be performed by a qualified person (e.g., AMP) before first use. Each program will be assessed based on specific needs. Reassessment occurs after source replacement or if measurements differ by more than 5% from previous calibration.
Independent Calibration Checks
Independent checks on full calibration measurements will be performed within 30 days, either by someone who did not perform the calibration, using a different dosimetry system, or by a properly instructed AMP or physician using thermoluminescence dosimetry.
GSR Verification
Particular emphasis will be on verifying that stereoscopic frame coordinates match between the patient’s skull and the treatment plan.
Emerging Technologies
For emerging technologies (e.g., Yttrium-90 Microsphere Brachytherapy, Leksell Gamma Knife Perfexion), the licensee should review guidance on the NRC Medical Uses Licensee Toolkit Web page to ensure the WD contains all necessary components. Link: https://www.nrc.gov/materials/miau/med-use-toolkit/emerg-licensed-med-tech.html
Teletherapy Output Measurement
A physical measurement of teletherapy output will be made under applicable conditions before administering the first fractional dose if:
-
Field sizes or treatment distances fall outside the range of the most recent full calibration,
Transmission factors for beam-modifying devices (excluding certain materials) were not measured in the last calibration.
Weekly Chart Checks
A qualified person under supervision of an AU (e.g., AMP, dosimetrist, physician, therapist) will perform weekly chart checks to detect errors in dose administration or changes in the WD or treatment plan.
Treatment Planning Computer Media
Computer systems storing treatment parameters on removable media must label each card with the patient’s name and ID. Media may be reused and relabeled per manufacturer instructions.
Review of Administrations Requiring a Written Directive
Periodic reviews of each program area (radiopharmaceutical therapy, brachytherapy, teletherapy, gamma stereotactic radiosurgery, emerging technologies) will be conducted. The number of cases sampled will follow statistical acceptance principles, ensuring representation of each modality.
Reviewers should not review their own work; if unavoidable, a team approach is recommended. Findings will be reviewed regularly to ensure procedures for WD-required administrations are effective.
For each case, deviations, causes, and preventive actions will be documented.
Reports of Medical Events
Notify VDH by telephone no later than the next calendar day after discovery of a medical event. Submit a written report within 15 days, as required by 12VAC5-481-2080. Also notify the referring physician and patient.
Telephone numbers:
-
Daytime: (804) 864-8150
After-hours: (804) 674-2400 or (800) 468-8892
Appendix T: Procedure for Safe Use of Licensed Material
This procedure provides acceptable methods for the safe use of unsealed licensed material. You may adopt this or develop your own to meet 12VAC5-481-630, 12VAC5-481-720, and 12VAC5-481-1850 requirements.
-
Wear laboratory coats or protective clothing at all times where radioactive materials are used.
Wear disposable gloves when handling radioactive materials.
Monitor hands for contamination after procedures or before leaving the area using an appropriate survey instrument.
Use syringe shields for reconstitution and administration, except when contraindicated (e.g., recessed veins, infants). In such cases, use remote delivery methods.
Do not eat, store food, drink, smoke, or apply cosmetics where licensed materials are stored or used.
Wear personnel monitoring devices if required, as prescribed by the RSO. Store devices in a designated low-background area when not in use.
Wear extremity dosimeters if required.
Dispose of radioactive waste only in designated, labeled, shielded receptacles.
Never pipette by mouth.
Wipe-test storage, preparation, and administration areas weekly for contamination; decontaminate if necessary.
Survey daily with a radiation detection meter all areas of licensed material use, including generator storage, kit prep, and injection areas. Decontaminate if needed.
Store radioactive solutions in shielded, labeled containers.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This section provides an overview of the guidelines and regulatory requirements for the medical use of radioactive materials, including radiopharmaceuticals, in diagnostic and therapeutic settings.
Description of VAREGS
VAREGS (Virginia Radiation Emergency Guidelines) are designed to ensure safe handling, storage, and disposal of radioactive materials used in medical practices, complying with state and federal regulations.
Application Process and Guidance
This section outlines the procedures for obtaining authorization to use radioactive materials, including licensing, site requirements, and operational protocols.
Appendices
Radiopharmaceutical Multi-Dose Diagnostic and Therapy Vials
Radiopharmaceutical multi-dose diagnostic and therapy vials must be labeled in accordance with 12VAC5-481-880 and 12VAC5-481-1850.
-
Mark the label with the radionuclide, the activity, the date for which the activity is estimated, and the kind of materials (i.e., radiopharmaceutical).
Syringes and unit dosages must be labeled in accordance with 12VAC5-481-880 and 12VAC5-481-1850.
Mark the label with the radionuclide, the activity, the date for which the activity is estimated, and the kind of materials (i.e., radiopharmaceutical).
If the container holds less than the quantities listed in 12VAC5-481-3700, the syringe or vial need only be labeled to identify the radioactive drug (12VAC5-481-1850).
To avoid mistaking patient dosages, label the syringe with the type of study and the patient’s name.
For prepared dosages, assay each patient dosage in the dose calibrator (or instrument) before administering it (12VAC5-481-1820).
Do not use a dosage if it does not fall within the prescribed dosage range or if it varies more than ±20% from the prescribed dosage, except as approved by an authorized user.
When measuring the dosage, you need not consider the radioactivity that adheres to the syringe wall or remains in the needle.
Check the patient’s name and identification number and the prescribed radionuclide, chemical form, and dosage before administering.
If the prescribed dosage requires a written directive, the patient’s identity must be verified, and the administration must be in accordance with the written directive (12VAC5-481-1730).
Always keep flood sources, syringes, waste, and other radioactive material in shielded containers.
Secure all licensed material when not under the constant surveillance and immediate control of the authorized user(s).
Release of Patients or Human Research Subjects Administered Radioactive Materials
12VAC5-481-1870, ‘Release of Individuals Containing Unsealed Radioactive Material or Implants Containing Radioactive Material,’ of 12VAC5-481 ‘Virginia Radiation Protection Regulations,’ Part VII ‘Use of Radionuclides in the Healing Arts,’ permits a licensee to “authorize the release from its control any individual who has been administered unsealed radioactive material or implants containing radioactive material if the total effective dose equivalent to any other individual from exposure to the released individual is not likely to exceed 5 mSv (0.5 rem).”
Additionally, 12VAC5-481-1870 requires that “Licensees shall provide the released individual, or the individual's parent or guardian, with instructions, including written instructions, on actions recommended to maintain doses to other individuals as low as is reasonably achievable if the total effective dose equivalent to any other individual is likely to exceed 100 mrem (1 mSv).”
Regulatory Guide (RG) 8.39, “Release of Patients Administered Radioactive Materials,” provides guidance for releasing patients under NRC 10 CFR 35.75. Licensees should use the most current revision of RG 8.39 when developing procedures for the release of patients who are administered radioactive materials.
Regulatory Guide 8.39 can be accessed at the following webpage: https://www.nrc.gov/reading-rm/doc-collections/reg-guides/occupational-health/rg/division-8/division-8-2.html
The guide contains the most updated guidance on the following subjects:
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Release of Patients Based on the Administered Activity.
Release of Patients Based on the Measured Dose Rate.
Release of Patients Based on Patient-Specific Dose Calculations.
Activities and Dose Rates That Require Instructions.
Additional Instructions for Release of Patients Who Could be Breastfeeding after Their Release.
Content of Instructions.
Discussions on the Administration of Radiopharmaceuticals.
Patient Acknowledgement of Instructions.
Death of a Patient Following Radiopharmaceutical or Implants Administrations.
Guidance for Mobile Medical Services
Mobile medical service providers must comply with all applicable sections of 12VAC5-481 ‘Virginia Radiation Protection Regulations,’ Part VII ‘Use of Radionuclides in the Healing Arts,’ as well as DOT regulations regarding approved source holders, placement of sources in approved containers prior to transport, and hazardous materials training.
For example, mobile medical service providers offering remote afterloaders must comply with 12VAC5-481-2040.
Type and Location of Use
In general, there are two types of mobile medical service:
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One type is to transport and use radioactive material within a transport vehicle (e.g., in-coach/van use).
A second type is to transport radioactive material to a client’s facility and use within a client’s facility by the mobile medical service’s employees.
Additionally, a licensee operating at a fixed location may contract for use of a mobile coach on a temporary (e.g., 3 months) or permanent basis under their own VDH license.
This is traditionally done when a licensee is in the process of constructing new nuclear medicine facilities or when the licensee starts a Positron Emission Tomography (PET) program.
This is not a mobile medical service, since the mobile coach will be parked at the fixed location of use and operated by the non-mobile licensee.
An amendment to add this additional area of use at their address of use should be requested as described herein.
For mobile medical service, which includes material use by the service provider, the service provider must apply for full service authorization.
Service providers who only transport and store a therapy device need only apply for authorization for possession and transportation of the radioactive material.
In this case, when the service provider is only transporting the therapy device for use, the client must possess a license for medical use of the radioactive material.
Additionally, in this case, the client is authorized to provide the patient treatments and is responsible for all aspects of the radioactive material use and patient treatments upon transfer of the radioactive material to their possession.
PET mobile medical service providers that use a “quiet room” and/or a patient waiting area in the client’s facility may either be authorized for “in-van or trailer use only” or “transport and use,” depending on whether the PET patients meet the criteria for release while they are in the “quiet room.”
If they do not, then the “quiet room” is an area of use for the mobile medical service licensee and should be under their control while onsite.
In addition, for mobile nuclear medicine and PET imaging, the licensee should consider the possibility of using the client’s bathroom dedicated for their use for PET patients and finding the bathroom with low levels of radioactive contamination during the end-of-day surveys.
In this event, the mobile licensee must provide direction to the client for restricting access to the bathroom until follow-up surveys show the bathroom free of contamination (e.g., post and close off the patient bathroom for a designated period of time to allow for radioactive decay).
The mobile medical service provider should also survey “quiet rooms,” provided for their use at the client’s site, for contamination and radiation levels, to ensure that public dose limits are not exceeded and that these areas are left free of contamination following use.
For all types, licensed activities must be conducted in accordance with the rules for compliance with 12VAC5-481-1880, which states that the licensee will obtain a letter signed by the management (i.e., chief executive officer or delegate) of each of its clients for which services are rendered.
The letter will permit the use of radioactive material at the client’s address and will clearly delineate the authority and responsibility of each entity.
This agreement must be applicable for the entire period of time over which the service is to be provided.
The letter will be retained for 3 years after the last provision of service, as required by 12VAC5-481-1880 and 12VAC5-481-2070.
Additionally, as required by 12VAC5-481-1880, the licensee will survey to ensure compliance with the requirements in 12VAC5-481 ‘Virginia Radiation Protection Regulations,’ Part IV ‘Standards for Protection Against Radiation’ (e.g., ensure that all radioactive material, including radiopharmaceuticals, sealed sources, and all associated wastes have been removed) before leaving a client’s address.
The location of use for mobile medical services is of two basic types:
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One type of location is the base location where licensed material is received, stored, and, sometimes, used.
The other type is the temporary job site at client facilities.
The following section describes the required information necessary for base locations and temporary job sites.
Base Location and Client Site(s)
The base location (e.g., the central radiopharmaceutical laboratory or the storage location for the remote afterloader) for the mobile medical service must be specified.
The base facility may be located in a medical institution, non-institutional medical practice, commercial facility, or the mobile coach/van.
Applicants must specify in what type of facility the proposed base facility is located.
A mobile licensee cannot provide a service to a private practice (non-licensee) located within a licensed medical institution (e.g., hospital).
As required by 12VAC5-481-450 and 12VAC5-481-500, applicants must submit a detailed description and diagram(s) of the proposed base facility and associated equipment in accordance with Items 8.1 through 8.5 of this VAREG.
The description and diagram of the proposed facility must demonstrate that the building (or coach/van) is of adequate construction and design to protect its contents from the elements (e.g., high winds, rain), ensure security of licensed material to prevent unauthorized access (e.g., control of keys), and ensure that radiation levels in unrestricted areas are in compliance with 12VAC5-481-720.
Include a diagram showing the location of the licensed material, receipt, and use areas, and identify all areas adjacent to restricted areas, including areas above and below the restricted areas.
For storage locations within the coach/van, the description of the coach/van must address radiation levels in the driver’s compartment to demonstrate compliance with 12VAC5-481-640.
• Applicants may request multiple base locations.
• Radioactive material must be delivered only to a facility licensed to receive the type of radioactive material ordered.
o For diagnostic uses, the mobile medical service provider may list a portion of a client’s site as a base location with a clear, written agreement with the facility owner addressing security against unauthorized removal and establishing responsibility for the licensed material.
• This agreement should indicate the receipt and storage location and confirm that the mobile medical service provider will have sole access to the receipt/storage location and will be granted access to the facilities to remove any licensed material or decontaminate the facility, as necessary.
• In this case, the mobile medical service provider may arrange to have licensed material delivered to the base location without their personnel present.
• Base locations can include the use of a mobile coach/van.
• When the base facility is in the coach/van, and there is no permanent structure for storage, the service must provide for the following: - Secured off-street parking under licensee control. - Public rights-of-way are not considered part of the address of the client. - Secured storage facilities available for storage of radioactive material and waste.
Guidance for Medical Use of Radioactive Material REVISION 4 JANUARY 14, 2022 EXECUTIVE SUMMARYThis document provides guidance on the proper procedures and safety measures for the medical use of radioactive materials, including transportation, storage, and handling protocols, as well as supervision and emergency procedures.
Introduction and PurposeThe purpose of this guidance is to ensure safe and compliant use of radioactive materials in medical settings, particularly for mobile medical services. It outlines requirements for delivery, storage, supervision, and emergency response to protect personnel and the public.
Description of VAREGSVAREG refers to the Virginia Radioactive Emergency Guidelines, which establish standards for the safe handling and transportation of radioactive materials in medical applications. These guidelines include specific requirements for facility construction, security, and radiation protection measures.
Application Process and Guidance Delivery and Storage of Radioactive Material-
Delivery to Coach/Van: Radioactive material can be delivered directly to the coach/van only if it is occupied by licensee's personnel at the time of delivery.
Diagnostic Uses Only: For mobile medical service providers, licensed material may be delivered to a parked van or trailer at a client site if the provider submits information demonstrating personnel will be present to accept delivery and ensure security.
Base Location: The provider may list a portion of a client’s site as a base location with a written agreement addressing security and responsibility for the licensed material. This agreement should specify receipt and storage locations, access rights, and responsibilities for removal or decontamination.
Residential Area Base Facility:
- Justification for using a private residence rather than a commercial location.
- Documentation of agreement between residence owner and licensee.
- Access provisions for decontamination if necessary.
- Program description demonstrating compliance with 12VAC5-481-720.
- Verification that the area does not contain residential quarters.
Perform surveys to ensure exposure rates do not exceed 2 mrem/hour or TEDE does not exceed 100 mrem/year. Restrict access if limits are exceeded using cones, ropes, and signs.
Transport within Client FacilitiesProvide detailed descriptions and diagrams of the use facility, including equipment placement, receipt, and use areas, ensuring construction protects contents from elements and maintains security. Confirm full control of treatment rooms during radioactive material use and compliance with regulations.
Delivery When Staff Are Not Present-
Client Agreement: Obtain commitment from the client that radioactive material will be secured against unauthorized access.
Storage Diagram: Provide diagram if storage is separate from use location.
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Client Site Listing: List all medical institutions, hospitals, or clinics involved, with addresses.
Facility Drawings:
- For treatments like high dose-rate remote afterloader, provide drawings showing device location relative to roads, structures, and public access points.
- Confirm device is on client-controlled property via signed agreement.
- Show protection measures against vehicular traffic, such as barriers or location away from traffic.
- Describe emergency lighting system that activates on power loss, providing sufficient light for emergency procedures.
Remote Afterloader Device Installation and Checks:
- Provide initial installation records and function checks as per 12VAC5-481-2040.
- For transport-only services, ensure clients are licensed, trained, and responsible for device operation.
- Ensure no responsibility assumption is implied by the mobile service in client agreements.
- Transfer of control records must be maintained per 12VAC5-481-570 and 12VAC5-481-571, with signed receipts retained for 3 years.
Designate an authorized user to supervise mobile medical staff at each location. The supervisor must periodically observe staff or ensure policies are followed. Staff must be instructed on radiation protection, directives, and license conditions. Notify VDH within 30 days of adding new supervising personnel.
Training for Individuals Working in or Frequenting Restricted AreasDrivers, technologists, and therapists must be trained in transportation regulations, emergency procedures, and applicable regulations (12VAC5-481-1960, 12VAC5-481-2010, 12VAC5-481-2040, 12VAC5-481-2270). Training includes VDH and DOT regulations, shielding, ALARA, and basic radiation protection.
Survey Instrument and Dose Measurement Instrument ChecksCheck survey instruments with a dedicated check source before use at each address. Check dose measurement instruments daily or before use. Verify all transported equipment functions properly before use.
Order and Receipt of Radioactive MaterialRadioactive material will be delivered by a supplier to the base location or licensed client address. Exceptions may be requested for dedicated locations within non-licensed facilities. Delivery to unoccupied coach/van is prohibited; alternatively, pick up from the supplier en route to client sites.
Emergency ProceduresDevelop, implement, and maintain emergency procedures per 12VAC5-481-630. Include typical response times of RSO and AU, and procedures for accidents such as vehicle collisions, wind, water, or fire damage.
The transportation emergency response plan should cover actions by headquarters and on-scene hazardous material personnel, and be accessible to all relevant staff. The plan must include:
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Emergency Contact Number: 24-hour number for mobile medical service emergency response personnel.
Virginia Department of Health Contact: Radioactive Materials Program, during office hours: 7:30 a.m. to 4:30 p.m., (804) 864-8150; after hours: [Insert after-hours contact info].
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
(Content not provided in the raw text, placeholder for introduction and purpose section.)
Description of VAREGS
(Content not provided in the raw text, placeholder for description of VAREGS.)
Application Process and Guidance
(Content not provided in the raw text, placeholder for application process and guidance.)
Appendices
Procedures for Transporting Radioactive Material
(Extracted procedures and considerations for transportation.)
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Procedures include:
Procedures for restricting access to the transport vehicle until surveys have been made to determine if any radiological hazards exist.
Procedures for retrieving and securing any radioactive material, including a sealed source that may become detached and/or dislodged to the extent that a radiological hazard is created, which may require one or more emergency shielded source containers.
Predetermined (calculated) exposure rates for an unshielded therapy source (if applicable) as a function of distance for use in controlling the exposures of emergency response personnel to the maximum extent possible under various emergency response scenarios.
Preplanned decontamination procedures, including ready access to all necessary materials.
A calibrated, operational survey meter maintained in the cab of the transporting vehicle, which may be used at an accident scene for conducting surveys.
Security of the transport vehicle against unauthorized access, including the driver’s compartment.
Transportation Procedures
Develop, document, and implement procedures to assure that the following take place:
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[b]Radioactive material is transported in accordance with DOT 49 CFR Parts 170-189.[/b]
Procedures will include: Use of approved packages; Use of approved labeling; Conduct of proper surveys; Complete and accurate shipping papers; Bracing of packages; Security provisions; and Written emergency instructions.
Radioactive Waste Management
If waste will be stored in coach/vans, the vehicle will be properly secured and posted as radioactive material storage locations.
You will ensure that the coach/van will be secured against unauthorized access and that the waste storage location will be posted as a radioactive material storage area.
Develop, document, and implement final waste disposal procedures in accordance with Item 10 of this guide.
Excreta from individuals undergoing medical diagnosis or therapy with radioactive material may be disposed of without regard to radioactivity if it is discharged into the sanitary sewerage system, in accordance with 12VAC5-481-930.
However, collecting excreta from patients in a coach/van restroom with a holding tank is not considered direct disposal into the sanitary sewerage system. If a restroom facility is provided in the coach/van for patient use, submit the following information for agency review:
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A description of the structure of the tank holding facility and the location of the tank in relation to members of the public, workers in the coach/van, and the driver of the coach/van; a description of procedures to assess the tank for possible leakage and a description of any restroom ventilation if any I-131 will be held in the tank.
A description of procedures to ensure doses to occupational workers and members of the public will not exceed the exposure limits in 12VAC5-481-640 and 12VAC5-481-720, that the external surfaces of the coach/van do not exceed 2 mrem/hour, and that doses to members of the public and workers are maintained ALARA, including considerations of external dose rates in the restroom caused by the proximity of the holding tank to the toilet.
A description of procedures for emptying and disposing of the contents of the holding tank, including the frequency of disposal, who empties the tank into the sanitary sewer system, and the location of disposal into the sanitary sewer, including precautions taken to minimize contamination in this process.
Mobile Medical Services With Remote Afterloader Devices
Because the movement of the remote afterloader device from one location to another increases the risk of electro-mechanical component failures or misalignments, it is important that proper operation of the device be fully checked after each such relocation.
Therefore, develop, document, and implement the following procedures to determine if a device is operating properly before the commencement of patient treatments:
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[b]Safety checks conducted on a remote afterloader device and facility.[/b]
The procedure must include the periodic spot checks and the additional spot checks required by 12VAC5-481-2040 before use at each address of use. Additionally, the procedure should include provisions for prompt repair of any system not operating properly. [b]The pretreatment operational function checks after each device move should include a review of any device alarm or error message and, if necessary, a resolution of problems indicated by such messages.[/b]
Such tests should be performed in accordance with written procedures. [b]Maintain records, as described in 12VAC5-481-2070, showing the results of the above safety checks for agency inspection and review for a period of 3 years.[/b] [b]Perform surveys of the source housing and areas adjacent to the treatment room following relocation of a HDR unit.[/b]
These surveys should include the source housing with the source in the shielded position and all areas adjacent to the treatment room with the source in the treatment position.
Appendix W: Summary of DOT Requirements for Transportation of Type A or Type B Quantities of Licensed Material
Licensed material must be transported in accordance with VDH and DOT regulations. The major areas in the DOT regulations that are most relevant for transportation of Type A or Type B quantities of licensed material are:
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[b]Table of Hazardous Materials and Special Provisions 49 CFR 172.101[/b]: Hazardous materials table, list of hazardous substances, and reportable quantities.
[b]Shipping Papers 49 CFR 172.200-204[/b]: Applicability, general entries, description of hazardous material on shipping papers, additional description requirements, shipper’s certification.
[b]Package Markings 49 CFR 172.300, 172.301, 172.303, 172.304, 172.310, 172.324[/b]: Applicability, general marking requirements for non-bulk packagings, prohibited marking, marking requirements, radioactive material, hazardous substances in non-bulk packaging.
[b]Package Labeling 49 CFR 172.400, 172.401, 172.403, 172.406, 172.407, 172.436, 172.438, 172.440[/b]: General labeling requirements, prohibited labeling, Class 7 (radioactive) material, placement of labels, label specifications, radioactive white-I label, radioactive yellow-II label, radioactive yellow-III label.
[b]Placarding of Vehicles 49 CFR 172.500, 172.502, 172.504, 172.506, 172.516, 172.519, 172.556[/b]: Applicability of placarding requirements, prohibited and permissive placarding, general placarding requirements, providing and affixing placards: highway, visibility and display of placards, general specifications for placards, RADIOACTIVE placard.
[b]Emergency Response Information 49 CFR 172.600, 172.602, 172.604[/b]: Applicability and general requirements, emergency response information, emergency response telephone number.
[b]Training 49 CFR 172.702, 172.704[/b]: Applicability and responsibility for training and testing, training requirements.
[b]Security Plans 49 CFR 172.800, 172.802[/b]: Purpose and applicability, components of a security plan.
[b]Shippers - General Requirements for Shipments and Packaging 49 CFR 173.403, 173.410, 173.411, 173.412, 173.413, 173.415, 173.416, 173.433, 173.435, 173.441, 173.471, 173.475, 173.476[/b]: Definitions, general design requirements, industrial packages, additional design requirements for Type A packages, requirements for Type B packages, authorized Type A packages, authorized Type B packages, requirements for determining A1 and A2 values for radionuclides and for the listing of radionuclides on shipping papers and labels, table of A1 and A2 values for radionuclides, radiation level limit, requirements for U.S. NRC-approved packages, quality control requirements prior to each shipment of Class 7 (radioactive) materials, approval of special form Class 7 (radioactive) materials.
[b]Carriage by Public Highway 49 CFR 177.816, 177.817, 177.834(a), 177.842[/b]: Driver training, shipping paper, general requirements (packages secured in a vehicle), Class 7 (radioactive) material.
For additional transportation information visit the DOT’s Office of Hazardous Materials Safety web site at http://hazmat.dot.gov/
Appendix X: Procedure for Waste Disposal by Decay-In-Storage, Generator Return, and Licensed Material Return
This procedure provides acceptable methods for waste disposal. Note that some short half-life radionuclide products [e.g., technetium (Tc)-99m/molybdenum (Mo)-99 generator columns and some yttrium (Y)-90 microspheres] may contain long half-life contaminants that may preclude disposal by decay-in-storage and may require disposal by alternate methods, such as return to the manufacturer.
Applicants may either adopt these procedures or develop alternative procedures to meet the requirements of 12VAC5-481-630, 12VAC5-481-910, and 12VAC5-481-1890. Procedure for Decay-In-Storage
12VAC5-481-1890 describes the requirements for decay-in-storage. Storage should be designed to allow for segregation of wastes with different half-lives (e.g., multiple shielded containers). Containers should have shielded covers to maintain occupational exposure at ALARA levels. Storage areas must be in a secure location.
• Only short-lived waste (physical half-life of less than or equal to 120 days) may be disposed of by DIS.
• Waste should be stored in suitable well-marked containers, and the containers should provide adequate shielding.
• Liquid and solid wastes should be stored separately.
• If possible, use separate containers for different types of waste; e.g., needles and syringes in one container, other injection paraphernalia such as swabs and gauze in another, and unused dosages in a third container.
• Because the waste will be surveyed with all shielding removed, the containers in which the waste will be stored should be properly shielded.
Guidance for Medical Use of Radioactive Material
REVISION 4 JANUARY 14, 2022
EXECUTIVE SUMMARY
Introduction and Purpose
This section provides an overview of the purpose and scope of the guidance document, outlining the regulatory framework and safety considerations for the medical use of radioactive materials.
Description of VAREGS
VAREGS (Virginia Radioactive Material and Equipment Guidance System) is a comprehensive program designed to ensure safe handling, disposal, and transportation of radioactive materials used in medical settings.
Application Process and Guidance
This section details the procedures for applying for licenses, returning generators, disposing of liquids, and recordkeeping requirements. It emphasizes compliance with federal and state regulations to maintain safety and legal adherence.
Appendices
Includes detailed tables, checklists, and procedural templates to assist licensees in maintaining compliance and documenting activities related to radioactive material management.
Disposal of Radioactive Waste
Disposed of must not provide any radiation shielding for the material.
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When the container is full, seal it, and attach an identification tag that includes the date sealed and the longest-lived radionuclide in the container.
The container may then be transferred to the decay-in-storage area.
When large quantities are held for decay-in-storage (DIS), measurable activities may be present even after many half-lives, and persons performing surveys should be aware of the potential for measurable radiation.
The contents of the container should be allowed to decay for a period of time after which it is expected that the radiation levels would not be distinguishable from background. The period depends on both the half-life of the radionuclide(s) and the original amount present.
Prior to disposal as in-house waste, monitor and record the results of monitoring of each container as follows:
Use a survey instrument appropriate for the type and energy of the radiation being measured.
Check the radiation detection survey meter for proper operation and current calibration status.
Monitor in a low-level radiation (<0.05 millirem per hour) area away from all sources of radioactive material, if possible.
Remove any shielding from around the container or generator column.
Monitor, at contact, all surfaces of each individual container.
Remove or deface any radioactive material labels (unless the containers will be managed as biomedical waste after they have been released from the licensee as described in 12VAC5-481-1890).
Discard as in-house waste only those containers that cannot be distinguished from background. Containers may include trash bags full of waste, generator columns, and biohazard (needle) boxes.
Record the disposal date, the survey instrument used, the background dose rate, the dose rate measured at the surface of each waste container, and the name of the individual who performed the disposal.
Containers that can be distinguished from background radiation levels must be returned to the storage area for further decay or transferred to an authorized radioactive material recipient.
Procedure for Returning Generators to the Manufacturer
Used Mo-99/Tc-99m, Sr-82/Rb-82, or Ge-68/Ga-68 generators may be returned to the manufacturer. This permission does not relieve licensees from the requirement to comply with VDH transportation requirements in 12VAC5-481-2980 and 12VAC5-481, ‘Virginia Radiation Protection Regulations,’ Part XIII ‘Transportation of Radioactive Material,’ and DOT regulations (incorporated by reference).
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Retain the records needed to demonstrate that the package qualifies as a DOT Specification 7A container.
Assemble the package in accordance with the manufacturer’s instructions.
Perform the dose rate and removable contamination measurements.
Label the package and complete the shipping papers in accordance with the manufacturer’s instructions.
Retain records of receipts and transfers in accordance with 12VAC5-481-100 and 12VAC5-481-571.
Procedure for Return of Licensed Material to Authorized Recipients
Perform the following steps when returning licensed material to authorized recipients:
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In accordance with 12VAC5-481-570, confirm that persons are authorized to receive radioactive material prior to transfer (e.g., obtain a copy of the transferee’s VDH, NRC, or another Agreement State license that authorizes the radioactive material).
Retain the records needed to demonstrate that the package qualifies as a DOT Specification 7A container.
Assemble the package in accordance with the manufacturer’s instructions.
Perform the dose rate and removable contamination measurements.
Label the package and complete the shipping papers in accordance with the manufacturer’s instructions.
Retain records of receipts and transfers in accordance with 12VAC5-481-100 and 12VAC5-481-571.
Model Procedure for Disposal of Liquids into Sanitary Sewerage
Confirm that the sewer system is a public system, not a private sanitary sewer, septic system, or leach field.
Confi rm that the liquid waste being discharged is soluble (or is biological material that is readily dispersible) in water.
Calculate the amount of each radionuclide that can be discharged by using the information from prior, similar discharges and the information in 10 CFR Part 20, Appendix B.
Make sure that the amount of each radionuclide does not exceed the monthly and annual discharge limits specified in 10 CFR 20.2003(a)(4) and 10 CFR Part 20, Appendix B, Table 3.
If more than one radionuclide is released, the sum of the ratios of the average monthly discharge of each radionuclide to the corresponding limit for each radionuclide in 10 CFR Part 20, Appendix B, Table 3 must not exceed unity.
Confirm that the total quantity of licensed material and other radioactive material released into the sanitary sewerage system in a year does not exceed 185 gigabecquerel (GBq) [5 Curies (Ci)] of tritium (H-3), 37 GBq [1 Ci] of carbon-14 (C-14), and 37 GBq [1 Ci] of all other radioactive materials combined.
Note: 10 CFR 20.2003(a)(4) further limits the disposal of H-3, C-14, and “other radioactive material” to the limits noted above even when sewerage totals determined under 10 CFR 20.2003(a)(3), and as noted in the bullet above, may have allowed a higher sanitary sewerage disposal activity.
Record the date, radionuclide(s), estimated activity of each radionuclide, location where the material is discharged, and the name of the individual discharging the waste.
Liquid waste should be discharged only via designated sinks, toilets, or other release points.
Discharge liquid waste slowly, to minimize splashing, with water running to be sure that the material moves out of the sink and into the sewer system.
Survey the sink and surrounding work surfaces to confirm that no residual material or contamination remained in the sink or on work surfaces.
Decontaminate all areas or surfaces if found to be contaminated.
Maintain records of releases of licensed material to the sanitary sewer system. These records should include, for each release, the date, radionuclide(s), estimated activity of each radionuclide, location where the material is discharged, and the initials of the individual discharging the waste.
For the licensed facility as a whole, records should be maintained of the quantity and concentration of radionuclides that are released into the sewer system that demonstrate compliance with the regulatory limits for total quantity released and concentrations released by the licensed facility.
Appendix Y Recordkeeping Requirements
Record Survey Requirement
Record Requirement
Retention Period
Results of surveys and calibrations
12VAC5-481-750; 12VAC5-481-900; 12VAC5-481-1000
3 years
Results of surveys to determine dose from external sources
12VAC5-481-1000
Duration of license
Results of measurements and calculations used to determine individual intakes
12VAC5-481-1000
Duration of license
Results of air samplings, surveys, and bioassays
12VAC5-481-830; 12VAC5-481-1000
Duration of license
Results of measurements and calculations used to evaluate the release of radioactive effluents to the environment
12VAC5-481-1000
Duration of license
Determination of prior occupational dose
12VAC5-481-1020
Duration of license
Planned special exposure
12VAC5-481-690; 12VAC5-481-1030
Duration of license
Individual monitoring results
12VAC5-481-760; 12VAC5-481-1040
Duration of license
Dose to individual members of the public
12VAC5-481-730; 12VAC5-481-1050
Duration of license
Waste Disposal
12VAC5-481-910; 12VAC5-481-1060
Duration of license
Receipt, transfer and disposal of radioactive material
12VAC5-481-570; 12VAC5-481-100; 12VAC5-481-571
Duration of possession and 3 years thereafter
Authority and responsibilities of radiation protection program
12VAC5-481-1700; 12VAC5-481-2070
5 years
Radiation protection program changes
12VAC5-481-1700; 12VAC5-481-2070
5 years
Written directives
12VAC5-481-1720; 12VAC5-481-2070
3 years
Calibrations of instruments used to measure activity of unsealed radioactive material
12VAC5-481-1800; 12VAC5-481-2070
3 years
Radiation survey instruments calibrations
12VAC5-481-1810; 12VAC5-481-2070
3 years
Dosages of unsealed radioactive material for medical use
12VAC5-481-1820; 12VAC5-481-2070
3 years
Leak tests and inventory of sealed sources and brachytherapy sources
12VAC5-481-1840; 12VAC5-481-2070
3 years
Surveys for ambient radiation exposure rate
12VAC5-481-1860; 12VAC5-481-2070
3 years
Release of individuals containing unsealed radioactive material or implants containing radioactive material
12VAC5-481-1870; 12VAC5-481-2070
3 years
Appendix Z Reporting Requirements
Revision 4 January 14, 2022
Event Telephone Notification
Written Report
12VAC5-481 REQUIREMENT
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Reports to individuals or workers: None; Annually
Reports to former individual workers: None; Upon request
Reports to worker terminating employment: None; Upon request
Theft or loss of material: Immediate; 30 days
Whole body dose greater than 0.25 Sv (25 rems): Immediate; 30 days
Extremity dose greater than 2.5 Sv (250 rems): Immediate; 30 days
Whole body dose greater than 0.05 Sv (5 rems) in 24 hours: 24 hours; 30 days
Extremity dose greater than 0.5 Sv (50 rems) in 24 hours: 24 hours; 30 days
Doses in excess of specified criteria: None; 30 days
Levels of radiation or concentrations of radioactive material in excess of specified criteria: None; 30 days
Planned special exposure: None; 30 days
Report to individuals of exceeding dose limits: None; 30 days
Report of individual monitoring: None; Annually
Event that prevents immediate protective actions necessary to avoid exposure: Immediate; 30 days
Equipment is disabled or fails to function as designed when required: 24 hours; 30 days
Unplanned fire or explosion affecting licensed material or equipment: 24 hours; 30 days
Licensee permits individual to work as AU, ANP, or AMP: None; 30 days