Compliance Analysis Overview

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VIRGINIA DEPARTMENT OF JUVENILE JUSTICE Confidentiality Agreement

I ______________________ (Receiving Party) hereby enter into this Confidentiality Agreement with the Virginia Department of Juvenile Justice (Department) for the purpose of preventing the unauthorized disclosure of Confidential Information as defined below. I understand that I may learn or have access to Confidential Information and agree to protect Confidential Information

against unauthorized access or disclosure.

1. Definition of Confidential Information. For the purpose of the Confidentiality Agreement, Confidential Information shall include but is not limited to the offense, social, medical, psychiatric, and psychological reports and records of individuals, whether identifiable or non-identifiable, who are or have been (i) before the court, (ii) under supervision, or (iii) receiving services from a court service unit or who are or have been committed to the Department. (See § 16.1-300 of the Code of Virginia.) Confidential Information also specifically includes arrest information the Department receives from

other agencies for the purposes of evaluating recidivism of Department-served populations.

1. Exclusions from Confidential Information. Receiving Party’s obligations under this Agreement do not extend to information that is: (a) Publicly known at the time of disclosure or subsequently becomes publicly known through no fault of the Receiving Party; or

(b) Learned by the Receiving Party through legitimate means other than from the Department or the Department’s representatives.

1. Obligations of Receiving Party. Receiving Party shall: (a) Adhere to all federal and state laws and regulations regarding Confidential Information; (b) Use the Confidential Information only for the purpose of fulfilling the goals of

the proposed research project; (c) Hold and maintain the Confidential Information in strictest confidence; (d) Agree to store all data on a password-protected computer or in a secure location (e.g., locked file cabinet or drawer); (e) Require any employee or any other individual associated with this project that has or potentially could have access to the Confidential Information sign a confidentiality agreement; (f) Agree to destroy or return to the Department all Confidential Information or

data within ten days of any request by the Department; (g) Agree not to publish, copy, or otherwise disclose to others, or permit the use by others any Confidential Information (however, this does not preclude publication of aggregate data with no individual-level information with prior permission of the Department);

Effective: April 15, 2021 Page 1 of 2

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(h) Agree to refer any person requesting access to Confidential Information who is not identified in subsection (e) to the Department; (i) Agree not to publish, disclose, or associate the Department’s name with any publications arising from information received from the Department without the express written permission of the Director of the Department; and

(j) Agree that any publication, presentation, or disclosure of information received from the Department will present the results or findings in aggregate form with no individual-level information.

1. Time Periods. The nondisclosure provisions of this Agreement shall survive the termination of the Confidentiality Agreement and Receiving Party's duty to hold Confidential Information in confidence shall remain in effect until the Confidential

Information is destroyed.

This Confidentiality Agreement and the Receiving Party’s obligations shall be binding on the representatives, assigns, and successors for the Receiving Party.

Project Name: ____________________________________________________________________________

Name Printed: _________________________________________________

Signature: _____________________________________________________

Date: ____________________

Effective: April 15, 2021 Page 2 of 2

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VIRGINIA DEPARTMENT OF JUVENILE JUSTICE Confidentiality Agreement

I ______________________ (Receiving Party) agree with the Virginia Department of Juvenile Justice to prevent unauthorized disclosure of Confidential Information as defined below and to protect Confidential Information I may access.

against unauthorized access or disclosure.

1. Definition of Confidential Information: includes offense, social, medical, psychiatric, psychological reports and records of individuals who are or have been (i) before the court, (ii) under supervision, or (iii) receiving services from a court unit or committed to the Department. Also includes arrest info received by the Department. (See § 16.1-300 of Virginia Code.)

for other agencies to evaluate recidivism of Department-served populations.

1. Exclusions: obligations do not extend to information that is (a) publicly known at disclosure or becomes so through no fault of the Receiving Party;

(b) Learned by the Receiving Party through legitimate means other than from the Department or the Department’s representatives.

1. Obligations: (a) Follow all federal and state laws regarding Confidential Information; (b) Use Confidential Information only to fulfill the goals of

the proposed research; (c) Maintain Confidential Information in strict confidence; (d) Store all data securely (e.g., password-protected device or locked cabinet); (e) Require anyone with access to sign a confidentiality agreement; (f) Destroy or return all Confidential Information or

data within ten days of Department request; (g) Not publish, copy, disclose, or permit use of Confidential Information, except aggregate data with no individual info with prior Department permission;

Effective: April 15, 2021 Page 1 of 2

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h) Refer anyone requesting access not identified in (e) to the Department; (i) Not publish, disclose, or associate the Department’s name with publications from Department information without written permission of the Department Director;

j) Any publication, presentation, or disclosure from Department information must present results in aggregate form with no individual data.

1. Time Periods: Nondisclosure survives termination; the duty to keep Confidential Information confidential remains until the Confidential

Information is destroyed.

This Agreement and obligations bind the Receiving Party’s representatives, assigns, and successors.

Project Name: ____________________________________________________________________________

Name Printed: _________________________________________________

Signature: _____________________________________________________

Date: ____________________

Effective: April 15, 2021 Page 2 of 2

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VIRGINIA DEPARTMENT OF JUVENILE JUSTICE Research Agreement

All research involving juveniles, families, or staff of the Virginia Department of Juvenile Justice (DJJ) or a Board of Juvenile Justice-regulated facility, program, or service must adhere to DJJ’s regulation and procedure governing research and the following requirements:

The proposed research project, listed on the subsequent page, shall begin only when all necessary reviews are complete; the Principal Researcher(s), the Student Researcher (if applicable), the DJJ Coordinator of External Research, and the DJJ Director or designee have signed this agreement; the study has been approved by an Institutional Review Board (IRB); and the DJJ Coordinator of External Research has confirmed receipt of the IRB approval letter.

Progress reports are due at the frequency indicated below to the DJJ Coordinator of External Research

for the duration of the project. At the time of the progress report submissions, DJJ will review the progress and determine continued approval. Approval may be revoked at any time if DJJ determines the regulatory requirements, the procedure governing research, or the approved research protocol have not been followed. A final report and executive summary must be submitted electronically to the DJJ Coordinator of External Research.

Any changes to the approved protocol (including procedures, forms, scripts, surveys, etc.) must be submitted to the DJJ Coordinator of External Research and approved by DJJ before being implemented.

DJJ also requires ongoing approval by an IRB for the duration of study, and all correspondence with the IRB should be forwarded to the DJJ Coordinator of External Research as they occur. Approval by an IRB does not supersede approval by DJJ; approval by both parties is required before implementation of the

study and any changes to the study.

DJJ requires all protocol violations, including (but not limited to) the reporting of adverse events, sponsor- or IRB-imposed protocol suspensions, protocol deviations/violations, confidentiality breaches, and participant complaints be reported to the DJJ Coordinator of External Research. Reports must be submitted within five business days of the investigator’s knowledge of the incident. The report should include relevant dates, times, locations, personnel involved, event details, and actions taken and planned.

Based on DJJ’s determination of the level of risk or harm to participants or others, DJJ may take any or all of the following actions:

• Require the investigator to submit a report to their IRB, copying DJJ on all correspondence;
• Temporarily halt research activities until a corrective action plan can be approved and

implemented; and/or

• Revoke approval of the research in whole or part.

Unless waived by the director or designee, all external articles, reports, and presentations made from the data collected shall include the statement, "The findings of this study are the responsibility of the researchers, and cooperation by the Virginia Department of Juvenile Justice in facilitating this research should not be construed as an endorsement of the conclusions drawn by the researchers." All external articles, reports, and presentations shall be submitted to the Coordinator of External Researcher as indicated below.

Consistent with professional standards, DJJ shall be permitted to use and reproduce information and

materials from the research study.

Attachment B- Procedure 07-006.3 External Research Page 1 of 2

Effective: April 15, 2021

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I, the undersigned, hereby affirm that I and my research staff have read, understand, and agree to abide by the requirements listed above and the DJJ regulation and procedure governing research.

Research Project Title:

Principal Researcher(s):

Student Researcher (if applicable):

_____________________________________________________________________________________ Signature of Principal Researcher (primary) Date

_____________________________________________________________________________________ Signature of Co-Principal Researcher (if applicable) Date

_____________________________________________________________________________________ Signature of Student Researcher (if applicable) Date

Scan and email the completed Research Agreement, the Research Proposal Summary with attachments, and signed Confidentiality Agreements for each individual accessing data to the DJJ Coordinator of External

Researcher (Dhara Amin) at Dhara.Amin@djj.virginia.gov.

Completed by DJJ:

_____________________________________________________________________________________ Signature of Coordinator of External Research Date

_____________________________________________________________________________________ Signature of Director or Designee Date

Date of Approval: __________________ First Progress Report Due: __________________

Progress Reports Due: ☐ Annually ☐ Bi-Annually ☐ Quarterly

☐ Endorsement Statement Required – All external articles, reports, presentations, and publications must be submitted to the Coordinator of External Research within 30 days of the publication/presentation date.

☐ Endorsement Statement Waived – All external articles, reports, presentations, and publications must be reviewed and approved by DJJ prior to release. Materials must be submitted to the Coordinator of External Research at least 30 days prior to the anticipated submission date.

Attachment B- Procedure 07-006.3 External Research Page 2 of 2

Effective: April 15, 2021 [TABLE 2-1] | Research Project Title: | | Principal Researcher(s): | | Student Researcher (if applicable): |

[/TABLE]

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VIRGINIA DEPARTMENT OF JUVENILE JUSTICE Research Agreement

All research involving juveniles, families, or staff of DJJ or a Board-regulated facility, program, or service must follow DJJ’s research regulations and requirements:

The research may start only after reviews are complete; all required signatures, IRB approval, and receipt confirmation by the DJJ Coordinator are obtained.

Progress reports are due as specified below to the DJJ Coordinator of External Research

Throughout the project, DJJ will review progress and may revoke approval if requirements or protocols are violated. A final report and summary are required electronically.

All protocol changes (procedures, forms, scripts, surveys, etc.) must be submitted to and approved by DJJ before implementation.

Ongoing IRB approval is required; all IRB correspondence must be sent to DJJ. IRB approval does not replace DJJ approval; both are needed before starting or changing the study.

study and any modifications.

All protocol violations (adverse events, suspensions, deviations, breaches, complaints) must be reported to DJJ within five business days, including relevant details and actions.

Depending on risk or harm, DJJ may take actions as determined.

• Require investigator to submit report to IRB, copying DJJ on all correspondence;
• Temporarily halt research activities until a corrective action plan is approved;

implemented; and/or

• Revoke approval of the research in whole or part.

Unless waived, all external articles, reports, and presentations must include the statement about researcher responsibility and submission to the Coordinator of External Research.

DJJ may use and reproduce information and

materials from the research study.

Attachment B- Procedure 07-006.3 External Research Page 1 of 2

Effective: April 15, 2021

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I and my staff affirm reading, understanding, and agreeing to abide by the above requirements and DJJ research procedures.

Research Project Title:

Principal Researcher(s):

Student Researcher (if applicable):

_____________________________________________________________________________________ Signature of Principal Researcher (primary) Date

_____________________________________________________________________________________ Signature of Co-Principal Researcher (if applicable) Date

_____________________________________________________________________________________ Signature of Student Researcher (if applicable) Date

Scan and email the completed Research Agreement, Proposal Summary, attachments, and Confidentiality Agreements to the DJJ Coordinator of External

Researcher (Dhara Amin) at Dhara.Amin@djj.virginia.gov.

Completed by DJJ:

_____________________________________________________________________________________ Signature of Coordinator of External Research Date

_____________________________________________________________________________________ Signature of Director or Designee Date

Date of Approval: __________________ First Progress Report Due: __________________

Progress Reports Due: ☐ Annually ☐ Bi-Annually ☐ Quarterly

☐ Endorsement Statement Required – All external articles, reports, presentations, and publications must be submitted within 30 days of publication/presentation.

☐ Endorsement Statement Waived – All external articles, reports, presentations, and publications require DJJ review and approval before release; submission at least 30 days prior to planned date.

Attachment B- Procedure 07-006.3 External Research Page 2 of 2

Effective: April 15, 2021 [TABLE 2-1] | Research Project Title: | Principal Researcher(s): | Student Researcher (if applicable): |

[/TABLE]

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"GUIDELINES FOR TRANSPORTING JUVENILES IN DETENTION" Revised September 8, 2004

PART I.

GUIDELINES FOR DETENTION HOMES AND COURT SERVICE UNITS WHEN

TRANSPORTING JUVENILES IN DETENTION

Purpose

The purpose of these Guidelines is to ensure the safety of detained juveniles and the staff who transport them; protect the public safety through appropriate security and supervision practices; and reduce the liability exposure of those who are responsible for transporting detained juveniles.

Statutory Authority

Part I of these Guidelines, applying to detention homes and court service units, are established in accordance with Code of Virginia §§ 16.1-254 (A) and 16.1-309.9. Section 16.1-254 sets out the respective responsibilities of detention homes and court service units for the transportation of juveniles in detention:

§ 16.1-254. Responsibility for and limitation on transportation of children.

A. The detention home having custody or responsibility for supervision of a child pursuant to §§ 16.1-246, 16.1-247, 16.1-248.1, 16.1-249, and 16.1-250 shall be

responsible for transportation of the child to all local medical appointments, dental appointments, psychological and psychiatric evaluations. Transportation of youth to special placements pursuant to § 16.1-286 shall be the responsibility of the court service unit.

Section 16.1-309 authorizes the Board to set standards for the supervision of detained juveniles, including supervision while being transported in detained status: § 16.1-309.9. Establishment of standards; determination of compliance.

B. The State Board of Juvenile Justice shall develop, promulgate and approve standards for the development, implementation, operation and evaluation of the range of community-based programs, services and facilities authorized by this

article. The State Board shall also approve minimum standards for the construction and equipment of detention homes or other facilities and for food, clothing, medical attention, and supervision of juveniles to be housed in these facilities and programs.

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Guidelines

A. Virginia Code § 16.1-254 (A) makes the detention home “responsible for” transportation to all local medical appointments, dental appointments, psychological and psychiatric evaluations, and makes the court service unit “responsible for” transporting detained juveniles to special placements made pursuant to§ 16.1-286. The detention home and the court service unit may fulfill these responsibilities by having their own staff transport the detained juvenile, or by entering into an agreement or contract with a public or private agency that can provide the required security and safety. In addition, the court service unit may fulfill its responsibility for transporting a detained juvenile to a special placement under § 16.1-286 by arrangement with the juvenile’s parents, guardians or other responsible adults, including volunteers, when deemed appropriate in accordance with unit operating procedures.

B. Staff court service units, including volunteers, shall not transport detained juveniles in their private vehicles. Staff of other public or private agencies, including locally-operated and commission-operated detention facilities, shall be governed by the policies of their employing agencies concerning the use of private vehicles.

C. No child shall be transported with adults suspected of or charged with criminal acts. (See Virginia Code § 16.1-254.)

D. Drivers must possess a valid driver's license.

E. The detention home may require notice of the date and time of the local medical appointment, dental appointment, or psychological and psychiatric evaluation at least 72 hours in advance.

Discussion: Because a detention home's primary responsibility is to provide safe and secure supervision of detained youth, reasonable notice is required to not only arrange for the transportation of the youth but also to ensure adequate staff for the continued staffing of the facility.

F. When the medical staff of a detention home have made the written determination that a youth's medical condition can be adequately treated without transporting the youth to a routine or previously scheduled appointment, the detention home is not required to transport the youth unless ordered by a court.

Discussion: A youth who has been detained in a secure detention facility should be removed from the facility only for a compelling reason. Routine or previously scheduled appointments that are not required by the court and which, if missed, would not jeopardize the youth's health, do not constitute sufficient reason.

G. Detention home staff will confirm all appointments made by the court or others prior to transporting a youth and shall enter such confirmation in the daily log or transportation log.

H. The transportation of a youth by detention personnel to an appointment shall not obligate the detention home to pay for any costs associated with the appointment, unless previously agreed.

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I. Unless provided for otherwise through agreement, the detention home shall not be required to transport youth to appointments that are outside of the geographical boundaries of the State of Virginia, or that are more than 25 miles from the facility in one direction.

J. In the event of a vehicle breakdown during transport, the transporting personnel shall immediately notify their agency and contact local law enforcement for assistance if necessary.

During the breakdown, the transporting staff shall not leave the juvenile unattended.

K. If it is determined that the juvenile will need a meal while in transit, the detention home shall provide a sack lunch whenever possible.

Discussion: Providing a sack lunch reduces the security risk associated with stopping for meals at drive-ins, restaurants, etc.

L. The detention home will send with the transporting staff any medication the juvenile will

require medication while in transit.

M. Detention homes and court service units shall have procedures to ensure adequate and appropriate security and supervision while transporting detained juveniles.

Discussion: These procedures should address the ratio of staff to juveniles, searches of the vehicle and of the juvenile; communications while en route; and the use of mechanical restraints when indicated.

N. In the event a juvenile absconds during transport, the transporting personnel shall immediately report the incident in accordance with Department policy and procedures regarding serious incidents.

O. Juveniles who were confined in a secure detention facility immediately prior to their court

hearing shall not be transported to the Reception and Diagnostic Center directly from court upon commitment, but shall be returned to the detention home until the commitment packet can be completed and transportation arranged.

Discussion: This requirement is in accord with Code of Virginia § 16.1-287, which provides that “[w]henever the court commits a child to the Department of Juvenile Justice, or to any other institution or agency, it shall transmit with the order of commitment copies of the clinical reports, predisposition study and other information it has pertinent to the care and treatment of the child. The Department shall not be responsible for any such committed child until it has received the court order and the information concerning the child.”

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PART II

GUIDELINES FOR DESIGNATING APPROPRIATE AGENCIES TO TRANSPORT

VIOLENT AND DISRUPTIVE YOUTH AND TO TRANSPORT DETAINED

JUVENILES TO DESTINATIONS NOT ADDRESSED IN PART I.

Statutory Authority

§ 16.1-254. Responsibility for and limitation on transportation of children.

B. However, the chief judge of the juvenile and domestic relations district court, on the basis of guidelines approved by the Board, shall designate the appropriate agencies in each county, city

and town, other than the Department of State Police, to be responsible for (i) the transportation of violent and disruptive children and (ii) the transportation of children to destinations other than those set forth in subsection A of this section, pursuant to §§ 16.1-246, 16.1-247, 16.1-248.1, 16.1-249, and 16.1-250, and as otherwise ordered by the judge.

No child shall be transported with adults suspected of or charged with criminal acts.

Guidelines

C. Violent and disruptive youth may be transported only by detention home staff or by law enforcement personnel other than the State Police.

B. Transportation of a detained juvenile to a residential placement pursuant to § 16.1-294 shall be

the responsibility of the court service unit that is supervising the juvenile or the agency or parent that is seeking the placement, unless otherwise ordered by the court. The court service unit may fulfill its responsibility for transporting a detained juvenile to a special placement under § 16.1-294 by contract or agreement with another public or private agency, or by arrangement with the juvenile’s parents, guardians or other responsible adults, including volunteers, when deemed appropriate in accordance with unit operating procedures.

C. The chief judge of the juvenile and domestic relations district court shall designate an appropriate agency other than the Department of State Police to transport detained juveniles to destinations not addressed in Part I of these Guidelines.

Discussion: Depending on the resources available locally and the nature of the needed transportation, appropriate agencies might include the detention home, the court service unit, a local law enforcement agency, or a public or private agency

Destinations not addressed in Part I include, but are not limited to:

• destinations across jurisdictional boundaries, or that are more than 25

miles, from the detention home in one direction, when there is not a standing administrative agreement or commission charter governing transportation of detained youth;

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• destinations in other states

• other secure detention facilities, such as detention homes or jails, when there is not a standing administrative agreement governing transportation of youth;
• a law enforcement agency for interrogation
• funerals, death bed visits, and other extreme circumstances;
• other destinations as determined by the court

E. Consistent with Virginia Code § 37.1-67.01, when a court commits a juvenile to a mental hospital or training center for observation, the committing court shall designate the appropriate law enforcement agency, other than the Department of State Police, to transport

the juvenile.

F. Virginia Code § 16.1-254 does not distinguish between pre-dsipostionally detained and post-dispostionally detained youth. Therefore, transportation of post-dispositionally detained youth to places other than those as set forth in 16.1-254(A) must be at the designation of the court. This may be accomplished by individual court orders, by standing court order, or by court approval of the plan for treating post-dispositionally detained juveniles required by Standards for Juvenile Residential Facilities, at 6VAC35-140-510 (B): “When a juvenile is ordered by a court, pursuant to §16.1-284.1 B of the

Code of Virginia, into a facility that houses postdispositionally detained youth, the facility shall: … 2. Have a written plan with the court service unit within five days to enable such youth to take part in one or more locally available treatment programs appropriate for their rehabilitation which may be provided in the community or at the facility.”

Discussion: The written plan between the detention home and the court service unit should address how post-dispostionally detained juveniles will be

transported. The written plan may provide for transportation of postdispositionally detained juveniles who are participating in treatment programs or work programs in the community, or receiving services in the community, by detention home staff, court service unit staff, or by any other responsible adult approved by the detention home.

G. Employees of court service units who transport post-dispositionally detained juveniles shall not use their personal vehicles to do so. Employees of detention homes or other agencies shall be subject to their agencies’ policies regarding the use of personal vehicles. If other responsible adults are approved to transport juveniles and choose to use their personal vehicle, they do so at their own risk.

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"GUIDELINES FOR TRANSPORTING JUVENILES IN DETENTION" Revised September 8, 2004

PART I.

GUIDELINES FOR DETENTION HOMES AND COURT SERVICE UNITS WHEN

TRANSPORTING JUVENILES IN DETENTION

Purpose

These Guidelines aim to ensure detained juveniles' and staff safety, protect public safety via security and supervision, and reduce liability of transporters.

Statutory Authority

Part I applies to detention homes and court service units per Code of Virginia §§ 16.1-254 (A) and 16.1-309.9, outlining responsibilities for juvenile transportation:

§ 16.1-254. Responsibility and limits on transporting children.

A. The detention home with custody or supervision responsibility per §§ 16.1-246, 16.1-247, 16.1-248.1, 16.1-249, 16.1-250 shall be

responsible for transporting the child to local medical, dental, psychological, and psychiatric appointments; transportation to special placements per § 16.1-286 is the court service unit's responsibility.

Section 16.1-309 authorizes the Board to set standards for supervising detained juveniles, including during transport: § 16.1-309.9.

B. The State Board of Juvenile Justice shall develop, promulgate, and approve standards for community-based programs, services, and facilities authorized by this

article. The State Board shall approve minimum standards for construction, equipment, food, clothing, medical care, and supervision of juveniles in detention homes and facilities.

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Guidelines

A. Virginia Code § 16.1-254 (A) makes detention homes responsible for local medical, dental, psychological, and psychiatric transport; court units handle special placements per § 16.1-286, via staff, agreements, or parent/guardian arrangements per procedures.

B. Court service staff and volunteers shall not transport juveniles in private vehicles; staff of other agencies shall follow their policies regarding private vehicle use.

C. No child shall be transported with adults suspected or charged with crimes. (See Virginia Code § 16.1-254.)

D. Drivers must possess a valid driver's license.

E. Detention homes may require at least 72 hours' notice of local medical, dental, or psychological appointments.

Discussion: Because a detention home's primary responsibility is to provide safe and secure supervision of detained youth, reasonable notice is required to not only arrange for the transportation of the youth but also to ensure adequate staff for the continued staffing of the facility.

F. When the medical staff of a detention home have made the written determination that a youth's medical condition can be adequately treated without transporting the youth to a routine or previously scheduled appointment, the detention home is not required to transport the youth unless ordered by a court.

Discussion: A youth who has been detained in a secure detention facility should be removed from the facility only for a compelling reason. Routine or previously scheduled appointments that are not required by the court and which, if missed, would not jeopardize the youth's health, do not constitute sufficient reason.

G. Detention home staff will confirm all appointments made by the court or others prior to transporting a youth and shall enter such confirmation in the daily log or transportation log.

H. The transportation of a youth by detention personnel to an appointment shall not obligate the detention home to pay for any costs associated with the appointment, unless previously agreed.

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I. Unless provided for otherwise through agreement, the detention home shall not be required to transport youth to appointments that are outside of the geographical boundaries of the State of Virginia, or that are more than 25 miles from the facility in one direction.

J. In the event of a vehicle breakdown during transport, the transporting personnel shall immediately notify their agency and contact local law enforcement for assistance if necessary.

During breakdown, staff shall not leave the juvenile unattended.

K. If it is determined that the juvenile will need a meal while in transit, the detention home shall provide a sack lunch whenever possible.

Discussion: Sack lunches reduce security risks from stops at restaurants or drive-ins.

L. The detention home will send with the transporting staff any medication the juvenile will

require medication while in transit.

M. Detention homes and court service units shall have procedures to ensure adequate and appropriate security and supervision while transporting detained juveniles.

Discussion: Procedures must address staff-to-juvenile ratio, vehicle and juvenile searches, en route communications, and mechanical restraints when indicated.

N. If a juvenile absconds during transport, personnel shall immediately report per Department policy on serious incidents.

O. Juveniles confined in a secure detention facility immediately before their court

hearing shall not be transported directly from court to the Reception and Diagnostic Center; instead, juveniles shall return to detention until the commitment packet is completed and transportation arranged.

Discussion: In line with Code of Virginia § 16.1-287, the court must transmit clinical reports, predisposition studies, and relevant info with the commitment order; the Department is responsible only after receipt.

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PART II

GUIDELINES FOR DESIGNATING APPROPRIATE AGENCIES TO TRANSPORT

VIOLENT AND DISRUPTIVE YOUTH AND TO TRANSPORT DETAINED

JUVENILES TO DESTINATIONS NOT ADDRESSED IN PART I.

Statutory Authority

§ 16.1-254. Responsibility for and limitation on transportation of children.

B. The chief judge of the juvenile and domestic relations district court shall, based on Board-approved guidelines, designate appropriate agencies in each county, city

and town, excluding the Department of State Police, responsible for (i) transporting violent/disruptive children and (ii) to destinations beyond subsection A, per §§ 16.1-246 to 16.1-250 and judge's orders.

No child shall be transported with adults suspected of or charged with criminal acts.

Guidelines

C. Violent/disruptive youth may only be transported by detention staff or law enforcement other than State Police.

B. Transportation of a detained juvenile to residential placement under § 16.1-294 shall be

the responsibility of the court service unit that is supervising the juvenile or the agency or parent that is seeking the placement, unless otherwise ordered by the court. The court service unit may fulfill its responsibility for transporting a detained juvenile to a special placement under § 16.1-294 by contract or agreement with another public or private agency, or by arrangement with the juvenile’s parents, guardians or other responsible adults, including volunteers, when deemed appropriate in accordance with unit operating procedures.

C. The chief judge shall designate an agency other than State Police to transport detained juveniles to destinations outside Part I.

Discussion: Based on local resources and transportation needs, appropriate agencies may include detention homes, court service units, law enforcement, or public/private agencies.

Destinations not addressed in Part I include, but are not limited to:

• destinations across jurisdictional boundaries or more than 25

miles from the detention home when no standing agreement or charter governs transportation;

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• destinations in other states

• other secure detention facilities, such as detention homes or jails, without a standing administrative agreement governing youth transportation;
• a law enforcement agency for interrogation
• funerals, death bed visits, and other extreme circumstances;
• other destinations as determined by the court

E. Under Virginia Code § 37.1-67.01, when a juvenile is committed to a mental hospital or training center for observation, the court shall designate an agency other than State Police to transport

the juvenile.

F. Virginia Code § 16.1-254 does not distinguish pre- and post-disposition youth; transportation outside 16.1-254(A) requires court designation via orders or approved treatment plans per 6VAC35-140-510(B).

Code Virginia requires facilities housing postdispositionally detained youth to have a written plan with the court service unit within five days for participation in local treatment or programs at the facility.

Discussion: The plan between detention home and court service unit should specify how post-disposition juveniles will be

transported. The plan may include transportation of juveniles in treatment, work, or receiving services in the community by detention staff, court staff, or approved responsible adults.

G. Court service employees shall not use personal vehicles for transporting juveniles; detention or other agency employees shall follow their policies; responsible adults using personal vehicles do so at their own risk.

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VIRGINIA DEPARTMENT OF JUVENILE JUSTICE (DJJ)

Research Proposal Summary I. Basic Information

Date submitted to DJJ: Principal Name: Researcher (If a Title and student project, the Affiliation: principal researcher is Address: the faculty advisor.) Telephone: Email: Project Coordinator Name: (If different from Telephone: Principal Researcher) Email: Student Researcher Name: (only if a student Address: project or Telephone: dissertation) Email: If there are any other individuals (e.g., Research Coordinators, Research Assistants) that may be included in communication with DJJ during the research review process, please include their names, telephone numbers, and email addresses in a separate attachment.

Funding Source (if applicable): Title of Proposal: II. Checklist

Review the checklist and ensure that all requirements have been met prior to submitting your research proposal. Please include your justification for any items that have not been completed as of the time of submission.

Request Type: ☐ VLDS ☐ Case-Specific Data ☐ Human Research

Complete for VLDS and Case-Specific Data Requests: Identifiers from DJJ

 Check all of the identifiers that are being requested for this project from DJJ*: ☐ Names ☐ Biometric identifiers, including finger and voice prints ☐ Postal street addresses ☐ Full face photographic images and comparable images ☐ Telephone numbers ☐ Dates (Date of admission, date of release, etc.) ☐ Email addresses ☐ Location more than town or city, state, and zip code ☐ Social security numbers ☐ Account numbers (Juvenile #, Direct Care #, etc.)

☐ Medical record numbers ☐ No identifiers are being requested *Provide a justification for all of the requested identifiers in your response for question #9.

Effective: April 15, 2021 [TABLE 1-1] Date submitted to DJJ: | | | | Principal Researcher (If a student project, the principal researcher is the faculty advisor.) | | Name: | | | | Title and Affiliation: | | | | Address: | | | | Telephone: | | | | Email: | | Project Coordinator (If different from Principal Researcher) | | Name: | | | | Telephone: | | | | Email: | | Student Researcher (only if a student project or dissertation) | | Name: | | | | Address: | | | | Telephone: | | | | Email: | | | If there are any other individuals (e.g., Research Coordinators, Research Assistants) that may be included | | | | in communication with DJJ during the research review process, please include their names, telephone | | | | numbers, and email addresses in a separate attachment. | | | Funding Source (if applicable): | | | | Title of Proposal: | | | |

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• Page 2 ---

Complete for Human Research Proposals:

Vulnerable Populations  Does your study include children? ☐ Yes – Included as a vulnerable population in the IRB proposal ☐ No

 Does your study include prisoners? ☐ Yes – Included as a vulnerable population in the IRB proposal ☐ No

Informed Consent/Assent  Did you include the appropriate consent/assent documents?

☐ Consent Form – Required for all participants 18 and older, unless waiver is approved ☐ Assent Form – Required for all participants under age 18, unless waiver is approved ☐ Parental Permission Form – Required for all participants under age 18, unless waiver is approved ☐ Waiver of consent, assent, and/or parental permission is requested  Will all participants and their parents/legal guardians sign their name on the form?

☐ Yes ☐ No – Waiver of documentation is requested  Does your consent, assent, and/or parental permission form include all federally required elements? ☐ Yes – Please review §46.116 General requirements for informed consent and §46.117 Documentation of informed consent, available at HHS Policy for Protection of Human Research Subjects 45 CFR 46.

Note: DJJ provides templates that include all required elements for consent and assent forms on its website. ☐ No – Please justify: Click here to enter text.  Is your consent, assent, and/or parental permission form written using language that is easily understood given the age and maturity level of the readers (approximately at or

below the 8th grade level for consent and parental permission forms and at or below the 6th grade level for assent forms)? ☐ Yes ☐ No – Please justify: Click here to enter text.

IRB  Have you submitted your IRB letter of approval?

☐ Yes ☐ No – Proposal is currently under review/needs to be submitted to IRB  Can you provide documentation that the IRB considered the inclusion of vulnerable populations, waiver of consent, or waiver of documentation of consent? ☐ N/A ☐ Yes ☐ No - Please justify: Click here to enter text.  Is your IRB proposal congruent with the research proposal submitted to DJJ (e.g., protocol details, vulnerable populations, consent/assent waivers)?

☐ Yes ☐ No – Please justify: Click here to enter text.  Has an IRB disapproved, suspended, or terminated this study? ☐ Yes ☐ No

Effective: April 15, 2021

• Page 3 ---

Training and Experience  Indicate the type(s) of training you and your research staff have had on the protection of human research subjects during the most recent two years. Select all that apply. ☐ Collaborative IRB Training Initiative (CITI) ☐ Investigator Meeting(s)

☐ Local Institution’s Training ☐ OHRP Training Modules ☐ NIH Protecting Human Research Participants Course ☐ Other – Specific below* ☐ None

• Specify the training courses you have taken: Click here to enter text.  Does the Principal Researcher have more than one year of human subject research experience? ☐ Yes ☐ No

Complete for All Types of Requests:

Principal Researcher Personnel History

 Has the principal researcher, any co-researchers, or research personnel ever had their research privileges denied, revoked, suspended, reduced, limited, not renewed, relinquished, sanctioned, or fined? ☐ No ☐ Yes – Please enclose all related documents with the application.  Is any action or investigation currently pending before any state licensing board, federal agency, or court of law concerning the professional conduct of the principal investigator,

any co-researchers, or research personnel? ☐ No ☐ Yes – Please enclose all related documents with the application.

Final Steps  Did you include all required documents?

☐ Study documents (e.g., surveys, assessments, scripts) ☐ Research Agreement form ☐ Confidentiality Agreement form(s)

☐ Letters of Support, as needed  Have you completed all final steps before submitting your research proposal to DJJ? ☐ Proofread all your documents for accuracy, consistency, and proper grammar ☐ Confirmed study timeline is realistic Note: The approval process duration can vary significantly depending on the number of revisions required. Data requests require additional time once approved to finalize the data request, add the request to the queue, and clean and produce the data.  The PI and the entire research team have read, understand, and agree to abide by Virginia Administrative Code 6VAC35-170 and the associated guidance document.

PI’s Name and Date (Typed – Please do not print, sign, and scan.)

Effective: April 15, 2021

• Page 4 ---

III. Purpose of the Research

1. Briefly state the research problem.

1. Provide background information about the research problem (include citations if necessary).

1. Briefly state the purpose, goals, and specific aims of the research project.

1. Describe how the anticipated results will directly benefit DJJ or a Board of Juvenile Justice-regulated facility, program, or service. Please indicate if you will be providing an action plan with recommendations based on the findings.

Effective: April 15, 2021

[TABLE 4-1]

1. Briefly state the research problem. | | | 2. Provide background information about the research problem (include citations if | | necessary). |
2. Briefly state the purpose, goals, and specific aims of the research project. | | | 4. Describe how the anticipated results will directly benefit DJJ or a Board of | | Juvenile Justice-regulated facility, program, or service. Please indicate if you will | | be providing an action plan with recommendations based on the findings. |

[/TABLE]

• Page 5 ---

IV. Research Design

1. Describe the planned subject population, including inclusion and exclusion

criteria.

1. For human research proposals, what techniques will be used to recruit

participants?

1. For human research proposals, how will consent/assent be obtained from participants (and their parents if minors)? Please attach all consent/assent forms. If

a waiver of consent is requested, please provide a justification for the waiver.

1. For human research proposals, describe the specific methods and procedures that will be used to deliver the intervention/program to be studied, if any.

Effective: April 15, 2021 [TABLE 5-1] | 5. Describe the planned subject population, including inclusion and exclusion | | criteria. | | 6. For human research proposals, what techniques will be used to recruit | | participants? | | 7. For human research proposals, how will consent/assent be obtained from | | participants (and their parents if minors)? Please attach all consent/assent forms. If | | a waiver of consent is requested, please provide a justification for the waiver. | | 8. For human research proposals, describe the specific methods and procedures that | | will be used to deliver the intervention/program to be studied, if any. |

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• Page 6 ---

1. Describe the specific methods and procedures that will be used to collect the data.

Please attach all scripts, surveys, etc. If requesting existing data, please list desired

fields in as much detail as possible. Provide a justification for all of the requested identifiers.

10. Describe the statistical analysis methodologies that will be used to analyze the

data.

11. All research studies have potential risks. Describe potential risks and benefits to participants.

12. Describe the plan for keeping information confidential and secure, including the physical storage and timeline for destruction of data.

Effective: April 15, 2021 [TABLE 6-1] | 9. Describe the specific methods and procedures that will be used to collect the data. | | Please attach all scripts, surveys, etc. If requesting existing data, please list desired | | fields in as much detail as possible. Provide a justification for all of the requested | | identifiers. | | 10. Describe the statistical analysis methodologies that will be used to analyze the | | data. | | 11. All research studies have potential risks. Describe potential risks and benefits to | | participants. | | 12. Describe the plan for keeping information confidential and secure, including the | | physical storage and timeline for destruction of data. |

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• Page 7 ---

V. Resources and Impact 13. List the specific DJJ unit/location involved and its role in the study.

14. List any resources needed for the research project that must be supplied by DJJ (e.g., staff, supplies, materials, equipment, workspace, access to participants, access to files).

15. Explain any possible impacts this research project may have on existing DJJ programs or operations.

VI. Proposed Timeline and Products 16. Indicate a proposed time frame (start date – end date) for each phase of the

research process. Note: time frames are strictly estimates. DJJ cannot ensure that the review process will be completed in time to meet all deadlines in the proposed timeline.

Data collection: Data analysis:

Preliminary report:

Final report and executive summary:

Effective: April 15, 2021 [TABLE 7-1] 13. List the specific DJJ unit/location involved and its role in the study. | | | 14. List any resources needed for the research project that must be supplied by DJJ | | (e.g., staff, supplies, materials, equipment, workspace, access to participants, | | access to files). | | 15. Explain any possible impacts this research project may have on existing DJJ | | programs or operations. |

[/TABLE]

[TABLE 7-2] | 16. Indicate a proposed time frame (start date – end date) for each phase of the | | | research process. Note: time frames are strictly estimates. DJJ cannot ensure that the | | | review process will be completed in time to meet all deadlines in the proposed timeline. | | Data collection: | | | Data analysis: | | | Preliminary report: | | | Final report and executive summary: | | |

[/TABLE]

• Page 8 ---

17. What are the anticipated final products of this project (e.g., internal reports, presentations, publications)? Include the anticipated audience for the results.

Specify in what form and to whom the results and findings will be distributed.

VII. Additional Attachments Please attach the signed Research Agreement Form after reviewing DJJ’s regulation and guidance document governing research. Confidentiality Agreement Form(s) must also be signed and submitted for each individual accessing data.

Attach any additional files used to conduct the research, including any document used with participants (e.g., consent forms, assent forms, surveys, assessments, scripts). All documents used with participants must be submitted to and approved by both the researcher’s Institutional Review Board and DJJ. Please do not refer to an attachment instead of answering any items on this form.

VIII. Endorsements Please attach evidence of endorsements from the following individuals in the form of an email

or signed letter on the organization’s letterhead if the proposed request is to take place in a particular organizational unit:  Head of the organizational unit (e.g., court service unit director, juvenile correctional center and/or juvenile detention center superintendent);  Deputy Director of the appropriate division (The organizational unit head supporting the project is responsible for requesting a written endorsement on behalf of the study prior to

the submission of the proposal packet to the Coordinator of External Research.); and  Institutional Review Board of the researcher’s institution/organization (for human research).

Note: The review process may begin before Institutional Review Board approval, but Institutional Review Board approval is required before DJJ will give final approval for human research.

Effective: April 15, 2021 [TABLE 8-1] | 17. What are the anticipated final products of this project (e.g., internal reports, | | presentations, publications)? Include the anticipated audience for the results. | | Specify in what form and to whom the results and findings will be distributed. |

[/TABLE]

• Page 9 ---

IX. VLDS Request (Skip for non-VLDS proposals.) The following are required elements for proposals in the VLDS portal. Please complete as you plan to submit in the VLDS portal; text may be copied from responses above, as appropriate.

18. State the purpose of the project.

19. Explain the project.

20. Alignment – Topics (Select one.) ☐ Collective, long-term impact of health, social service, education, and workforce programs

on people served ☐ Factors or conditions that have the greatest impact on educational achievement and later productivity ☐ Impact of health, social service, education, and workforce pipeline on Virginia’s economy

☐ Pathways to the workforce, patterns of employment, and factors or conditions that predict success ☐ Return on investment of health, social service, education, and workforce opportunities and programs

☐ Other 21. How does this research purpose align with the VLDS research agenda?

Effective: April 15, 2021 [TABLE 9-1] 18. State the purpose of the project. 19. Explain the project. 20. Alignment – Topics (Select one.) ☐ Collective, long-term impact of health, social service, education, and workforce programs on people served ☐ Factors or conditions that have the greatest impact on educational achievement and later productivity ☐ Impact of health, social service, education, and workforce pipeline on Virginia’s economy ☐ Pathways to the workforce, patterns of employment, and factors or conditions that predict success ☐ Return on investment of health, social service, education, and workforce opportunities and programs ☐ Other 21. How does this research purpose align with the VLDS research agenda?

[/TABLE]

• Page 10 ---

22. Funding Source (Select one.)

☐ Non Funded ☐ Funded – Please name the funding organization: Click here to enter text. 23. Target Sample – Describe your target sample cohort (e.g., males between the ages of 25 to

40; Graduate students who attended the University of Virginia between the Years of 1989 to 2005)

24. Expected Data Requirements – Agency Data Being Used – List the agencies that have partnered with VLDS whose data you want to include in your request.

Effective: April 15, 2021 [TABLE 10-1] 22. Funding Source (Select one.) | | ☐ Non Funded ☐ Funded – Please name the funding organization: Click here to enter text. | | | 23. Target Sample – Describe your target sample cohort (e.g., males between the ages of 25 to | | 40; Graduate students who attended the University of Virginia between the Years of 1989 | | to 2005) | | 24. Expected Data Requirements – Agency Data Being Used – List the agencies that | | have partnered with VLDS whose data you want to include in your request. |

[/TABLE]

• Page 1 ---

VIRGINIA DEPARTMENT OF JUVENILE JUSTICE (DJJ)

Research Proposal Summary I. Basic Information

Date submitted to DJJ: Principal Name: Researcher (If a Title and student project, the Affiliation: principal researcher is Address: the faculty advisor.) Telephone: Email: Project Coordinator Name: (If different from Telephone: Principal Researcher) Email: Student Researcher Name: (only if a student Address: project or Telephone: dissertation) Email: If there are any other individuals (e.g., Research Coordinators, Research Assistants) that may be included in communication with DJJ during the research review process, please include their names, telephone numbers, and email addresses in a separate attachment.

Funding Source (if applicable): Title of Proposal: II. Checklist

Review checklist to confirm all requirements are met before submission; justify any incomplete items.

Request Type: ☐ VLDS ☐ Case-Specific Data ☐ Human Research

Complete for VLDS and Case-Specific Data Requests: Identifiers from DJJ

 Check all of the identifiers that are being requested for this project from DJJ*: ☐ Names ☐ Biometric identifiers, including finger and voice prints ☐ Postal street addresses ☐ Full face photographic images and comparable images ☐ Telephone numbers ☐ Dates (Date of admission, date of release, etc.) ☐ Email addresses ☐ Location more than town or city, state, and zip code ☐ Social security numbers ☐ Account numbers (Juvenile #, Direct Care #, etc.)

☐ Medical record numbers ☐ No identifiers are being requested *Provide a justification for all of the requested identifiers in your response for question #9.

Effective: April 15, 2021 [TABLE 1-1] Date submitted to DJJ: | | | | Principal Researcher (If a student project, the principal researcher is the faculty advisor.) | | Name: | | | | Title and Affiliation: | | | | Address: | | | | Telephone: | | | | Email: | | Project Coordinator (If different from Principal Researcher) | | Name: | | | | Telephone: | | | | Email: | | Student Researcher (only if a student project or dissertation) | | Name: | | | | Address: | | | | Telephone: | | | | Email: | | | If there are any other individuals (e.g., Research Coordinators, Research Assistants) that may be included | | | | in communication with DJJ during the research review process, please include their names, telephone | | | | numbers, and email addresses in a separate attachment. | | | Funding Source (if applicable): | | | | Title of Proposal: | | | |

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• Page 2 ---

Complete for Human Research Proposals:

Vulnerable Populations  Does your study include children? ☐ Yes – Included as a vulnerable population in the IRB proposal ☐ No

 Does your study include prisoners? ☐ Yes – Included as a vulnerable population in the IRB proposal ☐ No

Informed Consent/Assent  Did you include the appropriate consent/assent documents?

☐ Consent Form – Required for all participants 18 and older, unless waiver is approved ☐ Assent Form – Required for all participants under age 18, unless waiver is approved ☐ Parental Permission Form – Required for all participants under age 18, unless waiver is approved ☐ Waiver of consent, assent, and/or parental permission is requested  Will all participants and their parents/legal guardians sign their name on the form?

☐ Yes ☐ No – Waiver of documentation is requested  Does your consent, assent, and/or parental permission form include all federally required elements? ☐ Yes – Please review §46.116 General requirements for informed consent and §46.117 Documentation of informed consent, available at HHS Policy for Protection of Human Research Subjects 45 CFR 46.

Note: DJJ provides templates that include all required elements for consent and assent forms on its website. ☐ No – Please justify: Click here to enter text.  Is your consent, assent, and/or parental permission form written using language that is easily understood given the age and maturity level of the readers (approximately at or

below the 8th grade level for consent and parental permission forms and at or below the 6th grade level for assent forms)? ☐ Yes ☐ No – Please justify: Click here to enter text.

IRB  Have you submitted your IRB letter of approval?

☐ Yes ☐ No – Proposal is currently under review/needs to be submitted to IRB  Can you provide documentation that the IRB considered the inclusion of vulnerable populations, waiver of consent, or waiver of documentation of consent? ☐ N/A ☐ Yes ☐ No - Please justify: Click here to enter text.  Is your IRB proposal congruent with the research proposal submitted to DJJ (e.g., protocol details, vulnerable populations, consent/assent waivers)?

☐ Yes ☐ No – Please justify: Click here to enter text.  Has an IRB disapproved, suspended, or terminated this study? ☐ Yes ☐ No

Effective: April 15, 2021

• Page 3 ---

Training and Experience  Indicate the type(s) of training you and your research staff have had on the protection of human research subjects during the most recent two years. Select all that apply. ☐ Collaborative IRB Training Initiative (CITI) ☐ Investigator Meeting(s)

☐ Local Institution’s Training ☐ OHRP Training Modules ☐ NIH Protecting Human Research Participants Course ☐ Other – Specific below* ☐ None

• Specify the training courses you have taken: Click here to enter text.  Does the Principal Researcher have more than one year of human subject research experience? ☐ Yes ☐ No

Complete for All Requests:

Principal Researcher Personnel History

 Has the principal researcher, any co-researchers, or research personnel ever had their research privileges denied, revoked, suspended, reduced, limited, not renewed, relinquished, sanctioned, or fined? ☐ No ☐ Yes – Please enclose all related documents with the application.  Is any action or investigation currently pending before any state licensing board, federal agency, or court of law concerning the professional conduct of the principal investigator,

any co-researchers, or research personnel? ☐ No ☐ Yes – Please enclose all related documents with the application.

Final Steps  Did you include all required documents?

☐ Study documents (e.g., surveys, assessments, scripts) ☐ Research Agreement form ☐ Confidentiality Agreement form(s)

☐ Letters of Support, as needed  Have you completed all final steps before submitting your research proposal to DJJ? ☐ Proofread all your documents for accuracy, consistency, and proper grammar ☐ Confirmed study timeline is realistic Note: The approval process duration can vary significantly depending on the number of revisions required. Data requests require additional time once approved to finalize the data request, add the request to the queue, and clean and produce the data.  The PI and the entire research team have read, understand, and agree to abide by Virginia Administrative Code 6VAC35-170 and the associated guidance document.

PI’s Name and Date (Typed – Please do not print, sign, and scan.)

Effective: April 15, 2021

• Page 4 ---

III. Purpose of the Research

1. Briefly state the research problem.

1. Provide background information about the research problem (include citations if necessary).

1. State the research purpose, goals, and aims briefly.

1. Explain how results will benefit DJJ or juvenile facilities, including if an action plan with recommendations will be provided.

Effective: April 15, 2021

[TABLE 4-1]

1. Briefly state the research problem. | | | 2. Provide background information about the research problem (include citations if | | necessary). |
2. Briefly state the purpose, goals, and specific aims of the research project. | | | 4. Describe how the anticipated results will directly benefit DJJ or a Board of | | Juvenile Justice-regulated facility, program, or service. Please indicate if you will | | be providing an action plan with recommendations based on the findings. |

[/TABLE]

• Page 5 ---

IV. Research Design

1. Describe the planned subject population, including inclusion and exclusion

criteria.

1. For human research proposals, specify recruitment techniques

participants?

1. For human research proposals, describe how consent/assent will be obtained from participants (and parents if minors). Attach all consent/assent forms.

A waiver of consent is requested; justify the waiver.

1. For human research proposals, describe methods and procedures for delivering the intervention/program, if any.

Effective: April 15, 2021 [TABLE 5-1] | 5. Describe the planned subject population, including inclusion and exclusion | | criteria. | | 6. For human research proposals, specify recruitment techniques | | participants? | | 7. For human research proposals, how will consent/assent be obtained from | | participants (and their parents if minors)? Please attach all consent/assent forms. If | | a waiver of consent is requested, please provide a justification for the waiver. | | 8. For human research proposals, describe the specific methods and procedures that | | will be used to deliver the intervention/program to be studied, if any. |

[/TABLE]

• Page 6 ---

1. Describe the specific methods and procedures that will be used to collect the data.

Attach all scripts, surveys, etc. If requesting existing data, list desired

Fields in detail; justify all requested identifiers.

10. Describe the statistical analysis methods to analyze the

data.

11. All research has risks. Describe risks and benefits to participants.

12. Describe plans for confidentiality, security, physical storage, and data destruction timeline.

Effective: April 15, 2021 [TABLE 6-1] | 9. Describe methods and procedures for data collection. | | Please attach all scripts, surveys, etc. If requesting existing data, please list desired | | fields in as much detail as possible. Provide a justification for all of the requested | | identifiers. | | 10. Describe the statistical analysis methodologies that will be used to analyze the | | data. | | 11. All research studies have potential risks. Describe potential risks and benefits to | | participants. | | 12. Describe the plan for keeping information confidential and secure, including the | | physical storage and timeline for destruction of data. |

[/TABLE]

• Page 7 ---

V. Resources and Impact 13. List the DJJ unit/location involved and its role.

14. List resources needed from DJJ (staff, supplies, materials, equipment, workspace, access to participants/files).

15. Explain any possible impacts this research project may have on existing DJJ programs or operations.

VI. Timeline and Products 16. Indicate proposed start and end dates for each research phase.

Note: Time frames are estimates; DJJ cannot guarantee review completion by deadlines.

Data collection: Data analysis:

Preliminary report:

Final report and executive summary:

Effective: April 15, 2021 [TABLE 7-1] 13. List the specific DJJ unit/location involved and its role in the study. | | | 14. List any resources needed for the research project that must be supplied by DJJ | | (e.g., staff, supplies, materials, equipment, workspace, access to participants, | | access to files). | | 15. Explain any possible impacts this research project may have on existing DJJ | | programs or operations. |

[/TABLE]

[TABLE 7-2] | 16. Indicate a proposed time frame (start date – end date) for each phase of the | | | research process. Note: time frames are strictly estimates. DJJ cannot ensure that the | | | review process will be completed in time to meet all deadlines in the proposed timeline. | | Data collection: | | | Data analysis: | | | Preliminary report: | | | Final report and executive summary: | | |

[/TABLE]

• Page 8 ---

17. List final products (reports, presentations, publications) and their audience.

Specify how and to whom results will be distributed.

VII. Attachments: Submit signed Research Agreement and Confidentiality Forms for data access, after reviewing DJJ regulations.

Attach all research documents (consent, assent, surveys, scripts). Must be approved by IRB and DJJ. Do not refer to attachments instead of answering.

VIII. Endorsements: Attach email evidence from endorsers.

or signed letter on letterhead if in a specific unit:  Head of unit (e.g., court, juvenile center);  Deputy Director of division (unit head must request endorsement before

submitting proposal to External Research Coordinator; IRB approval required for human research.

Note: Review may start before IRB approval, but final DJJ approval requires IRB approval.

Effective: April 15, 2021 [TABLE 8-1] | 17. List final products (reports, presentations, publications) and audience. Specify distribution form and recipients. |

[/TABLE]

• Page 9 ---

IX. VLDS Request: For VLDS proposals only. Complete as planned; responses may copy from above.

18. State the project purpose.

19. Explain the project.

20. Alignment – Topics (Select one.) ☐ Collective, long-term impact of health, social service, education, and workforce programs

on people served ☐ Factors or conditions that have the greatest impact on educational achievement and later productivity ☐ Impact of health, social service, education, and workforce pipeline on Virginia’s economy

☐ Pathways to the workforce, patterns of employment, and factors or conditions that predict success ☐ Return on investment of health, social service, education, and workforce opportunities and programs

☐ Other 21. How does this research purpose align with the VLDS research agenda?

Effective: April 15, 2021 [TABLE 9-1] 18. State the purpose of the project. 19. Explain the project. 20. Alignment – Topics (Select one.) ☐ Collective, long-term impact of health, social service, education, and workforce programs on people served ☐ Factors or conditions that have the greatest impact on educational achievement and later productivity ☐ Impact of health, social service, education, and workforce pipeline on Virginia’s economy ☐ Pathways to the workforce, patterns of employment, and factors or conditions that predict success ☐ Return on investment of health, social service, education, and workforce opportunities and programs ☐ Other 21. How does this research purpose align with the VLDS research agenda?

[/TABLE]

• Page 10 ---

22. Funding Source (Select one.)

☐ Non Funded ☐ Funded – Please name the funding organization: Click here to enter text. 23. Target Sample – Describe your target sample cohort (e.g., males between the ages of 25 to

40; Graduate students who attended UVA between 1989 and 2005)

24. Expected Data Requirements – Agency Data Being Used – List the agencies that have partnered with VLDS whose data you want to include in your request.

Effective: April 15, 2021 [TABLE 10-1] 22. Funding Source (Select one.) | | ☐ Non Funded ☐ Funded – Please name the funding organization: Click here to enter text. | | | 23. Target Sample – Describe your target sample cohort (e.g., males between the ages of 25 to | | 40; Graduate students who attended the University of Virginia between the Years of 1989 | | to 2005) | | 24. Expected Data Requirements – Agency Data Being Used – List the agencies that | | have partnered with VLDS whose data you want to include in your request. |

[/TABLE]

• Page 1 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

COMPLIANCE MANUAL

6VAC35-150 - REGULATION FOR NONRESIDENTIAL SERVICES

This compliance manual for the Regulation for Nonresidential Services shall govern all compliance audits of state and locally operated court service units, established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia, conducted by the Department of Juvenile Justice.

1

• Page 2 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Part I General Provisions

6VAC35-150-40. Variances.

6VAC35-150-40. Variances.

A variance may be requested by a program administrator or service provider when conditions exist where the program or service provider is not able to comply with a section or subsection of this chapter. Any such request must meet the criteria and comply with the procedural requirements provided in the Regulations Governing the Monitoring, Approval, and Certification of Juvenile Justice Programs, 6VAC35-20 et seq. and in accordance with written procedures.

Interpretation: Goal: To ensure that (1) any programmatic changes approved for implementation outside the scope of the applicable regulatory requirement meet specific requirements and (2) all programs (including CSUs) follow the same procedure for seeking a variance.

Additional information:

• The variance requests will be reviewed for compliance with this section and the Regulations Governing the Monitoring, Approval, and Certification of Juvenile Justice Programs (specifically, the requirements of 6VAC35-20-92).
• Program administrator means the CSU director.
• Applicable DJJ CSU procedure: 9019

Compliance Determination: Interview CSU director:

• Inquire whether the CSU has any practices in noncompliance with applicable regulatory requirements.
• Inquire whether the CSU has requested or been issued a variance by the Board.

Examine documentation: If a variance has been requested or issued, review documentation for compliance with the applicable regulatory requirements.

Applicable definitions: (cid:1) "Provider" means a person, corporation, partnership, association, organization, or public agency that is legally responsible for compliance with regulatory and statutory requirements relating to the provision of services or the functioning of a program. (cid:1) "Variance" means a Board action that relieves a program from having to meet or develop a plan of action for the requirements of a section or subsection of this chapter. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

2

[TABLE 2-1] 6VAC35-150-40. Variances.

[/TABLE]

[TABLE 2-2] 6VAC35-150-40. Variances.

A variance may be requested by a program administrator or service provider when conditions exist where the program or service provider is not able to comply with a section or subsection of this chapter. Any such request must meet the criteria and comply with the procedural requirements provided in the Regulations Governing the Monitoring, Approval, and Certification of Juvenile Justice Programs, 6VAC35-20 et seq. and in accordance with written procedures.

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• Page 3 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-50. Licensure by other agencies.

6VAC35-150-50. Licensure by other agencies.

A current license or certificate issued by the Commonwealth shall be accepted as evidence of a program's compliance with one or more specific standards of this chapter when the requirements for licensure or certification are substantially the same as, or exceed, the requirements set out in this chapter.

Interpretation: Goal: To avoid duplicative licensing/certification processes.

Additional information: The Department may inquire into the licensure/certification requirements and auditing processes.

Compliance Determination: Interview CSU director: Inquire whether the unit or a program is licensed/certified by another agency.

Examine documentation: If the unit/program is licensed/certified by another agency, review license/certificate and any other applicable documentation for compliance with applicable regulatory requirements.

Applicable definitions: None.

3

[TABLE 3-1] 6VAC35-150-50. Licensure by other agencies.

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[TABLE 3-2] 6VAC35-150-50. Licensure by other agencies.

A current license or certificate issued by the Commonwealth shall be accepted as evidence of a program's compliance with one or more specific standards of this chapter when the requirements for licensure or certification are substantially the same as, or exceed, the requirements set out in this chapter.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Part II Operating Standards for Court Service Units Article 1 Administration

6VAC35-150-60. Organizational structure.

6VAC35-150-60. Organizational structure.

There shall be a written description and organizational chart of the unit showing current lines of authority, responsibility, and accountability, including the unit director's reporting responsibility.

Interpretation: Goal: To ensure the current lines of authority, responsibility, and accountability are formalized.

Additional information:

• There is no standardized format for the design of the "organizational chart." The chart must be of sufficient detail so that the reviewer can follow the lines of authority.
• The “unit director’s reporting responsibility” means the individual to whom the CSU reports.
• The “written description” is inclusive of the titles provided in the organizational chart.

Compliance Determination: Examine documentation: Review organizational chart.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

4

[TABLE 4-1] 6VAC35-150-60. Organizational structure.

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[TABLE 4-2] 6VAC35-150-60. Organizational structure.

There shall be a written description and organizational chart of the unit showing current lines of authority, responsibility, and accountability, including the unit director's reporting responsibility.

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• Page 5 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-62 (A) & (B). Suitable quarters.

6VAC35-150-62 (A). Suitable quarters.

A. The CSU director annually shall review the unit's needs for suitable quarters, utilities, and furnishings and shall request from the appropriate governing body the resources to meet these needs.

Interpretation: Goal: To ensure that CSU has sufficient work space and materials.

Additional information: There is no standardized format for the review and request process. The CSU must be able to show that, annually, the needs are reviewed and, if needs are identified, a request for resources was made.

Compliance Determination: Interview CSU director: Inquire whether and how the unit's needs for suitable quarters, utilities, and furnishings were reviewed and regarding the outcome of the review.

Examine documentation: If the review indicated a need for additional resources, examine the unit's request to the appropriate governing body (i.e., annual budget request).

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

6VAC35-150-62 (B). Suitable quarters.

B. Intake, probation, and parole officers shall have access to private office space.

Interpretation: Goal: To ensure that CSU personnel have access to private office space to protect confidential communications and information.

Additional information: None.

Compliance Determination: Interview staff: Inquire regarding access to private office space.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

5

[TABLE 5-1] 6VAC35-150-62 (A) & (B). Suitable quarters.

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[TABLE 5-2] 6VAC35-150-62 (A). Suitable quarters.

A. The CSU director annually shall review the unit's needs for suitable quarters, utilities, and furnishings and shall request from the appropriate governing body the resources to meet these needs.

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[TABLE 5-3] 6VAC35-150-62 (B). Suitable quarters.

B. Intake, probation, and parole officers shall have access to private office space.

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• Page 6 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-64. Prohibited financial transactions.

6VAC35-150-64. Prohibited financial transactions.

The unit shall not collect or disburse support payments, fines, restitution, court fees, or court costs.

Interpretation: Goal: To ensure the CSU does not collect or disburse funds.

Additional information: None.

Compliance Determination: Interview staff: Inquire regarding any practices related to the collection and disbursement of support payments, fines, restitution, court fees, and court costs.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

6

[TABLE 6-1] 6VAC35-150-64. Prohibited financial transactions.

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[TABLE 6-2] 6VAC35-150-64. Prohibited financial transactions.

The unit shall not collect or disburse support payments, fines, restitution, court fees, or court costs.

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• Page 7 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-66. Procedures for handling funds.

6VAC35-150-66. Procedures for handling funds.

The unit director shall establish written procedures for handling any ongoing unit employee fund established and maintained by the employees that is derived from employee contributions, the operation of vending machines, special fundraising projects, or other employee canteen services, that utilizes the name of the unit or the Department, or that the unit approves the obtaining of or obtains a tax identification number for such funds.

Any such funds are not state funds and shall not be commingled in any way with state funds. The Department's tax identification number shall not be used for such funds.

Interpretation: Goal: To (1) ensure the unit has procedures for handling funds and (2) maintain the fiscal integrity of state funds.

Additional information: Employee funds include those such as a flower fund, drink machine fund, etc.

Compliance Determination: Interview CSU director: Inquire whether the unit has any employee funds that utilize the name of the unit or the Department or that use the unit's or Department's tax identification number.

Review procedures: If the unit has or had, within the audit period, an applicable employee fund, the unit's procedure shall be reviewed.

Examine documentation: If the unit has or had, within the audit period, an applicable employee fund, the account statement or other relevant documents may be reviewed to determine compliance with this section.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

7

[TABLE 7-1] 6VAC35-150-66. Procedures for handling funds.

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[TABLE 7-2] 6VAC35-150-66. Procedures for handling funds.

The unit director shall establish written procedures for handling any ongoing unit employee fund established and maintained by the employees that is derived from employee contributions, the operation of vending machines, special fundraising projects, or other employee canteen services, that utilizes the name of the unit or the Department, or that the unit approves the obtaining of or obtains a tax identification number for such funds.

Any such funds are not state funds and shall not be commingled in any way with state funds. The Department's tax identification number shall not be used for such funds.

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• Page 8 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (A), (B), (C), & (D). Background checks.

6VAC35-150-80 (A). Background checks.

A. Except as provided in subsection C of this section, all persons who (i) accept a position of employment, (ii) volunteer on a regular basis or are interns and will be alone with a juvenile in the performance of their duties, or (iii) provide contractual services directly to a juvenile on a regular basis and will be alone with a juvenile in the performance of their duties in a CSU, or as required by 6VAC35-150-430 C, shall undergo the following background checks to ascertain whether there are criminal acts or other circumstances that would be detrimental to the safety of juveniles:

1. A reference check;
2. A criminal history record check;
3. A fingerprint check with (i) the Virginia State Police (VSP) and (ii) the Federal Bureau of Investigation (FBI);
4. A central registry check with Child Protective Services (CPS); and
5. A driving record check, if applicable to the individual's job duties.

Interpretation: Goal: To standardize screening and hiring procedures to determine suitability of employees, volunteers, interns, and contractual service providers. To protect the safety of juveniles, who are receiving services, under the court's or unit's supervision by ensuring that all required background checks are completed on staff and applicable volunteers, interns, and contract service providers.

Additional information:

• Each CSU must maintain a record of background checks completed since the last audit.
• For state-operated CSUs, the audit team will review the presence of documentation that the investigation was conducted by the Department's background unit. A statement from the Background Unit is satisfactory documentation.
• Review CPS registry check.
• For locally operated CSUs, the auditor will review information on file for each of the required elements. A statement from human resource personnel is satisfactory documentation if it shows that all required elements were completed.
• “In a CSU” means the duties are conducted or services are provided on-site, at the CSU office.

Compliance Determination: Examine documentation: Review new staff, volunteer or intern, or contractual service provider information for each requirement. (The audit team will not review the content of the information on file.) Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Volunteer" or "intern" means any individual or group who of their own free will and without any financial gain provides services without competitive compensation.

8

[TABLE 8-1] 6VAC35-150-80 (A), (B), (C), & (D). Background checks.

[/TABLE]

[TABLE 8-2] 6VAC35-150-80 (A). Background checks.

A. Except as provided in subsection C of this section, all persons who (i) accept a position of employment, (ii) volunteer on a regular basis or are interns and will be alone with a juvenile in the performance of their duties, or (iii) provide contractual services directly to a juvenile on a regular basis and will be alone with a juvenile in the performance of their duties in a CSU, or as required by 6VAC35-150-430 C, shall undergo the following background checks to ascertain whether there are criminal acts or other circumstances that would be detrimental to the safety of juveniles:

1. A reference check;
2. A criminal history record check;
3. A fingerprint check with (i) the Virginia State Police (VSP) and (ii) the Federal Bureau of Investigation (FBI);
4. A central registry check with Child Protective Services (CPS); and
5. A driving record check, if applicable to the individual's job duties.

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• Page 9 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (B). Background checks.

B. To minimize vacancy time when the fingerprint checks, required by subdivision A (3), have been requested, unit staff may be hired pending the results of the fingerprint checks, provided:

1. All of the other applicable components of subsection A of this section have been completed;
2. The applicant is given written notice that continued employment is contingent on the fingerprint check results, as required by subdivision A (3); and
3. Staff hired under this exception shall not be allowed to be alone with juveniles and may work with juveniles only when under the direct supervision of staff whose background checks have been completed until such time as all background checks are completed.

Interpretation: Goal: To minimize vacancy in employee positions while protecting the safety of juveniles under the court's or unit's supervision or receiving services from the unit.

Additional information: None.

Compliance Determination: Examine documentation: Review new staff information for each requirement. Review documentation to ensure written notice is provided to applicants of requirements of this section.

Interview CSU director: Inquire regarding whether the unit's hiring and supervision practices meet the requirements of this section.

Interview staff: Inquire whether new staff, subject to this exception, were left alone with juveniles.

Applicable definitions: (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

9

[TABLE 9-1] 6VAC35-150-80 (B). Background checks.

B. To minimize vacancy time when the fingerprint checks, required by subdivision A (3), have been requested, unit staff may be hired pending the results of the fingerprint checks, provided:

1. All of the other applicable components of subsection A of this section have been completed;
2. The applicant is given written notice that continued employment is contingent on the fingerprint check results, as required by subdivision A (3); and
3. Staff hired under this exception shall not be allowed to be alone with juveniles and may work with juveniles only when under the direct supervision of staff whose background checks have been completed until such time as all background checks are completed.

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• Page 10 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (C). Background checks.

C. The unit, program, or service provider shall have procedures for supervising nonstaff persons, who are not subject to the provisions of subsection A, who have contact with juveniles.

Interpretation: Goal: To ensure juveniles are not left alone with individuals not subject to the background check requirements.

Additional information: This applies to a contract worker or to a service contract provider, such as a maintenance person, who is not alone with a juvenile (and thus has not completed a background check) but may have incidental contact with juveniles just because the worker is present in the office. Applicable DJJ CSU procedure: 9461

Compliance Determination: Review procedures: Review procedures to ensure compliance with the requirements of this section.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Provider" means a person, corporation, partnership, association, organization, or public agency that is legally responsible for compliance with regulatory and statutory requirements relating to the provision of services or the functioning of a program.

10

[TABLE 10-1] 6VAC35-150-80 (C). Background checks.

C. The unit, program, or service provider shall have procedures for supervising nonstaff persons, who are not subject to the provisions of subsection A, who have contact with juveniles.

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• Page 11 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (D). Background checks.

D. Subsection A of this section shall apply to programs to which the CSU refers juveniles who are before the court or before an intake officer, including, but not limited to, programs included in a local Virginia Juvenile Community Crime Control Act plan. When an agency or program refers juveniles to other service providers, excluding community service programs and licensed professionals or programs licensed or regulated by other state agencies, the referring agency shall require the service provider to document that all persons who provide services or supervision through substantial one-on-one contact with juveniles have undergone a background check as required in subsection A of this section.

Interpretation: Goal: To ensure programs to which the CSU refers juveniles comply with the background check requirements.

Additional information: This section applies to programs to which the CSU refers juveniles if (1) the program is not licensed or regulated by another state agency or (2) the service provider is not a licensed professional.

Compliance Determination: Interview CSU director: Inquire regarding processes of approving service providers and referring juveniles to service providers.

Examine documentation: Review the documentation of the CSU's notice that requires programs to which it refers juveniles to document that all persons who provide services have undergone applicable background checks. Review list of programs used by CSU.

• Review notice to programs by CSU.
• Review response from programs confirming compliance.

Applicable definitions: (cid:1) "Agency" means any governmental entity of the Commonwealth or any unit of local government including counties, cities, towns, and regional governments and the Departments thereof, and including any entity, whether public or private, with which any of the foregoing has entered into a contractual relationship for the provision of services as described in this chapter. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Provider" means a person, corporation, partnership, association, organization, or public agency that is legally responsible for compliance with regulatory and statutory requirements relating to the provision of services or the functioning of a program.

11

[TABLE 11-1] 6VAC35-150-80 (D). Background checks.

D. Subsection A of this section shall apply to programs to which the CSU refers juveniles who are before the court or before an intake officer, including, but not limited to, programs included in a local Virginia Juvenile Community Crime Control Act plan. When an agency or program refers juveniles to other service providers, excluding community service programs and licensed professionals or programs licensed or regulated by other state agencies, the referring agency shall require the service provider to document that all persons who provide services or supervision through substantial one-on-one contact with juveniles have undergone a background check as required in subsection A of this section.

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• Page 12 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-90 (A) & (B). Training.

6VAC35-150-90 (A). Training.

A. All employees, volunteers, and interns shall receive documented orientation appropriate to their duties and to address any needs identified by the individual and the supervisor.

Interpretation: Goal: To ensure employee, volunteers, and interns receive appropriate orientation.

Additional information: None.

Compliance Determination: Examine documentation: Review records of employees, volunteers, and interns for documentation of applicable orientations.

Applicable definitions: (cid:1) "Volunteer" or "intern" means any individual or group who of their own free will and without any financial gain provides services without competitive compensation.

6VAC35-150-90 (B). Training.

B. All employees shall receive on-going training and development appropriate to their duties and to address any needs identified by the individual and the supervisor, if applicable.

Interpretation: Goal: To ensure employees receive appropriate on-going training and development.

Additional information:

• This is a new regulatory requirement, replacing the 40-hour per year standing requirement. CSU personnel should closely monitor and skill deficiencies and training expectations detailed in employee work profiles (EWP). The audit team will review the EWP and compared with the training logs and records to ensure that any needed and identified trainings have been completed as indicated in the EWP.
• Trainings can be formal training classes related to the position or informational training through staff meetings if attendance and topics covered are documented.
• Such training shall include training as required by 6VAC35-150-200 (safety and security procedures). If such training is not completed, the unit shall be found in noncompliance with only one regulatory requirement and such noncompliance shall be attributed to section 200.
• Best practice is for the CSU to maintain individual training logs for each staff either through LMS or on-site in the employee’s training or personnel file.

Compliance Determination: Examine documentation: Review the following:

• The Department’s or unit’s training plan or procedure for training requirements; or
• If a training plan or procedure is not in place, review the employee work profile or employee performance evaluations for (1) performance deficiencies or (2) recommended training requirements that are appropriate to their duties; and
• Documentation of applicable trainings.

Interview staff and supervisor: Inquire whether there are adequate and appropriate trainings or any unaddressed training needs.

Applicable definitions: None.

12

[TABLE 12-1] 6VAC35-150-90 (A) & (B). Training.

[/TABLE]

[TABLE 12-2] 6VAC35-150-90 (A). Training.

A. All employees, volunteers, and interns shall receive documented orientation appropriate to their duties and to address any needs identified by the individual and the supervisor.

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[TABLE 12-3] 6VAC35-150-90 (B). Training.

B. All employees shall receive on-going training and development appropriate to their duties and to address any needs identified by the individual and the supervisor, if applicable.

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• Page 13 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-100. Personnel and operating procedures.

6VAC35-150-100. Personnel and operating procedures.

All staff shall have access to approved procedures governing:

1. Recruitment and selection;
2. Grievance and appeal;
3. Confidential individual employee personnel records;
4. Discipline;
5. Equal employment opportunity;
6. Leave and benefits;
7. Resignations and terminations;
8. Orientation;
9. Promotion; 10. Probationary period; and 11. Competitive salary.

Interpretation: Goal: To ensure staff have access to procedures governing their performance and work environment.

Additional information: Procedures may be issued by the Division of Operations, the agency human resources department, the Department of Human Resources Management, or the local equivalents.

Compliance Determination: Examine procedures: Review procedures to ensure that required components are covered. Observe location and availability of the documents.

Interview staff: Inquire regarding access to and availability of applicable procedures.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures.

13

[TABLE 13-1] 6VAC35-150-100. Personnel and operating procedures.

[/TABLE]

[TABLE 13-2] 6VAC35-150-100. Personnel and operating procedures.

All staff shall have access to approved procedures governing:

1. Recruitment and selection;
2. Grievance and appeal;
3. Confidential individual employee personnel records;
4. Discipline;
5. Equal employment opportunity;
6. Leave and benefits;
7. Resignations and terminations;
8. Orientation;
9. Promotion; 10. Probationary period; and 11. Competitive salary.

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• Page 14 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-110 (A), (B), (C), & (D). Volunteers and interns.

6VAC35-150-110 (A). Volunteers and interns.

A. For every volunteer and intern, the unit shall maintain a current description of duties and responsibilities and a list of the minimum required qualifications;

Interpretation: Goal: To ensure every volunteer and intern is qualified for the applicable assignment and has a description of the duties and responsibilities so that expectations are known.

Additional information: None.

Compliance Determination: Examine documentation: Review position descriptions for duties and required qualifications.

Additional information: If qualifications are not included on the volunteer position descriptions, the audit team may examine additional documentation of required qualifications (i.e., correspondence with volunteer or intern).

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Volunteer" or "intern" means any individual or group who of their own free will and without any financial gain provides services without competitive compensation.

6VAC35-150-110 (B). Volunteers and interns.

B. Volunteers and interns shall comply with all applicable regulations, policies, and approved procedures;

Interpretation: Goal: To ensure that volunteers and interns comply with legal and Department requirements.

Additional information: Applicable DJJ Administrative Directive: 15-001.

Compliance Determination: Interview CSU director and/or volunteer coordinator: Inquire regarding compliance with this section.

Examine documentation: Review documentation if there are instances of noncompliance.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Volunteer" or "intern" means any individual or group who of their own free will and without any financial gain provides services without competitive compensation.

14

[TABLE 14-1] 6VAC35-150-110 (A), (B), (C), & (D). Volunteers and interns.

[/TABLE]

[TABLE 14-2] 6VAC35-150-110 (A). Volunteers and interns.

A. For every volunteer and intern, the unit shall maintain a current description of duties and responsibilities and a list of the minimum required qualifications;

[/TABLE]

[TABLE 14-3] 6VAC35-150-110 (B). Volunteers and interns.

B. Volunteers and interns shall comply with all applicable regulations, policies, and approved procedures;

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-110 (C). Volunteers and interns.

C. One or more designated persons shall coordinate volunteer services; and

Interpretation: Goal: To ensure volunteer services are coordinated.

Additional information: None.

Compliance Determination: Interview CSU director and/or volunteer coordinator: Inquire regarding compliance with this section.

Applicable definitions: (cid:1) "Volunteer" or "intern" means any individual or group who of their own free will and without any financial gain provides services without competitive compensation.

6VAC35-150-110 (D). Volunteers and interns.

D. Volunteers and interns shall be registered with the Department.

Interpretation: Goal: To ensure that volunteers and interns are registered with the Department.

Additional information: The Department's primary purpose in requiring registration is for liability insurance purposes, as applicable.

Compliance Determination: Examine documentation: Review the volunteer roster and documentation of it having been sent to the Department on a periodic basis. Compare sample from the active roster of volunteers with the volunteers in the Department's volunteer database.

Additional information: The regulation does not indicate a time frame for when the volunteers and interns are registered.

Applicable definitions: (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Volunteer" or "intern" means any individual or group who of their own free will and without any financial gain provides services without competitive compensation.

15

[TABLE 15-1] 6VAC35-150-110 (C). Volunteers and interns.

C. One or more designated persons shall coordinate volunteer services; and

[/TABLE]

[TABLE 15-2] 6VAC35-150-110 (D). Volunteers and interns.

D. Volunteers and interns shall be registered with the Department.

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• Page 16 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-130 (A) & (B). Research.

6VAC35-150-130 (A). Research.

A. Juveniles shall not be used as subjects of human research, except as provided in 6VAC35-170 and in accord with Chapter 5.1 (§ 32.1-162.16 et seq.) of Title 32.1 of the Code of Virginia.

Interpretation: Goal: To ensure research involving juveniles is conducted in compliance with applicable statutes and regulations.

Additional information: Applicable DJJ Administrative Directive: 07-006.3.

Compliance Determination: Examine documentation: Review any research project for approval (from the Department’s Research and Evaluation Unit or as required by the locality).

Applicable definitions: (cid:1) "Human research" means any systematic investigation using human subjects as defined by § 32.1-162.16 of the Code of Virginia and 6VAC35-170, et seq. Human research shall not include research prohibited by state and federal statutes or regulations or research exempt from federal regulations or mandated by any applicable statutes or regulations. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

6VAC35-150-130 (B). Research.

B. The testing of medicines or drugs for experimentation or research is prohibited.

Interpretation: Goal: To ensure testing of medicines or drugs for experimentation or research does not occur.

Additional information: None.

Compliance Determination: Interview CSU director: Inquire regarding compliance with this section.

Examine documentation: Review approved research projects.

Applicable definitions: None.

16

[TABLE 16-1] 6VAC35-150-130 (A) & (B). Research.

[/TABLE]

[TABLE 16-2] 6VAC35-150-130 (A). Research.

A. Juveniles shall not be used as subjects of human research, except as provided in 6VAC35-170 and in accord with Chapter 5.1 (§ 32.1-162.16 et seq.) of Title 32.1 of the Code of Virginia.

[/TABLE]

[TABLE 16-3] 6VAC35-150-130 (B). Research.

B. The testing of medicines or drugs for experimentation or research is prohibited.

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• Page 17 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-140 (A), (B), (C), & (D). Records management.

6VAC35-150-140 (A). Records management.

A. Case records shall be indexed and kept up to date and uniformly in content and arrangement in accordance with approved procedures.

Interpretation: Goal: To ensure case records are maintained uniformly and in accordance with approved procedures.

Additional information: The CSU director should have procedures that map and describe the case management process. Applicable DJJ CSU procedure: 9450.

Compliance Determination: Review procedure: Examine requirements of applicable procedures.

Examine case records: Review case records and the file management system to ensure they are maintained uniformly and are in accordance with the procedural requirements.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures.

6VAC35-150-140 (B). Records management.

B. Case records shall be kept in a secure location accessible only to authorized staff.

Interpretation: Goal: To ensure case records are maintained securely and information is kept confidential.

Additional information: Case records are not considered secure if they are left in an area where persons other than CSU staff may have access to them (i.e., cleaning personnel).

• “Secure locations” include, but are not limited to, locked cabinets, rooms, or desk drawers.

Case records should be kept in a secure location when not in use.

• The key should not be available to non-CSU staff (except individuals who may require access in case of an emergency).

Compliance Determination: Interview CSU director and staff: Inquire regarding compliance with this section.

Applicable definitions: (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures.

17

[TABLE 17-1] 6VAC35-150-140 (A), (B), (C), & (D). Records management.

[/TABLE]

[TABLE 17-2] 6VAC35-150-140 (A). Records management.

A. Case records shall be indexed and kept up to date and uniformly in content and arrangement in accordance with approved procedures.

[/TABLE]

[TABLE 17-3] 6VAC35-150-140 (B). Records management.

B. Case records shall be kept in a secure location accessible only to authorized staff.

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• Page 18 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-140 (C). Records management.

C. All case records shall be maintained and disposed of in accordance with The Library of Virginia regulations and record retention schedules and with approved procedures.

Interpretation: Goal: To ensure proper maintenance and disposal of case records.

Additional information: None.

Compliance Determination: Review procedure: Review requirements of applicable procedures.

Interview CSU director and staff: Inquire regarding compliance with this section.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures. 6VAC35-150-140 (D). Records management.

D. Any disclosure or release of information shall be in accordance with the Code of Virginia and applicable federal statutes and regulations and approved procedures.

Interpretation: Goal: To ensure records are disclosed only in accordance with applicable statutes, regulations, and procedures.

Additional information: The approved procedure should include the applicable statutory restrictions and requirements (i.e., §§ 16.1-300 and 16.1-309.1 of the Code of Virginia). Applicable DJJ CSU procedure: 9451.

Compliance Determination: Review procedure: Review requirements of applicable procedures.

Interview CSU director and staff: Inquire regarding compliance with this section.

Examine documentation: Review case files for documentation of appropriate release of information (i.e., release of information forms).

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures.

18

[TABLE 18-1] 6VAC35-150-140 (C). Records management.

C. All case records shall be maintained and disposed of in accordance with The Library of Virginia regulations and record retention schedules and with approved procedures.

[/TABLE]

[TABLE 18-2] 6VAC35-150-140 (D). Records management.

D. Any disclosure or release of information shall be in accordance with the Code of Virginia and applicable federal statutes and regulations and approved procedures.

[/TABLE]

• Page 19 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

Article 2 Security and Safety

6VAC35-150-200. Safety and security procedures.

6VAC35-150-200. Safety and security procedures.

In accordance with approved procedures, the unit shall implement:

1. Safety and security practices for the office environment to include at least fire, bomb threat, natural disasters, and hostage and medical emergency situations;
2. Safety and security practices for staff making field visits to juveniles and their families; and
3. Training on appropriate crisis prevention and intervention techniques for the office and the field that staff may use to respond to behavior that poses a risk to the safety of themselves or others.

Interpretation: Goals:

1. To ensure CSU implements procedures for safety and security of staff, juveniles, families, and visitors to the CSU and in the field.
2. To establish that unit staff are trained in safety and security practices in the office environment and for field visits.

Additional information:

• Applicable DJJ CSU procedure: 9461.
• Training requirements are referenced in 6VAC35-150-90 (B). If safety and security and crisis intervention training is not completed, the unit will be found in noncompliance with only the section 200 regulatory requirement (and not section 90).

Compliance Determination: Interview staff: Inquire regarding staff knowledge of procedures and implementation of procedures.

Examine documentation: Review orientation records for new staff.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

19

[TABLE 19-1] 6VAC35-150-200. Safety and security procedures.

[/TABLE]

[TABLE 19-2] 6VAC35-150-200. Safety and security procedures.

In accordance with approved procedures, the unit shall implement:

1. Safety and security practices for the office environment to include at least fire, bomb threat, natural disasters, and hostage and medical emergency situations;
2. Safety and security practices for staff making field visits to juveniles and their families; and
3. Training on appropriate crisis prevention and intervention techniques for the office and the field that staff may use to respond to behavior that poses a risk to the safety of themselves or others.

[/TABLE]

• Page 20 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-210 (A) & (B). Physical force.

6VAC35-150-210 (A). Physical force.

A. Physical force shall be used only as a last resort and shall never be used as punishment. Staff shall use only the minimum force deemed reasonable and necessary to eliminate the imminent risk to the safety of themselves or others.

Interpretation: Goal: To ensure physical force is used only as required by this section.

Additional information: None.

Compliance Determination: Interview staff: Inquire regarding use of physical force.

Examine documentation: Review documentation of any instances involving physical force for compliance with this section.

Applicable definitions: None.

6VAC35-150-210 (B). Physical force.

B. Each use of physical force shall be reported in writing to the CSU director, who shall ensure that all reportable incidents are further reported in accordance with the Department's procedures for reporting serious incidents.

Interpretation: Goal: To ensure use of physical force is reported in compliance with this section.

Additional information: Applicable DJJ CSU procedure: 9462

Compliance Determination: Interview staff: Inquire regarding use of physical force.

Examine documentation: Review documentation of any instances involving physical force for compliance with this section.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Department" means the Department of Juvenile Justice.

20

[TABLE 20-1] 6VAC35-150-210 (A) & (B). Physical force.

[/TABLE]

[TABLE 20-2] 6VAC35-150-210 (A). Physical force.

A. Physical force shall be used only as a last resort and shall never be used as punishment. Staff shall use only the minimum force deemed reasonable and necessary to eliminate the imminent risk to the safety of themselves or others.

[/TABLE]

[TABLE 20-3] 6VAC35-150-210 (B). Physical force.

B. Each use of physical force shall be reported in writing to the CSU director, who shall ensure that all reportable incidents are further reported in accordance with the Department's procedures for reporting serious incidents.

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• Page 21 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-220. Searches.

6VAC35-150-220. Searches.

Searches of an individual's person and immediate area may be conducted only in accordance with approved procedures, with all applicable state and federal statutes and regulations, and with the Virginia and United States constitutions. Only staff who have received training approved by the Department shall conduct searches.

Interpretation: Goal: To ensure searches are conducted by trained staff in accordance with the Constitution and applicable statutes, regulations, and procedures.

Additional information: Applicable DJJ CSU procedure: 9469.

Compliance Determination: Review procedure: Review procedure.

Interview CSU director or staff: Inquire whether CSU personnel conduct searches. If searches are performed, inquire whether search practices are conducted in compliance with this section.

Examine documentation: If staff are approved to conduct searches, (1) ensure training has been approved by the Department and (2) examine training records for compliance with this section.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Department" means the Department of Juvenile Justice.

21

[TABLE 21-1] 6VAC35-150-220. Searches.

[/TABLE]

[TABLE 21-2] 6VAC35-150-220. Searches.

Searches of an individual's person and immediate area may be conducted only in accordance with approved procedures, with all applicable state and federal statutes and regulations, and with the Virginia and United States constitutions. Only staff who have received training approved by the Department shall conduct searches.

[/TABLE]

• Page 22 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-230 (A) & (B). Weapons.

6VAC35-150-230 (A). Weapons.

A. A probation officer may obtain authorization to carry a weapon as provided by § 16.1-237 of the Code of Virginia only in accordance with approved procedures that require at least: (i) firearms safety training, (ii) a psychological or mental health assessment, (iii) approval by the CSU director, and (iv) approval by the unit director's supervisor.

Interpretation: Goal: To ensure that (1) probation officers obtain authorization to carry a weapon in accordance with the applicable statute and procedures and (2) procedures contain components required by this section.

Applicable DJJ Administrative Directive: 18-004.1.

Additional information: “Weapon” means a firearm.

Compliance Determination: Interview CSU director and staff: Inquire whether probation officers have been authorized to carry a weapon.

Examine documentation: If probation officers have been authorized to carry a weapon, examine (1) procedure to ensure compliance with this section and (2) records of staff authorized to carry a weapon for elements required by this section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a).

22

[TABLE 22-1] 6VAC35-150-230 (A) & (B). Weapons.

[/TABLE]

[TABLE 22-2] 6VAC35-150-230 (A). Weapons.

A. A probation officer may obtain authorization to carry a weapon as provided by § 16.1-237 of the Code of Virginia only in accordance with approved procedures that require at least: (i) firearms safety training, (ii) a psychological or mental health assessment, (iii) approval by the CSU director, and (iv) approval by the unit director's supervisor.

[/TABLE]

• Page 23 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-230 (B). Weapons.

B. All CSU staff authorized to carry weapons shall have received training and retraining, in accordance with approved procedures, which shall include the limited circumstances when weapons may be carried and used as required by law and liability insurance coverage.

Interpretation: Goal: To ensure that CSU staff authorized to carry weapons receive appropriate training and retraining.

Additional information: Applicable DJJ Administrative Directive: 18-004.1

Compliance Determination: Examine documentation: If CSU staff are authorized to carry weapons, review (1) procedure for required training elements; (2) documentation for training approval by the Department; and (3) the authorized staff's training records.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

23

[TABLE 23-1] 6VAC35-150-230 (B). Weapons.

B. All CSU staff authorized to carry weapons shall have received training and retraining, in accordance with approved procedures, which shall include the limited circumstances when weapons may be carried and used as required by law and liability insurance coverage.

[/TABLE]

• Page 24 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-240. Arrest of juvenile by staff.

6VAC35-150-240. Arrest of juvenile by staff.

Probation officers shall exercise their arrest powers in accordance with approved procedures.

Interpretation: Goal: To ensure probation officers exercise their arrest powers in accordance with approved procedures.

Additional information: Applicable DJJ CSU procedure: 9463.

Compliance Determination: Interview CSU director and staff: Inquire whether arrests have been made by probation officers.

Examine procedure: Review components of the procedure.

Examine documentation: If probation officers have made arrests, review documentation to ensure compliance with the requirements of the procedure (i.e., training).

Additional information: If probation officers have made arrests and documentation of the arrests are not maintained, the audit team may interview staff for compliance with the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a).

24

[TABLE 24-1] 6VAC35-150-240. Arrest of juvenile by staff.

[/TABLE]

[TABLE 24-2] 6VAC35-150-240. Arrest of juvenile by staff.

Probation officers shall exercise their arrest powers in accordance with approved procedures.

[/TABLE]

• Page 25 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-250. Absconders.

6VAC35-150-250. Absconders.

Unit staff shall cooperate with Department personnel and state and local law-enforcement authorities to help locate and recover juveniles who violate the conditions of their probation or parole supervision and upon whom a detention order has been issued or who escape or run away from a juvenile correctional center, detention home, or other juvenile placement.

Interpretation: Goal: To ensure cooperation between the Department and law-enforcement personnel.

Additional information: CSUs are also subject to the requirements of § 16.1-309.1 of the Code of Virginia.

Compliance Determination: Interview CSU director and staff: Inquire whether any juveniles have absconded.

Examine documentation: If juveniles have absconded, examine case records for compliance with this section.

Additional information: The audit team may also interview staff who liaisoned with law enforcement to determine compliance with this section.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Parole" means supervision of a juvenile released from commitment to the Department as provided for by §§ 16.1-285, 16.1-285.1, and 16.1-285.2 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a). (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

25

[TABLE 25-1] 6VAC35-150-250. Absconders.

[/TABLE]

[TABLE 25-2] 6VAC35-150-250. Absconders.

Unit staff shall cooperate with Department personnel and state and local law-enforcement authorities to help locate and recover juveniles who violate the conditions of their probation or parole supervision and upon whom a detention order has been issued or who escape or run away from a juvenile correctional center, detention home, or other juvenile placement.

[/TABLE]

• Page 26 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-260. Transportation of detained juveniles.

6VAC35-150-260 . Transportation of detained juveniles.

Detained juveniles shall be transported in accord with "Guidelines for Transporting Juveniles in Detention," current edition issued by the board in accord with § 16.1-254 of the Code of Virginia.

Interpretation: Goal: To ensure transportation of detained juveniles is conducted in accordance with the guidelines issued by the Board of Juvenile Justice.

Additional information: None.

Compliance Determination: Interview CSU director and staff: Inquire regarding procedures for transporting detained juveniles.

Examine documentation: Observe guideline availability if transportation is conducted by CSU staff.

Compare practices ascertained in the interviews with the requirements of the guidelines.

Applicable definitions: (cid:1) "Board" means the Board of Juvenile Justice. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

26

[TABLE 26-1] 6VAC35-150-260. Transportation of detained juveniles.

[/TABLE]

[TABLE 26-2] 6VAC35-150-260 . Transportation of detained juveniles.

Detained juveniles shall be transported in accord with "Guidelines for Transporting Juveniles in Detention," current edition issued by the board in accord with § 16.1-254 of the Code of Virginia.

[/TABLE]

• Page 27 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Article 3 Intake

6VAC35-150-270 (A), (B), & (C). Intake duties.

6VAC35-150-270 (A). Intake duties.

A. When making an intake determination as provided for by § 16.1-260 of the Code of Virginia, whether in person or by telephone or interactive video conferencing, the intake officer shall, in accordance with approved procedures:

1. Explain the steps and options in the intake process to each person present as provided for in approved procedures;
2. Make all required data entries into the Department's electronic data collection system in accordance with § 16.1-224 of the Code of Virginia and approved procedures;
3. Consult with available parents, guardians, legal custodian, or other person standing in loco parentis to determine the appropriate placement; and
4. Notify the juvenile's parents, guardians, legal custodian, or other person standing in loco parentis in cases involving the juvenile's detention.

Interpretation: Goal: To ensure that intake determinations comply with this section and procedures.

Additional information: Applicable DJJ CSU procedure: 9115.

Compliance Determination: Review procedure: Review procedural requirements to ensure compliance with this section.

Interview intake officers: Inquire whether the requirements of this section and procedures are followed.

Examine documentation: Examine electronic data system and/or case records for required entries.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Intake" means the process for screening complaints and requests alleged to be within the jurisdiction of the juvenile and domestic relations district court pursuant to § 16.1-260 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

27

[TABLE 27-1] 6VAC35-150-270 (A), (B), & (C). Intake duties.

[/TABLE]

[TABLE 27-2] 6VAC35-150-270 (A). Intake duties.

A. When making an intake determination as provided for by § 16.1-260 of the Code of Virginia, whether in person or by telephone or interactive video conferencing, the intake officer shall, in accordance with approved procedures:

1. Explain the steps and options in the intake process to each person present as provided for in approved procedures;
2. Make all required data entries into the Department's electronic data collection system in accordance with § 16.1-224 of the Code of Virginia and approved procedures;
3. Consult with available parents, guardians, legal custodian, or other person standing in loco parentis to determine the appropriate placement; and
4. Notify the juvenile's parents, guardians, legal custodian, or other person standing in loco parentis in cases involving the juvenile's detention.

[/TABLE]

• Page 28 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 6VAC35-150-270 (B). Intake duties.

B. When making a detention decision pursuant to § 16.1-248.1 of the Code of Virginia and when making recommendations to the court at a detention hearing pursuant to § 16.1-250 of the Code of Virginia, CSU personnel shall make use of the uniform risk assessment instrument and related procedure mandated by Chapter 648 of the 2002 Acts of Assembly.

Interpretation: Goal: To ensure detention decisions are made using the uniform risk assessment instrument and related procedure.

Additional information: Applicable DJJ CSU procedures: 9115, 9131, and 9135.

Compliance Determination: Interview intake officers: Inquire whether detention decisions are made in accordance with this section.

Examine documentation: Review case records of detained juveniles or electronic data system entries for compliance with this section. Such review will examine whether use of the risk assessment instrument comported with the requirements of the procedures.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

6VAC35-150-270 (C). Intake duties.

C. When the chief judge in a jurisdiction requests the provision of a replacement intake officer pursuant to § 16.1-235.1 of the Code of Virginia, the CSU shall enter into a written agreement with the requesting court that shall address, at a minimum, the scope of the intake duties, the location where intake cases will be processed, and the protocol for arranging any required face-to-face contact between the intake officer and juvenile.

Interpretation: Goal: To ensure the provision of replacement intake officers is provided as required by statute.

Additional information: None.

Compliance Determination: Interview CSU director: Inquire whether the chief judge requested the provision of replacement intake officers.

Examine documentation: If a chief judge requested replacement intake officers, review agreement for compliance with this section and § 16.1-235.1 of the Code of Virginia.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Intake" means the process for screening complaints and requests alleged to be within the jurisdiction of the juvenile and domestic relations district court pursuant to § 16.1-260 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form. 28

[TABLE 28-1] 6VAC35-150-270 (B). Intake duties.

B. When making a detention decision pursuant to § 16.1-248.1 of the Code of Virginia and when making recommendations to the court at a detention hearing pursuant to § 16.1-250 of the Code of Virginia, CSU personnel shall make use of the uniform risk assessment instrument and related procedure mandated by Chapter 648 of the 2002 Acts of Assembly.

[/TABLE]

[TABLE 28-2] 6VAC35-150-270 (C). Intake duties.

C. When the chief judge in a jurisdiction requests the provision of a replacement intake officer pursuant to § 16.1-235.1 of the Code of Virginia, the CSU shall enter into a written agreement with the requesting court that shall address, at a minimum, the scope of the intake duties, the location where intake cases will be processed, and the protocol for arranging any required face-to-face contact between the intake officer and juvenile.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-280. Medical and psychiatric emergencies at intake.

6VAC35-150-280. Medical and psychiatric emergencies at intake.

If during the intake interview, the intake officer suspects that the juvenile requires emergency medical or psychiatric care, the intake officer shall:

1. Immediately contact the juvenile's parents or legal guardians to advise them of the emergency and any responsibilities they may have; and
2. Before placing a juvenile in a more restrictive setting, the intake officer shall arrange for the juvenile to receive the needed emergency care.

Interpretation: Goal: To ensure the intake officer complies with this section when, during the intake interview, the officer suspects a juvenile requires emergency medical or psychiatric care.

Additional information: Applicable DJJ CSU procedure: 9125.

Compliance Determination: Interview CSU director and intake officer: Inquire whether any intake officers have suspected a medical or psychiatric emergency during an intake interview.

Examine documentation: If an intake officer dealt with a medical or psychiatric emergency during the intake interview, examine case record or electronic data system for compliance with this section.

Applicable definitions: (cid:1) "Intake" means the process for screening complaints and requests alleged to be within the jurisdiction of the juvenile and domestic relations district court pursuant to § 16.1-260 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

29

[TABLE 29-1] 6VAC35-150-280. Medical and psychiatric emergencies at intake.

[/TABLE]

[TABLE 29-2] 6VAC35-150-280. Medical and psychiatric emergencies at intake.

If during the intake interview, the intake officer suspects that the juvenile requires emergency medical or psychiatric care, the intake officer shall:

1. Immediately contact the juvenile's parents or legal guardians to advise them of the emergency and any responsibilities they may have; and
2. Before placing a juvenile in a more restrictive setting, the intake officer shall arrange for the juvenile to receive the needed emergency care.

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• Page 30 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-290. Intake communication with detention.

6VAC35-150-290. Intake communication with detention.

When CSU staff facilitate the placement of a juvenile in detention, they shall give detention staff, by telephone, in writing, or by electronic means, no later than the time the juvenile arrives at the detention facility, the reason for detention and the offenses for which the juvenile is being detained including any ancillary offenses. CSU staff shall also give detention staff the following information when available and applicable: medical information; parents' or guardians' names, addresses and phone numbers; prior record as regards sexual offenses, violence against persons, or arson; suicide attempts or self-injurious behaviors; gang membership and affiliation; and any other information as required by approved procedure.

Interpretation: Goal: To ensure CSU staff share necessary information in facilitating the placement of a juvenile in detention.

Additional information: Applicable DJJ CSU procedure: 9132.

Compliance Determination: Examine procedure: Review procedure for required components.

Interview CSU staff: Inquire regarding CSU contacts with detention center when facilitating the placement of a juvenile in detention.

Interview detention center staff: Contact the most frequently used detention center; inquire regarding compliance with the section and the applicable procedure.

Examine documentation: Review case record or electronic data system to ensure information (if available) is shared with the detention center in compliance with this section and applicable procedures.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

30

[TABLE 30-1] 6VAC35-150-290. Intake communication with detention.

[/TABLE]

[TABLE 30-2] 6VAC35-150-290. Intake communication with detention.

When CSU staff facilitate the placement of a juvenile in detention, they shall give detention staff, by telephone, in writing, or by electronic means, no later than the time the juvenile arrives at the detention facility, the reason for detention and the offenses for which the juvenile is being detained including any ancillary offenses. CSU staff shall also give detention staff the following information when available and applicable: medical information; parents' or guardians' names, addresses and phone numbers; prior record as regards sexual offenses, violence against persons, or arson; suicide attempts or self-injurious behaviors; gang membership and affiliation; and any other information as required by approved procedure.

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• Page 31 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Article 4 Out-of-Home Placements

6VAC35-150-300 (A), (B), & (C). Predispositionally placed juvenile.

6VAC35-150-300 (A). Predispositionally placed juvenile.

A. In accordance with approved procedures, a representative of the CSU shall make contact, either face-to-face or via videoconferencing, with each juvenile placed in predispositional detention, jail, or shelter care pursuant to § 16.1-248.1 of the Code of Virginia, within five days of the placement. A representative of the CSU shall make contact with the juvenile at least once every 10 days thereafter either face-to-face or by telephone or videoconferencing. All such contacts shall include direct communication between the CSU staff and the juvenile.

Interpretation: Goal: To ensure that a representative of the CSU maintains contact with juveniles placed predispositionally in detention, jail, or shelter care as required by this section.

Additional information:

• A representative of the CSU should inquire regarding the adjustment and safety of, answer any questions posed by, and provide any necessary information to the detained juvenile. This visit can be a private meeting away from the courtroom prior to transport to detention home. Applicable DJJ CSU procedure: 9134.
• This requirement applies to juveniles whose cases have been transferred to circuit court for trial as an adult who are confined in a jail pending trial.

Compliance Determination: Examine procedure: Review components of the procedure.

Examine documentation: Review case records or other documentation of the contact with predispositionally detained juveniles to determine compliance with this section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

31

[TABLE 31-1] 6VAC35-150-300 (A), (B), & (C). Predispositionally placed juvenile.

[/TABLE]

[TABLE 31-2] 6VAC35-150-300 (A). Predispositionally placed juvenile.

A. In accordance with approved procedures, a representative of the CSU shall make contact, either face-to-face or via videoconferencing, with each juvenile placed in predispositional detention, jail, or shelter care pursuant to § 16.1-248.1 of the Code of Virginia, within five days of the placement. A representative of the CSU shall make contact with the juvenile at least once every 10 days thereafter either face-to-face or by telephone or videoconferencing. All such contacts shall include direct communication between the CSU staff and the juvenile.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-300 (B). Predispositionally placed juvenile.

B. The case of each predispositionally placed juvenile shall be reviewed at least every 10 days in accordance with approved procedures to determine whether there has been a material change sufficient to warrant recommending a change in placement.

Interpretation: Goal: To ensure the case of each predispositionally placed juvenile is reviewed as required by this section.

Additional information: The CSU staff should take all efforts to ensure the continued detention of juveniles is appropriate. Applicable DJJ CSU procedure: 9134.

Compliance Determination: Examine procedure: Review procedural requirements.

Examine documentation: Review case records or other documentation of the review of predispositionally detained juveniles for compliance with this section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

32

[TABLE 32-1] 6VAC35-150-300 (B). Predispositionally placed juvenile.

B. The case of each predispositionally placed juvenile shall be reviewed at least every 10 days in accordance with approved procedures to determine whether there has been a material change sufficient to warrant recommending a change in placement.

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• Page 33 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-300 (C). Predispositionally placed juvenile.

C. When the unit is the placing agency and is supervising a juvenile in a residential facility, designated staff of the CSU shall be available to the facility's staff 24 hours a day in case of emergency.

Interpretation: Goal: To ensure that the residential facility has access to CSU personnel in case of emergency.

Additional information: None.

Compliance Determination: Interview staff: Inquire regarding on-call/24-hour coverage practices.

Examine documentation: Review on-call/24-hour schedule for coverage.

Applicable definitions: (cid:1) "Agency" means any governmental entity of the Commonwealth or any unit of local government including counties, cities, towns, and regional governments and the Departments thereof, and including any entity, whether public or private, with which any of the foregoing has entered into a contractual relationship for the provision of services as described in this chapter. (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

33

[TABLE 33-1] 6VAC35-150-300 (C). Predispositionally placed juvenile.

C. When the unit is the placing agency and is supervising a juvenile in a residential facility, designated staff of the CSU shall be available to the facility's staff 24 hours a day in case of emergency.

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• Page 34 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-310 (A) & (B). Postdispositional detention.

6VAC35-150-310 (A). Postdispositional detention.

A. When a court orders a juvenile to be detained postdispositionally for more than 30 days pursuant to subsection B of § 16.1-284.1 of the Code of Virginia, the CSU staff shall develop a written plan with the facility to enable such juvenile to take part in one or more community treatment programs appropriate for that juvenile's rehabilitation, which may be provided at the facility or while the juvenile is on temporary release status, as determined by that juvenile's risk to public safety and other relevant factors. The CSU shall provide a copy of the juvenile's social history to the postdispositional detention program upon request.

Interpretation: Goal: To ensure collaboration between the CSU staff and postdispositional detention program staff in accordance with this section.

Additional information: None.

Compliance Determination: Examine documentation: Review case records of postdispositionally placed juveniles for compliance with this section including CSU development of the plan and documentation that, if requested, a copy of the social history was sent. .

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

34

[TABLE 34-1] 6VAC35-150-310 (A) & (B). Postdispositional detention.

[/TABLE]

[TABLE 34-2] 6VAC35-150-310 (A). Postdispositional detention.

A. When a court orders a juvenile to be detained postdispositionally for more than 30 days pursuant to subsection B of § 16.1-284.1 of the Code of Virginia, the CSU staff shall develop a written plan with the facility to enable such juvenile to take part in one or more community treatment programs appropriate for that juvenile's rehabilitation, which may be provided at the facility or while the juvenile is on temporary release status, as determined by that juvenile's risk to public safety and other relevant factors. The CSU shall provide a copy of the juvenile's social history to the postdispositional detention program upon request.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-310 (B). Postdispositional detention.

B. The case record of a juvenile placed in a postdispositional detention program pursuant to subsection B of § 16.1-284.1 of the Code of Virginia shall contain:

1. Social history;
2. Court order;
3. Reason for placement; and
4. Current supervision plan, if applicable.

Interpretation: Goal: To ensure case records of postdispositionally placed juveniles are maintained in accordance with this section.

Additional information: None.

Compliance Determination: Examine documentation: Review case records of postdispositionally placed juveniles for compliance with this section.

Applicable definitions: (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures. (cid:1) "Individual supervision plan" means a written plan developed, updated as needed, and modified at intervals to meet the needs of a juvenile or adult. It specifies measurable short-term and long-term goals, the objectives, strategies, and time frames for reaching the goals, and the individuals responsible for carrying out the plan. Individual supervision plans are applicable during probation and parole and for treatment of a juvenile or an adult and the services for the juvenile's family for the time during which a juvenile is committed to the Department. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

35

[TABLE 35-1] 6VAC35-150-310 (B). Postdispositional detention.

B. The case record of a juvenile placed in a postdispositional detention program pursuant to subsection B of § 16.1-284.1 of the Code of Virginia shall contain:

1. Social history;
2. Court order;
3. Reason for placement; and
4. Current supervision plan, if applicable.

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• Page 36 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-320. Notice of juvenile's transfer.

6VAC35-150-320. Notice of juvenile's transfer.

When CSU staff have knowledge that a juvenile has been moved from one residential facility to another residential facility and do not have knowledge that the juvenile's parents or legal guardians have been advised of the transfer, CSU staff shall notify the juvenile's parents or legal guardians within 24 hours and shall document the notification in the juvenile's case record.

Interpretation: Goal: To ensure parents or legal guardians are advised of juveniles' transfer from one residential facility to another while avoiding duplicative work for CSU personnel.

Additional information: None.

Compliance Determination: Examine documentation: Review a sample of case records for knowledge of move. If knowledge of move, review for knowledge of parental notification. Examine record for documentation of notice having been sent to the parent or legal guardian in compliance with this section.

Applicable definitions: (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

36

[TABLE 36-1] 6VAC35-150-320. Notice of juvenile's transfer.

[/TABLE]

[TABLE 36-2] 6VAC35-150-320. Notice of juvenile's transfer.

When CSU staff have knowledge that a juvenile has been moved from one residential facility to another residential facility and do not have knowledge that the juvenile's parents or legal guardians have been advised of the transfer, CSU staff shall notify the juvenile's parents or legal guardians within 24 hours and shall document the notification in the juvenile's case record.

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• Page 37 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Article 5 Probation, Parole, and Other Supervision

6VAC35-150-335 (A), (B), & (C). Diversion.

6VAC35-150-335 (A). Diversion.

A. When an intake officer proceeds with diversion in accordance with subsection B of § 16.1-260 of the Code of Virginia, such supervision shall not exceed 120 days. For a juvenile alleged to be a truant pursuant to a complaint filed in accordance with § 22.1-258 of the Code of Virginia, such supervision shall be limited to 90 days.

Interpretation: Goal: To ensure diversions are processed in accordance with this section and the Code of Virginia.

Additional information: Applicable DJJ CSU procedure: 9123.

Compliance Determination: Examine documentation: Review a sample of case records of diverted juveniles for compliance with this section.

Applicable definitions: (cid:1) "Diversion" means the provision of counseling, informal supervision, programs, or services, or a combination thereof, which is consistent with the protection of the public safety and the welfare of the juvenile as provided for in §§ 16.1-227 and 16.1-260 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

37

[TABLE 37-1] 6VAC35-150-335 (A), (B), & (C). Diversion.

[/TABLE]

[TABLE 37-2] 6VAC35-150-335 (A). Diversion.

A. When an intake officer proceeds with diversion in accordance with subsection B of § 16.1-260 of the Code of Virginia, such supervision shall not exceed 120 days. For a juvenile alleged to be a truant pursuant to a complaint filed in accordance with § 22.1-258 of the Code of Virginia, such supervision shall be limited to 90 days.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-335 (B). Diversion.

B. When a new complaint is filed against a juvenile who is currently under supervision in accordance with subsection A of this section, and the juvenile qualifies for diversion in accordance with subsection B of § 16.1-260 of the Code of Virginia, then the intake officer may proceed with diversion for an additional 120 days from the date of the subsequent complaint.

Interpretation: Goal: To ensure subsequent diversions are processed in accordance with this section and the Code of Virginia.

Additional information: This section is permissive. The second or subsequent offense does not have to be diverted. However, if it is diverted, the diversion must not exceed 120 days.

Compliance Determination: Examine documentation: Review a sample of case records of juveniles with a second or subsequent diversion for compliance with this section.

Applicable definitions: (cid:1) "Diversion" means the provision of counseling, informal supervision, programs, or services, or a combination thereof, which is consistent with the protection of the public safety and the welfare of the juvenile as provided for in §§ 16.1-227 and 16.1-260 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

6VAC35-150-335 (C). Diversion.

C. In no case shall a petition be filed by the CSU based on acts or offenses in the original complaint after 120 days from the date of the initial referral on the original complaint.

Interpretation: Goal: To ensure diversion cases are processed in accordance with this section.

Additional information: None.

Compliance Determination: Examine documentation: Review a sample of case records of diverted juveniles for compliance with this section (whether petitions are filed more than 120 days from the date of the original complaint).

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

38

[TABLE 38-1] 6VAC35-150-335 (B). Diversion.

B. When a new complaint is filed against a juvenile who is currently under supervision in accordance with subsection A of this section, and the juvenile qualifies for diversion in accordance with subsection B of § 16.1-260 of the Code of Virginia, then the intake officer may proceed with diversion for an additional 120 days from the date of the subsequent complaint.

[/TABLE]

[TABLE 38-2] 6VAC35-150-335 (C). Diversion.

C. In no case shall a petition be filed by the CSU based on acts or offenses in the original complaint after 120 days from the date of the initial referral on the original complaint.

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• Page 39 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-336 (A), (B), &(C). Social histories.

6VAC35-150-336 (A). Social histories.

A. A social history shall be prepared in accordance with approved procedures (i) when ordered by the court, (ii) for each juvenile placed on probation supervision with the unit, (iii) for each juvenile committed to the Department, (iv) for each juvenile placed in a postdispositional detention program for more than 30 days pursuant to § 16.1-284.1 of the Code of Virginia, or (v) upon written request from another unit when accompanied by a court order. Social history reports shall include the following information:

1. Identifying and demographic information on the juvenile;
2. Current offense and prior court involvement;
3. Social, medical, psychological, and educational information about the juvenile;
4. Information about the family; and
5. Dispositional recommendations, if permitted by the court.

Interpretation: Goal: To ensure social history reports are completed in accordance with the Code of Virginia, this section, and the procedures.

Additional information: Internal procedures and format should be developed by the CSU Director.

Applicable DJJ CSU procedure: 9230.

Compliance Determination: Review procedure: Examine the procedure for required components and compliance with this section.

Examine documentation: Review a sample of case records for compliance with this section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a). (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

39

[TABLE 39-1] 6VAC35-150-336 (A), (B), &(C). Social histories.

[/TABLE]

[TABLE 39-2] 6VAC35-150-336 (A). Social histories.

A. A social history shall be prepared in accordance with approved procedures (i) when ordered by the court, (ii) for each juvenile placed on probation supervision with the unit, (iii) for each juvenile committed to the Department, (iv) for each juvenile placed in a postdispositional detention program for more than 30 days pursuant to § 16.1-284.1 of the Code of Virginia, or (v) upon written request from another unit when accompanied by a court order. Social history reports shall include the following information:

1. Identifying and demographic information on the juvenile;
2. Current offense and prior court involvement;
3. Social, medical, psychological, and educational information about the juvenile;
4. Information about the family; and
5. Dispositional recommendations, if permitted by the court.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-336 (B). Social histories.

B. An existing social history that is less than 12 months old may be used provided an addendum is prepared updating all changed information. A new social history shall be prepared as required in subsection A of this section or when ordered by the court if the existing social history is more than 12 months old.

Interpretation: Goal: To ensure social history information is up-to-date and that judicial/service referral decisions are not based on information that is not current.

Additional information: Format of the addendum may be provided in unit procedures.

Compliance Determination: Interview CSU director and staff: Inquire regarding social histories and addendum practices.

Examine documentation: Review case files for compliance with this section.

Applicable definitions: None.

6VAC35-150-336 (C). Social histories.

C. Social history reports on adults may be modified as provided for in procedures approved by the CSU director after consultation with the judge or judges of the court.

Interpretation: Goal: To ensure social histories on adults are in a format provided for in approved procedures or in a format approved by the CSU director after consultation with the judge or judges of the court.

Additional information: Internal procedures and format should be developed by the CSU director.

Applicable DJJ CSU procedure: 9230.

Compliance Determination: Interview CSU director: Inquire whether the CSU utilizes the format (1) provided for in section 336 and approved procedures or (2) approved by the CSU director after consultation with the judge or judges of the court.

Review procedure: If modified format is used, review procedure for required components.

Examine documentation: Examine adult case records for compliance with applicable format and content requirements.

Applicable definitions: (cid:1) "Adult" means a person 18 years of age or older who is not a delinquent child as defined in § 16.1-228 of the Code of Virginia. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

40

[TABLE 40-1] 6VAC35-150-336 (B). Social histories.

B. An existing social history that is less than 12 months old may be used provided an addendum is prepared updating all changed information. A new social history shall be prepared as required in subsection A of this section or when ordered by the court if the existing social history is more than 12 months old.

[/TABLE]

[TABLE 40-2] 6VAC35-150-336 (C). Social histories.

C. Social history reports on adults may be modified as provided for in procedures approved by the CSU director after consultation with the judge or judges of the court.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-340. Beginning supervision.

6VAC35-150-340. Beginning supervision.

Within the timeframes established by approved procedures for beginning supervision, a probation or parole officer shall:

1. See the juvenile face-to-face;
2. Give the juvenile the written rules of supervision, including any special conditions, and explain these to the juvenile and, when appropriate, to the juvenile's parents or guardians; and
3. Document these actions in the case record.

Interpretation: Goal: To ensure probation and parole officers follow approved procedures and the requirements of this section when beginning supervision.

Additional information: The required time frames begin to run when the court order placing the individual under the supervision of the unit is received by the unit. Best practice is for the court order to be date stamped. If the court order is not date stamped, the time frames will begin to run on the date the court order was issued. Applicable DJJ CSU procedure: 9323.

Compliance Determination: Review procedure: Examine procedure to determine applicable time frames.

Examine documentation: Review a sample of case records for compliance with the section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Parole" means supervision of a juvenile released from commitment to the Department as provided for by §§ 16.1-285, 16.1-285.1, and 16.1-285.2 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a). (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

41

[TABLE 41-1] 6VAC35-150-340. Beginning supervision.

[/TABLE]

[TABLE 41-2] 6VAC35-150-340. Beginning supervision.

Within the timeframes established by approved procedures for beginning supervision, a probation or parole officer shall:

1. See the juvenile face-to-face;
2. Give the juvenile the written rules of supervision, including any special conditions, and explain these to the juvenile and, when appropriate, to the juvenile's parents or guardians; and
3. Document these actions in the case record.

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• Page 42 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-350 (A) & (B). Supervision plans for juveniles.

6VAC35-150-350 (A). Supervision plans for juveniles.

A. To provide for the public safety and address the needs of a juvenile and that juvenile's family, a juvenile shall be supervised according to a written individual supervision plan, developed in accordance with approved procedures and timeframes, that describes the range and nature of field and office contact with the juvenile, with the parents or guardians of the juvenile, and with other agencies or providers providing treatment or services.

Interpretation: Goal: To ensure the supervision of juveniles is provided in accordance with the individual supervision plan in accordance with procedures.

Additional information:

• The unit may develop supervision plans, specific to the unit, which do not conflict with approved procedures. Juveniles are to be supervised according to the established procedures.
• Applicable DJJ CSU procedures: 9324 and 9338.
• CSU will need to provide list of levels to audit team prior to the audit to establish frequency of contacts for different levels of supervision.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements and time frames.

Examine documentation: Review a sample of case records for compliance with the section and the procedure.

Applicable definitions: (cid:1) "Agency" means any governmental entity of the Commonwealth or any unit of local government including counties, cities, towns, and regional governments and the Departments thereof, and including any entity, whether public or private, with which any of the foregoing has entered into a contractual relationship for the provision of services as described in this chapter. (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Individual supervision plan" means a written plan developed, updated as needed, and modified at intervals to meet the needs of a juvenile or adult. It specifies measurable short-term and long-term goals, the objectives, strategies, and time frames for reaching the goals, and the individuals responsible for carrying out the plan. Individual supervision plans are applicable during probation and parole and for treatment of a juvenile or an adult and the services for the juvenile's family for the time during which a juvenile is committed to the Department. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Provider" means a person, corporation, partnership, association, organization, or public agency that is legally responsible for compliance with regulatory and statutory requirements relating to the provision of services or the functioning of a program. (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form. 42

[TABLE 42-1] 6VAC35-150-350 (A) & (B). Supervision plans for juveniles.

[/TABLE]

[TABLE 42-2] 6VAC35-150-350 (A). Supervision plans for juveniles.

A. To provide for the public safety and address the needs of a juvenile and that juvenile's family, a juvenile shall be supervised according to a written individual supervision plan, developed in accordance with approved procedures and timeframes, that describes the range and nature of field and office contact with the juvenile, with the parents or guardians of the juvenile, and with other agencies or providers providing treatment or services.

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• Page 43 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-350 (B). Supervision plans for juveniles.

B. In accordance with approved procedures, each written individual supervision plan shall be reviewed (i) with the juvenile and the juvenile's family, and (ii) by a supervisor from both a treatment and a case management perspective to confirm the appropriateness of the plan.

Interpretation: Goal: To ensure that the supervision plan is reviewed in accordance with this section.

Additional information: Applicable DJJ CSU procedures: 9260, 9324, 9325, 9334, 9338, and 9339.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of case records or alternative documentation for compliance with the section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Individual supervision plan" means a written plan developed, updated as needed, and modified at intervals to meet the needs of a juvenile or adult. It specifies measurable short-term and long-term goals, the objectives, strategies, and time frames for reaching the goals, and the individuals responsible for carrying out the plan. Individual supervision plans are applicable during probation and parole and for treatment of a juvenile or an adult and the services for the juvenile's family for the time during which a juvenile is committed to the Department. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

43

[TABLE 43-1] 6VAC35-150-350 (B). Supervision plans for juveniles.

B. In accordance with approved procedures, each written individual supervision plan shall be reviewed (i) with the juvenile and the juvenile's family, and (ii) by a supervisor from both a treatment and a case management perspective to confirm the appropriateness of the plan.

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• Page 44 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-355. Supervision of juvenile on electronic monitoring.

6VAC35-150-355. Supervision of juvenile on electronic monitoring.

When a unit places a juvenile in an electronic monitoring program, use of the program shall be governed by approved procedures that shall provide for criteria for placement in the program, parental involvement, required contacts, consequences for tampering with and violating program requirements, and time limits.

Interpretation: Goal: To ensure electronic monitoring programs are governed by the requirements of approved procedures governing the components of this section.

Additional information: Applicable DJJ CSU procedure: 9467.

Compliance Determination: Review procedure: Examine procedure or description of the Electronic Monitoring Program used by the Unit to determine that the Unit and Program have agreed to the regulatory requirements.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Electronic monitoring" means the use of electronic devices, including, but not limited to, voice recognition and global positioning systems, to verify a juvenile's or adult's compliance with certain judicial orders or conditions of release from incarceration, as an alternative to detention, or as a short-term sanction for noncompliance with rules of probation or parole. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Tamper" means any purposeful alteration to electronic monitoring equipment that interferes with or weakens the monitoring system.

44

[TABLE 44-1] 6VAC35-150-355. Supervision of juvenile on electronic monitoring.

[/TABLE]

[TABLE 44-2] 6VAC35-150-355. Supervision of juvenile on electronic monitoring.

When a unit places a juvenile in an electronic monitoring program, use of the program shall be governed by approved procedures that shall provide for criteria for placement in the program, parental involvement, required contacts, consequences for tampering with and violating program requirements, and time limits.

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• Page 45 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-365. Supervision of adult on probation.

6VAC35-150-365. Supervision of adult on probation.

For an adult convicted of a criminal act for which the juvenile court retained jurisdiction pursuant to § 16.1-241 of the Code of Virginia and the juvenile court does not order specific conditions of supervision, a supervision plan for the adult probationer shall be prepared within 30 days of the disposition. The adult and that adult's family, if appropriate, must be consulted in development of the supervision plan.

Interpretation: Goal: To ensure supervision plans are developed for adult probationers in accordance with this section.

Additional information: None.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of adult case records for compliance with the section and the procedure.

Applicable definitions: (cid:1) "Adult" means a person 18 years of age or older who is not a delinquent child as defined in § 16.1-228 of the Code of Virginia. (cid:1) "Individual supervision plan" means a written plan developed, updated as needed, and modified at intervals to meet the needs of a juvenile or adult. It specifies measurable short-term and long-term goals, the objectives, strategies, and time frames for reaching the goals, and the individuals responsible for carrying out the plan. Individual supervision plans are applicable during probation and parole and for treatment of a juvenile or an adult and the services for the juvenile's family for the time during which a juvenile is committed to the Department. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a). (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

45

[TABLE 45-1] 6VAC35-150-365. Supervision of adult on probation.

[/TABLE]

[TABLE 45-2] 6VAC35-150-365. Supervision of adult on probation.

For an adult convicted of a criminal act for which the juvenile court retained jurisdiction pursuant to § 16.1-241 of the Code of Virginia and the juvenile court does not order specific conditions of supervision, a supervision plan for the adult probationer shall be prepared within 30 days of the disposition. The adult and that adult's family, if appropriate, must be consulted in development of the supervision plan.

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• Page 46 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-380. Violation of probation or parole.

6VAC35-150-380. Violation of probation or parole.

When a probationer or parolee violates the conditions of the individual's probation or parole, unit personnel shall take action in accordance with approved procedures.

Interpretation: Goal: To ensure violations of probation and parole are managed in accordance with approved procedures.

Additional information: Applicable DJJ CSU procedure: 9326.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of case records for compliance with the section and the procedure (i.e., if formal action is taken, ensure that the required discussion with the supervisor occurred).

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Parole" means supervision of a juvenile released from commitment to the Department as provided for by §§ 16.1-285, 16.1-285.1, and 16.1-285.2 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a).

46

[TABLE 46-1] 6VAC35-150-380. Violation of probation or parole.

[/TABLE]

[TABLE 46-2] 6VAC35-150-380. Violation of probation or parole.

When a probationer or parolee violates the conditions of the individual's probation or parole, unit personnel shall take action in accordance with approved procedures.

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• Page 47 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-390 (A) & (B). Transfer of case supervision.

6VAC35-150-390 (A). Transfer of case supervision.

A. When the legal residence of an individual under the supervision of a CSU is not within the jurisdiction of the original CSU, the supervision of the case may be transferred to another unit in Virginia in accordance with § 16.1-295 of the Code of Virginia and approved procedures.

Interpretation: Goal: To ensure supervision of cases within Virginia is transferred in accordance with this section, the statute, and the procedure.

Additional information: Applicable DJJ CSU procedure: 9351. This does not include transfers between branch offices in the same CSU

Compliance Determination: Interview CSU director: Inquire whether supervision was transferred on any cases.

Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of case records for compliance with the statute, this section, and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

47

[TABLE 47-1] 6VAC35-150-390 (A) & (B). Transfer of case supervision.

[/TABLE]

[TABLE 47-2] 6VAC35-150-390 (A). Transfer of case supervision.

A. When the legal residence of an individual under the supervision of a CSU is not within the jurisdiction of the original CSU, the supervision of the case may be transferred to another unit in Virginia in accordance with § 16.1-295 of the Code of Virginia and approved procedures.

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• Page 48 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-390 (B). Transfer of case supervision.

B. When transferring or receiving supervision of a juvenile on probation or parole to or from another state CSU staff shall do so in accordance with the Interstate Compact Relating to Juveniles, Article 14 (§ 16.1-323 et seq.) of Chapter 11 of Title 16.1 of the Code of Virginia.

Interpretation: Goal: To ensure the supervision of cases to and from another state is transferred in accordance with the applicable statutes.

Additional information: None.

Compliance Determination: Interview CSU director: Inquire whether supervision was transferred to or from another state on any cases.

Examine documentation: Review a sample of case records for compliance with the statutes and this section.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Parole" means supervision of a juvenile released from commitment to the Department as provided for by §§ 16.1-285, 16.1-285.1, and 16.1-285.2 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a). (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

48

[TABLE 48-1] 6VAC35-150-390 (B). Transfer of case supervision.

B. When transferring or receiving supervision of a juvenile on probation or parole to or from another state CSU staff shall do so in accordance with the Interstate Compact Relating to Juveniles, Article 14 (§ 16.1-323 et seq.) of Chapter 11 of Title 16.1 of the Code of Virginia.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-400. Notice of release from supervision.

6VAC35-150-400. Notice of release from supervision.

Notice of release from supervision shall be given in writing to the individual under the supervision of a CSU and to the parents or guardians of juveniles. Such notification shall be appropriately documented in the case record in accordance with approved procedures.

Interpretation: Goal: To ensure the individual being released from supervision and the juvenile's parents are notified in writing of release from supervision.

Additional information: Applicable DJJ CSU procedure: 9327. Copies of written notification and or court orders releasing a probationer shall be placed in the case file and the probation officer shall document the release in the case narrative.

Compliance Determination: Review procedure: Examine procedure to determine applicable documentation requirements.

Examine documentation: Review a sample of closed supervision case records for compliance with this section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

49

[TABLE 49-1] 6VAC35-150-400. Notice of release from supervision.

[/TABLE]

[TABLE 49-2] 6VAC35-150-400. Notice of release from supervision.

Notice of release from supervision shall be given in writing to the individual under the supervision of a CSU and to the parents or guardians of juveniles. Such notification shall be appropriately documented in the case record in accordance with approved procedures.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Article 6 Juvenile in Direct Care

6VAC35-150-410 (A) & (B). Commitment information.

6VAC35-150-410 (A). Commitment information.

A. When a juvenile is committed to the Department, the juvenile may not be transported to the Reception and Diagnostic Center (RDC) until (i) the items and information required by the Code of Virginia and approved procedures have been received by RDC and (ii) the case is accepted by RDC.

Interpretation: Goal: To ensure that the appropriate information is provided to RDC prior to the resident being transported to RDC.

Additional information: Applicable DJJ CSU procedure: 9332.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Interview director: Inquire whether there are any “drop offs” Examine documentation: Review a sample of case records for compliance with the statute, this section, and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Direct care" means the time during which a resident, who is committed to the Department pursuant to §§ 16.1-272, 16.1-285.1, or subdivision A 14 or A 17 of § 16.1-278.8 of the Code of Virginia, is under the supervision of staff in a juvenile correctional center or other juvenile residential facility operated by or under contract with the Department. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

50

[TABLE 50-1] 6VAC35-150-410 (A). Commitment information.

A. When a juvenile is committed to the Department, the juvenile may not be transported to the Reception and Diagnostic Center (RDC) until (i) the items and information required by the Code of Virginia and approved procedures have been received by RDC and (ii) the case is accepted by RDC.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-410 (B). Commitment information.

B. If a juvenile is transported to the Department directly from the court, in addition to ensuring the immediate delivery of the items required in subsection A of this section, unit staff shall immediately notify RDC by telephone of the juvenile's impending arrival.

Interpretation: Goal: To ensure RDC immediately receives notice of a juvenile's impending arrival and the appropriate information when transported to RDC directly from court.

Additional information: Applicable DJJ CSU procedure: 9351.

Compliance Determination: Interview CSU director: Inquire whether any juveniles were transported to RDC directly from court.

Review procedure: Examine procedure to determine applicable requirements (i.e., information to be provided to RDC).

Examine documentation: Review a sample of case records of juveniles committed to the Department who are transported directly from court for compliance with this section and the procedure.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

51

[TABLE 51-1] 6VAC35-150-410 (B). Commitment information.

B. If a juvenile is transported to the Department directly from the court, in addition to ensuring the immediate delivery of the items required in subsection A of this section, unit staff shall immediately notify RDC by telephone of the juvenile's impending arrival.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-415. Supervision of juvenile in direct care.

6VAC35-150-415. Supervision of juvenile in direct care.

For a juvenile placed in direct care, the probation or parole officer shall, in accordance with approved procedures, do the following:

1. Develop and implement a family involvement plan.
2. Develop a parole supervision plan. a. For a juvenile indeterminately committed to the Department pursuant to subsection A (14) of § 16.1-278.8 and § 16.1-272 of the Code of Virginia, CSU staff shall complete a parole supervision plan in accordance with approved procedure. b. For a juvenile determinately committed to the Department pursuant to subdivision A (17) of § 16.1-278.8 or §§ 16.1-285.1 or 16.1-272 of the Code of Virginia, a parole supervision plan shall be prepared for all serious offender judicial review hearings as required by law and in accordance with approved procedures.
3. Send a report on the family's progress toward planned goals of the family involvement plan to the facility at which the juvenile is housed.

Interpretation: Goal: To ensure family involvement plans, supervision plans, and progress reports are completed in accordance with applicable statutes, this section, and the procedures.

Additional information: Quarterly means every 90 days after the development of the plan. Applicable DJJ CSU procedures: 9332, 9334, and 9338.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of case records of commitments for compliance with the statute, this section, and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Direct care" means the time during which a resident, who is committed to the Department pursuant to §§ 16.1-272, 16.1-285.1, or subdivision A 14 or A 17 of § 16.1-278.8 of the Code of Virginia, is under the supervision of staff in a juvenile correctional center or other juvenile residential facility operated by or under contract with the Department. (cid:1) "Individual supervision plan" means a written plan developed, updated as needed, and modified at intervals to meet the needs of a juvenile or adult. It specifies measurable short-term and long-term goals, the objectives, strategies, and time frames for reaching the goals, and the individuals responsible for carrying out the plan. Individual supervision plans are applicable during probation and parole and for treatment of a juvenile or an adult and the services for the juvenile's family for the time during which a juvenile is committed to the Department. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before

52

[TABLE 52-1] 6VAC35-150-415. Supervision of juvenile in direct care.

[/TABLE]

[TABLE 52-2] 6VAC35-150-415. Supervision of juvenile in direct care.

For a juvenile placed in direct care, the probation or parole officer shall, in accordance with approved procedures, do the following:

1. Develop and implement a family involvement plan.
2. Develop a parole supervision plan. a. For a juvenile indeterminately committed to the Department pursuant to subsection A (14) of § 16.1-278.8 and § 16.1-272 of the Code of Virginia, CSU staff shall complete a parole supervision plan in accordance with approved procedure. b. For a juvenile determinately committed to the Department pursuant to subdivision A (17) of § 16.1-278.8 or §§ 16.1-285.1 or 16.1-272 of the Code of Virginia, a parole supervision plan shall be prepared for all serious offender judicial review hearings as required by law and in accordance with approved procedures.
3. Send a report on the family's progress toward planned goals of the family involvement plan to the facility at which the juvenile is housed.

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• Page 53 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Parole" means supervision of a juvenile released from commitment to the Department as provided for by §§ 16.1-285, 16.1-285.1, and 16.1-285.2 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a). (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-420. Contacts during juvenile's commitment.

6VAC35-150-420. Contacts during juvenile's commitment.

During the period of a juvenile's commitment, a designated staff person shall make contact with the committed juvenile, the juvenile's parents, guardians, or other custodians, and the treatment staff at the juvenile's direct care placement as required by approved procedures. The procedures shall specify when contact must be face-to-face contact and when contacts may be made by video conferencing or by telephone.

Interpretation: Goal: To ensure CSU personnel have contact with (1) the juvenile, (2) the juvenile's parents or guardians, and (3) treatment staff at the residential facility during the juvenile's period of commitment in accordance with this section and the procedure.

Additional information: Applicable DJJ CSU procedures: 9332 and 9334.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of case records of committed juveniles for compliance with this section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Direct care" means the time during which a resident, who is committed to the Department pursuant to §§ 16.1-272, 16.1-285.1, or subdivision A 14 or A 17 of § 16.1-278.8 of the Code of Virginia, is under the supervision of staff in a juvenile correctional center or other juvenile residential facility operated by or under contract with the Department. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

DOCUMENTS INCORPORATED BY REFERENCE (6VAC35-150) "Guidelines for Transporting Juveniles in Detention," State Board of Juvenile Justice, September 2004.

54

[TABLE 54-1] 6VAC35-150-420. Contacts during juvenile's commitment.

[/TABLE]

[TABLE 54-2] 6VAC35-150-420. Contacts during juvenile's commitment.

During the period of a juvenile's commitment, a designated staff person shall make contact with the committed juvenile, the juvenile's parents, guardians, or other custodians, and the treatment staff at the juvenile's direct care placement as required by approved procedures. The procedures shall specify when contact must be face-to-face contact and when contacts may be made by video conferencing or by telephone.

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• Page 1 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

COMPLIANCE MANUAL

6VAC35-150 - REGULATION FOR NONRESIDENTIAL SERVICES

This manual governs all compliance audits of state and local court service units established under §§ 16.1-233, 16.1-235 of the Virginia Code, by DJJ.

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• Page 2 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Part I General Provisions

6VAC35-150-40. Variances.

6VAC35-150-40. Variances.

A variance can be requested by a program administrator or provider when unable to comply with this chapter. Requests must meet criteria and follow procedures in 6VAC35-20 et seq.

Goal: Ensure programmatic changes outside regulatory scope meet requirements and all programs (including CSUs) follow the same variance procedures.

Additional information:

• Variance requests will be reviewed for compliance with this section and the Regulations Governing Juvenile Justice Programs (6VAC35-20-92).
• Program administrator means the CSU director.
• Applicable DJJ CSU procedure: 9019

Compliance Determination: Interview CSU director:

• Inquire if CSU practices violate applicable regulations.
• Inquire if CSU has requested or received a variance from the Board.

Review documentation for compliance if a variance has been requested or issued.

Definitions: "Provider" is responsible for compliance; "Variance" is a Board action relieving a program from requirements; "Written" means communicated in writing, in hard copy or electronic.

2

[TABLE 2-1] 6VAC35-150-40. Variances.

[/TABLE]

[TABLE 2-2] 6VAC35-150-40. Variances.

A variance may be requested by a program administrator or service provider when conditions exist where the program or service provider is not able to comply with a section or subsection of this chapter. Any such request must meet the criteria and comply with the procedural requirements provided in the Regulations Governing the Monitoring, Approval, and Certification of Juvenile Justice Programs, 6VAC35-20 et seq. and in accordance with written procedures.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-50. Licensure by other agencies.

6VAC35-150-50. Licensure by other agencies.

A current Commonwealth license or certificate is accepted as evidence of compliance if it meets or exceeds this chapter's standards.

Goal: Avoid duplicative licensing/certification processes.

The Department may inquire into licensure/certification and auditing processes.

Interview CSU director to verify if the unit or program is licensed/certified by another agency.

Review license/certificate and documentation for compliance if licensed/certified by another agency.

Applicable definitions: None.

3

[TABLE 3-1] 6VAC35-150-50. Licensure by other agencies.

[/TABLE]

[TABLE 3-2] 6VAC35-150-50. Licensure by other agencies.

A current license or certificate issued by the Commonwealth shall be accepted as evidence of a program's compliance with one or more specific standards of this chapter when the requirements for licensure or certification are substantially the same as, or exceed, the requirements set out in this chapter.

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• Page 4 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Part II Operating Standards for Court Service Units Article 1 Administration

6VAC35-150-60. Organizational structure.

6VAC35-150-60. Organizational structure.

A written description and organizational chart must show current lines of authority, responsibility, and the unit director's reporting relationship.

Goal: Formalize current lines of authority, responsibility, and accountability.

Additional information:

• The organizational chart has no standard format but must be detailed enough for reviewers to follow lines of authority.
• The “unit director’s reporting responsibility” means the individual to whom the CSU reports.
• The 'written description' includes titles from the organizational chart.

Compliance Determination: Examine documentation: Review organizational chart.

Definitions: "Court service unit," "CSU," or "unit" means a state or local court service unit established under §§ 16.1-233, 16.1-235 of Virginia Code.

4

[TABLE 4-1] 6VAC35-150-60. Organizational structure.

[/TABLE]

[TABLE 4-2] 6VAC35-150-60. Organizational structure.

There shall be a written description and organizational chart of the unit showing current lines of authority, responsibility, and accountability, including the unit director's reporting responsibility.

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• Page 5 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-62 (A) & (B). Suitable quarters.

6VAC35-150-62 (A). Suitable quarters.

A. The CSU director shall annually review the unit's needs for suitable quarters, utilities, and furnishings and request resources from the appropriate governing body.

Interpretation: Goal: Ensure CSU has sufficient workspace and materials.

Additional info: No standard format for review and request; CSU must show annual review and resource request if needs are identified.

Compliance: Interview CSU director on whether and how the unit's needs for suitable quarters, utilities, and furnishings were reviewed and the review outcome.

Examine documentation: If review indicated a need, review the unit's request to the governing body (e.g., annual budget request).

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

6VAC35-150-62 (B). Suitable quarters.

B. Intake, probation, and parole officers shall have access to private office space.

Interpretation: Goal: Ensure CSU personnel have access to private office space to protect confidential communications and information.

Additional information: None.

Compliance: Interview staff about access to private office space.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

5

[TABLE 5-1] 6VAC35-150-62 (A) & (B). Suitable quarters.

[/TABLE]

[TABLE 5-2] 6VAC35-150-62 (A). Suitable quarters.

A. The CSU director annually shall review the unit's needs for suitable quarters, utilities, and furnishings and shall request from the appropriate governing body the resources to meet these needs.

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[TABLE 5-3] 6VAC35-150-62 (B). Suitable quarters.

B. Intake, probation, and parole officers shall have access to private office space.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-64. Prohibited financial transactions.

6VAC35-150-64. Prohibited financial transactions.

The unit shall not collect or disburse support payments, fines, restitution, court fees, or court costs.

Interpretation: Goal: Ensure CSU does not collect or disburse funds.

Additional information: None.

Compliance: Interview staff about practices on collecting/disbursing support payments, fines, restitution, court fees, or costs.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

6

[TABLE 6-1] 6VAC35-150-64. Prohibited financial transactions.

[/TABLE]

[TABLE 6-2] 6VAC35-150-64. Prohibited financial transactions.

The unit shall not collect or disburse support payments, fines, restitution, court fees, or court costs.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-66. Procedures for handling funds.

6VAC35-150-66. Procedures for handling funds.

The unit director shall establish written procedures for handling employee funds derived from contributions, vending, fundraising, or canteen services, using the unit or Department name, or obtaining a tax ID.

Such funds are not state funds and shall not be commingled; the Department's tax ID shall not be used for them.

Interpretation: Goal: Ensure procedures for handling funds and maintain state fund integrity.

Additional info: Employee funds include flower, drink machine, etc.

Compliance Determination: Interview CSU director: Inquire if the unit has employee funds using the unit or Department name or tax ID.

Review procedures: If the unit had an applicable employee fund during the audit period, review its procedures.

Examine documentation: If the unit had an applicable employee fund during the audit, review account statements or relevant documents for compliance.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or local court service unit per §§ 16.1-233 and 16.1-235. (cid:1) "Department" means DJJ. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

7

[TABLE 7-1] 6VAC35-150-66. Procedures for handling funds.

[/TABLE]

[TABLE 7-2] 6VAC35-150-66. Procedures for handling funds.

The unit director shall establish written procedures for handling any ongoing unit employee fund established and maintained by the employees that is derived from employee contributions, the operation of vending machines, special fundraising projects, or other employee canteen services, that utilizes the name of the unit or the Department, or that the unit approves the obtaining of or obtains a tax identification number for such funds.

Any such funds are not state funds and shall not be commingled in any way with state funds. The Department's tax identification number shall not be used for such funds.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (A)-(D). Background checks.

6VAC35-150-80 (A). Background checks.

A. Except as in subsection C, all persons accepting employment, volunteering regularly, interning alone with juveniles, or providing contractual services alone with juveniles in a CSU, per 6VAC35-150-430 C, must undergo background checks to identify criminal acts or detrimental circumstances.

1. A reference check;
2. A criminal history record check;
3. Fingerprint check with VSP and FBI;
4. CPS registry check; and
5. Driving record check, if applicable to job duties.

Interpretation: Standardize screening and hiring to assess suitability of staff, volunteers, interns, and contractors, ensuring all background checks are completed to protect juveniles under supervision.

Additional information:

• Each CSU must keep records of background checks since last audit.
• For state CSUs, audit reviews documentation of investigation by the Department's background unit; a statement from the unit suffices.
• Review CPS registry check.
• For local CSUs, the auditor reviews file information for each required element. HR statement suffices if it shows completion of all elements.
• "In a CSU" means duties or services are provided on-site at the CSU office.

Compliance Determination: Review new staff, volunteer, intern, or contractor info for each requirement. Definitions: "Court service unit" means a state/local court unit per §§ 16.1-233, 16.1-235; "Juvenile" means under 18 or under court supervision; "Volunteer" or "Intern" means unpaid individuals providing services voluntarily.

8

[TABLE 8-1] 6VAC35-150-80 (A)-(D). Background checks.

[/TABLE]

[TABLE 8-2] 6VAC35-150-80 (A). Background checks.

A. Except as provided in subsection C of this section, all persons who (i) accept a position of employment, (ii) volunteer on a regular basis or are interns and will be alone with a juvenile in the performance of their duties, or (iii) provide contractual services directly to a juvenile on a regular basis and will be alone with a juvenile in the performance of their duties in a CSU, or as required by 6VAC35-150-430 C, shall undergo the following background checks to ascertain whether there are criminal acts or other circumstances that would be detrimental to the safety of juveniles:

1. A reference check;
2. A criminal history record check;
3. A fingerprint check with (i) the Virginia State Police (VSP) and (ii) the Federal Bureau of Investigation (FBI);
4. A central registry check with Child Protective Services (CPS); and
5. A driving record check, if applicable to the individual's job duties.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (B). Background checks.

B. To reduce vacancy time while awaiting fingerprint check results per A(3), staff may be hired pending results if:

1. All other components of subsection A have been completed;
2. The applicant receives written notice that employment depends on fingerprint check results, as required by subdivision A (3);
3. Staff hired under this exception cannot be alone with juveniles and may work only under direct supervision of staff with completed background checks until all are finished.

Interpretation: Minimize vacancy in employee roles while ensuring juvenile safety under supervision or services.

Additional information: None.

Compliance: Review new staff info for each requirement and ensure written notice of these requirements is provided to applicants.

Interview CSU director: Confirm if hiring and supervision practices meet this section's requirements.

Interview staff: Inquire whether new staff, subject to this exception, were left alone with juveniles.

Applicable definitions: "Juvenile" is under 18 or under court supervision, including individuals with past court involvement, regardless of age, receiving services or committed to the Department.

9

[TABLE 9-1] 6VAC35-150-80 (B). Background checks.

B. To minimize vacancy time when the fingerprint checks, required by subdivision A (3), have been requested, unit staff may be hired pending the results of the fingerprint checks, provided:

1. All of the other applicable components of subsection A of this section have been completed;
2. The applicant is given written notice that continued employment is contingent on the fingerprint check results, as required by subdivision A (3); and
3. Staff hired under this exception shall not be allowed to be alone with juveniles and may work with juveniles only when under the direct supervision of staff whose background checks have been completed until such time as all background checks are completed.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (C). Background checks.

C. The unit, program, or provider must have procedures to supervise non-staff persons not covered by subsection A who contact juveniles.

Interpretation: Ensure juveniles are not left alone with individuals not subject to background checks.

Additional info: Applies to contract workers or providers, like maintenance, not alone with juveniles and without background checks but may have incidental contact. DJJ CSU procedure: 9461

Compliance: Review procedures to ensure compliance with this section.

Applicable definitions: "Court service unit" means a state/local court unit per §§ 16.1-233, 16.1-235; "Juvenile" includes those under 18 or court supervision, regardless of age, receiving services or committed. (cid:1) "Provider" means a person, corporation, partnership, association, organization, or public agency that is legally responsible for compliance with regulatory and statutory requirements relating to the provision of services or the functioning of a program.

10

[TABLE 10-1] 6VAC35-150-80 (C). Background checks.

C. The unit, program, or service provider shall have procedures for supervising nonstaff persons, who are not subject to the provisions of subsection A, who have contact with juveniles.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-80 (D). Background checks.

D. Subsection A applies to programs CSU refers juveniles to, including those in a local Virginia Juvenile Community Crime Control Act plan. When referring juveniles to other providers, excluding community service or licensed professionals regulated by other agencies, the referring agency must require documentation that all persons providing services or supervision through substantial one-on-one contact have undergone background checks as in subsection A.

Interpretation: Ensure CSU-referred juvenile programs comply with background check requirements.

Additional info: This section applies to CSU-referred juvenile programs if (1) not licensed or regulated by another state agency or (2) the provider is not a licensed professional.

Compliance: Interview CSU director about processes for approving and referring juveniles to service providers.

Examine documentation: Review the documentation of the CSU's notice that requires programs to which it refers juveniles to document that all persons who provide services have undergone applicable background checks. Review list of programs used by CSU.

• Review notice to programs by CSU.
• Review response from programs confirming compliance.

Applicable definitions: "Agency" includes government entities, units, departments, and entities with service contracts. "Court service unit," "CSU," or "unit" is a Virginia court service unit. "Intake officer" is a probation officer performing intake. "Juvenile" is under 18, a delinquent, or in need of supervision/services, including those before the court or under supervision. "Provider" is a person, organization, or agency responsible for compliance.

11

[TABLE 11-1] 6VAC35-150-80 (D). Background checks.

D. Subsection A of this section shall apply to programs to which the CSU refers juveniles who are before the court or before an intake officer, including, but not limited to, programs included in a local Virginia Juvenile Community Crime Control Act plan. When an agency or program refers juveniles to other service providers, excluding community service programs and licensed professionals or programs licensed or regulated by other state agencies, the referring agency shall require the service provider to document that all persons who provide services or supervision through substantial one-on-one contact with juveniles have undergone a background check as required in subsection A of this section.

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• Page 12 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-90 (A) & (B). Training.

6VAC35-150-90 (A). Training.

A. All employees, volunteers, and interns shall receive documented orientation appropriate to their duties and needs identified by the individual and supervisor.

Interpretation: Ensure employees, volunteers, and interns receive appropriate orientation.

Additional information: None.

Compliance: Review records of employees, volunteers, and interns for documentation of orientations.

Applicable definitions: "Volunteer" or "intern" means individuals or groups providing services voluntarily without pay or compensation.

6VAC35-150-90 (B). Training.

B. All employees shall receive ongoing training and development appropriate to duties and needs identified by the individual and supervisor.

Interpretation: Ensure employees receive ongoing training and development.

Additional information:

• This new requirement replaces the 40-hour annual standard. CSU personnel must monitor skill deficiencies and training expectations in EWPs. The audit reviews EWPs against logs to verify completion.
• Trainings include formal classes or informational staff meetings with documented attendance and topics.
• Training must include safety and security per 6VAC35-150-200. Noncompletion results in noncompliance with one requirement, attributed to section 200.
• Best practice: maintain individual training logs via LMS or on-site in personnel files.

Compliance Determination: Review documentation:

• Department or unit training plan or procedure; or
• If no plan exists, review employee work profiles or evaluations for (1) deficiencies or (2) recommended training relevant to duties;
• Documentation of applicable trainings.

Interview staff and supervisors to assess adequacy of training and identify unmet needs.

Applicable definitions: None.

12

[TABLE 12-1] 6VAC35-150-90 (A) & (B). Training.

[/TABLE]

[TABLE 12-2] 6VAC35-150-90 (A). Training.

A. All employees, volunteers, and interns shall receive documented orientation appropriate to their duties and to address any needs identified by the individual and the supervisor.

[/TABLE]

[TABLE 12-3] 6VAC35-150-90 (B). Training.

B. All employees shall receive on-going training and development appropriate to their duties and to address any needs identified by the individual and the supervisor, if applicable.

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• Page 13 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-100. Personnel and operating procedures.

6VAC35-150-100. Personnel and operating procedures.

All staff shall access approved procedures governing:

1. Recruitment and selection;
2. Grievance and appeal;
3. Confidential individual employee personnel records;
4. Discipline;
5. Equal employment opportunity;
6. Leave and benefits;
7. Resignations and terminations;
8. Orientation;
9. Promotion, probation, and competitive salary.

Interpretation: Ensure staff access procedures governing performance and environment.

Additional info: Procedures may be issued by the Division of Operations, HR department, DHRM, or local equivalents.

Compliance: Review procedures to ensure required components are included. Observe document location and availability.

Interview staff about access to and availability of procedures.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by DJJ applicable to all state-operated court service units and voluntarily observed by local units; or (ii) modifications approved by the director or designee; or (iii) procedures for local units approved locally.

13

[TABLE 13-1] 6VAC35-150-100. Personnel and operating procedures.

[/TABLE]

[TABLE 13-2] 6VAC35-150-100. Personnel and operating procedures.

All staff shall have access to approved procedures governing:

1. Recruitment and selection;
2. Grievance and appeal;
3. Confidential individual employee personnel records;
4. Discipline;
5. Equal employment opportunity;
6. Leave and benefits;
7. Resignations and terminations;
8. Orientation;
9. Promotion; 10. Probationary period; and 11. Competitive salary.

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• Page 14 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-110 (A)-(D). Volunteers and interns.

6VAC35-150-110 (A). Volunteers and interns.

A. The unit shall maintain current descriptions of duties, responsibilities, and minimum qualifications for each volunteer and intern;

Interpretation: Ensure each volunteer and intern is qualified for their assignment and has a clear duties and responsibilities description.

Additional information: None.

Compliance: Review position descriptions for duties and qualifications.

If qualifications are missing from descriptions, the audit may review additional documentation, such as correspondence with volunteers or interns.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or local court service unit per §§ 16.1-233 and 16.1-235 VA. (cid:1) "Volunteer" or "intern" means individuals or groups who freely provide services without financial gain or compensation.

6VAC35-150-110 (B). Volunteers and interns.

B. Volunteers and interns shall comply with all applicable regulations, policies, and approved procedures;

Interpretation: Ensure volunteers and interns comply with legal and Department requirements.

Additional information: Applicable DJJ Administrative Directive: 15-001.

Compliance: Interview CSU director or volunteer coordinator about compliance with this section.

Examine documentation if noncompliance is suspected.

Applicable definitions: (cid:1) "Approved procedures" include DJJ-issued procedures for all court units, modifications approved by the director, or locally approved procedures. (cid:1) "Volunteer" or "intern" means individuals or groups who freely provide services without compensation.

14

[TABLE 14-1] 6VAC35-150-110 (A)-(D). Volunteers and interns.

[/TABLE]

[TABLE 14-2] 6VAC35-150-110 (A). Volunteers and interns.

A. For every volunteer and intern, the unit shall maintain a current description of duties and responsibilities and a list of the minimum required qualifications;

[/TABLE]

[TABLE 14-3] 6VAC35-150-110 (B). Volunteers and interns.

B. Volunteers and interns shall comply with all applicable regulations, policies, and approved procedures;

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• Page 15 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-110 (C). Volunteers and interns.

C. One or more designated persons shall coordinate volunteer services; and

Interpretation: Ensure volunteer services are coordinated.

Additional information: None.

Compliance Determination: Interview CSU director and/or volunteer coordinator: Inquire regarding compliance with this section.

Applicable definitions: (cid:1) "Volunteer" or "intern" means any individual or group who of their own free will and without any financial gain provides services without competitive compensation.

6VAC35-150-110 (D). Volunteers and interns.

D. Volunteers and interns shall be registered with the Department.

Interpretation: Ensure volunteers and interns are registered with the Department.

Additional info: Department requires registration primarily for liability insurance, as applicable.

Compliance: Review the volunteer roster and documentation sent periodically to the Department; compare active volunteers with the Department's database.

Additional information: The regulation does not specify a registration time frame for volunteers and interns.

Applicable definitions: (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Volunteer" or "intern" means individuals or groups who voluntarily provide services without pay or compensation.

15

[TABLE 15-1] 6VAC35-150-110 (C). Volunteers and interns.

C. One or more designated persons shall coordinate volunteer services; and

[/TABLE]

[TABLE 15-2] 6VAC35-150-110 (D). Volunteers and interns.

D. Volunteers and interns shall be registered with the Department.

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• Page 16 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-130 (A) & (B). Research.

6VAC35-150-130 (A). Research.

A. Juveniles shall not be subjects of human research except as provided in 6VAC35-170 and Chapter 5.1 (§ 32.1-162.16 et seq.) of Title 32.1 Virginia.

Interpretation: Goal: Ensure juvenile research complies with statutes and regulations.

Additional information: Applicable DJJ Administrative Directive: 07-006.3.

Compliance Determination: Review documentation: Examine research project approval from the Department’s Research and Evaluation Unit or as required locally.

Applicable definitions: (cid:1) "Human research" means systematic investigation involving human subjects as defined by § 32.1-162.16 and 6VAC35-170, excluding prohibited, exempt, or mandated research. (cid:1) "Juvenile" means under 18, delinquent, in need of supervision or services as defined in § 16.1-228, including individuals involved in court or under supervision or committed to the Department.

6VAC35-150-130 (B). Research.

B. Testing medicines or drugs for experimentation or research is prohibited.

Interpretation: Goal: Prevent testing of medicines or drugs for experimentation or research.

Additional information: None.

Compliance Determination: Interview CSU director to verify compliance.

Examine documentation: Review approved research projects.

Applicable definitions: None.

16

[TABLE 16-1] 6VAC35-150-130 (A) & (B). Research.

[/TABLE]

[TABLE 16-2] 6VAC35-150-130 (A). Research.

A. Juveniles shall not be used as subjects of human research, except as provided in 6VAC35-170 and in accord with Chapter 5.1 (§ 32.1-162.16 et seq.) of Title 32.1 of the Code of Virginia.

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[TABLE 16-3] 6VAC35-150-130 (B). Research.

B. The testing of medicines or drugs for experimentation or research is prohibited.

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• Page 17 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-140 (A)-(D). Records management.

6VAC35-150-140 (A). Records management.

A. Case records shall be indexed and kept up to date and uniformly in content and arrangement in accordance with approved procedures.

Interpretation: Goal: Ensure case records are maintained uniformly per approved procedures.

Additional information: CSU director should have procedures mapping the case management process. Applicable DJJ CSU procedure: 9450.

Compliance Determination: Review procedure: Examine requirements of applicable procedures.

Examine case records: Review records and system to ensure uniform maintenance per procedures.

Applicable definitions: (cid:1) "Approved procedures" are DJJ-issued, approved modifications, or locally approved procedures. (cid:1) "Case record" means written or electronic info about an individual and family maintained per approved procedures.

6VAC35-150-140 (B). Records management.

Case records must be stored securely and accessible only to authorized staff.

Interpretation: Ensure case records are maintained securely and kept confidential.

Case records are insecure if left where non-CSU staff, like cleaning personnel, can access them.

• ““Secure locations” include locked cabinets, rooms, or desk drawers.

Case records must be stored securely when not in use.

• The key should not be available to non-CSU staff except in emergencies.

Compliance: Interview CSU director and staff about compliance with this section.

Definitions: "Case record" or "record" means written or electronic info about an individual and family, maintained per approved procedures.

17

[TABLE 17-1] 6VAC35-150-140 (A)-(D). Records management.

[/TABLE]

[TABLE 17-2] 6VAC35-150-140 (A). Records management.

A. Case records shall be indexed and kept up to date and uniformly in content and arrangement in accordance with approved procedures.

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[TABLE 17-3] 6VAC35-150-140 (B). Records management.

B. Case records shall be kept in a secure location accessible only to authorized staff.

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• Page 18 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-140 (C). Records management.

C. All case records must be maintained and disposed of per Library of Virginia regulations, retention schedules, and approved procedures.

Interpretation: Ensure proper maintenance and disposal of case records.

Additional information: None.

Compliance Determination: Review procedure: Review requirements of applicable procedures.

Interview CSU director and staff: Inquire regarding compliance with this section.

Definitions: "Approved procedures" include DJJ-issued procedures for all court service units, modifications approved by the director, or locally approved procedures. "Case record" means written/electronic info about an individual and family, maintained per approved procedures.

D. Disclosure or release of info must comply with Virginia law, federal statutes, regulations, and approved procedures.

Interpretation: Ensure disclosures comply with statutes, regulations, and procedures.

Additional info: Approved procedures must include statutory restrictions (e.g., §§ 16.1-300, 16.1-309.1). DJJ CSU procedure: 9451.

Compliance Determination: Review procedure: Review requirements of applicable procedures.

Interview CSU director and staff: Inquire regarding compliance with this section.

Examine case files for documentation of proper information release (e.g., release forms).

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures.

18

[TABLE 18-1] 6VAC35-150-140 (C). Records management.

C. All case records shall be maintained and disposed of in accordance with The Library of Virginia regulations and record retention schedules and with approved procedures.

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[TABLE 18-2] 6VAC35-150-140 (D). Records management.

D. Any disclosure or release of information shall be in accordance with the Code of Virginia and applicable federal statutes and regulations and approved procedures.

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• Page 19 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

Article 2 Security and Safety

6VAC35-150-200. Safety and security procedures.

6VAC35-150-200. Safety and security procedures.

In accordance with approved procedures, the unit shall implement:

1. Office safety practices must include fire, bomb threats, natural disasters, hostage, and medical emergencies;
2. Safety practices for staff during field visits to juveniles and families;
3. Training on crisis prevention and intervention techniques for office and field staff to respond to risky behavior;

Interpretation: Goals:

1. Ensure CSU implements safety and security procedures for staff, juveniles, families, visitors, and in the field.
2. Establish that unit staff are trained in safety and security for office and field visits.

Additional information:

• Applicable DJJ CSU procedure: 9461.
• Training requirements are in 6VAC35-150-90(B). If safety, security, or crisis training is incomplete, the unit is noncompliant with section 200 only.

Compliance: Interview staff about their knowledge and implementation of procedures.

Examine documentation: Review orientation records for new staff.

Definitions: "Approved procedures" include DJJ-issued procedures for all court units, modifications approved by the director, or locally approved procedures. "Court service unit" or "CSU" means a state or local court unit per §§ 16.1-233, 16.1-235. "Juvenile" is under 18, includes delinquent, supervised, or service-receiving individuals, regardless of age, involved with the court or Department.

19

[TABLE 19-1] 6VAC35-150-200. Safety and security procedures.

[/TABLE]

[TABLE 19-2] 6VAC35-150-200. Safety and security procedures.

In accordance with approved procedures, the unit shall implement:

1. Safety and security practices for the office environment to include at least fire, bomb threat, natural disasters, and hostage and medical emergency situations;
2. Safety and security practices for staff making field visits to juveniles and their families; and
3. Training on appropriate crisis prevention and intervention techniques for the office and the field that staff may use to respond to behavior that poses a risk to the safety of themselves or others.

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• Page 20 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-210 (A) & (B). Physical force.

6VAC35-150-210 (A). Physical force.

A. Physical force shall be used only as a last resort and never as punishment. Staff shall use only the minimum force necessary to eliminate imminent risk to safety.

Interpretation: Goal: To ensure physical force is used only as required by this section.

Additional information: None.

Compliance Determination: Interview staff: Inquire regarding use of physical force.

Examine documentation: Review instances involving physical force for compliance.

Applicable definitions: None.

6VAC35-150-210 (B). Physical force.

B. Each physical force use shall be reported in writing to the CSU director, who shall ensure all reportable incidents are reported per Department procedures.

Interpretation: Goal: Ensure physical force use is reported in compliance with this section.

Additional information: Applicable DJJ CSU procedure: 9462

Compliance Determination: Interview staff: Inquire regarding use of physical force.

Examine documentation: Review documentation of any instances involving physical force for compliance with this section.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Department" means the Department of Juvenile Justice.

20

[TABLE 20-1] 6VAC35-150-210 (A) & (B). Physical force.

[/TABLE]

[TABLE 20-2] 6VAC35-150-210 (A). Physical force.

A. Physical force shall be used only as a last resort and shall never be used as punishment. Staff shall use only the minimum force deemed reasonable and necessary to eliminate the imminent risk to the safety of themselves or others.

[/TABLE]

[TABLE 20-3] 6VAC35-150-210 (B). Physical force.

B. Each use of physical force shall be reported in writing to the CSU director, who shall ensure that all reportable incidents are further reported in accordance with the Department's procedures for reporting serious incidents.

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• Page 21 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-220. Searches.

6VAC35-150-220. Searches.

Searches of individuals and immediate areas may only be conducted per approved procedures, statutes, regulations, and constitutions. Only trained staff approved by the Department shall conduct searches.

Interpretation: Goal: Ensure searches are conducted by trained staff per the Constitution, statutes, regulations, and procedures.

Additional information: Applicable DJJ CSU procedure: 9469.

Compliance: Review procedure.

Interview CSU director/staff: Inquire if searches are conducted and in compliance with this section.

Examine documentation: If staff are approved, verify training approval and records for compliance.

Definitions: "Approved procedures" are DJJ-issued procedures for all court service units, including modifications or local approvals. "Department" means DJJ.

21

[TABLE 21-1] 6VAC35-150-220. Searches.

[/TABLE]

[TABLE 21-2] 6VAC35-150-220. Searches.

Searches of an individual's person and immediate area may be conducted only in accordance with approved procedures, with all applicable state and federal statutes and regulations, and with the Virginia and United States constitutions. Only staff who have received training approved by the Department shall conduct searches.

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• Page 22 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-230 (A) & (B). Weapons.

6VAC35-150-230 (A). Weapons.

A. Probation officers may carry weapons per § 16.1-237, following approved procedures requiring: (i) firearms safety, (ii) mental health assessment, (iii) CSU director approval, and (iv) supervisor approval.

Interpretation: Goal: Ensure probation officers obtain weapon authorization per statute and procedures include required components.

Applicable DJJ Administrative Directive: 18-004.1.

Additional information: “Weapon” means a firearm.

Compliance: Interview CSU director and staff to verify probation officers' weapon authorization.

Examine documentation: If authorized, review procedures for compliance and staff records for required elements.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a).

22

[TABLE 22-1] 6VAC35-150-230 (A)&(B). Weapons.

[/TABLE]

[TABLE 22-2] 6VAC35-150-230 (A). Weapons.

A. A probation officer may obtain authorization to carry a weapon as provided by § 16.1-237 of the Code of Virginia only in accordance with approved procedures that require at least: (i) firearms safety training, (ii) a psychological or mental health assessment, (iii) approval by the CSU director, and (iv) approval by the unit director's supervisor.

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• Page 23 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-230 (B). Weapons.

B. All CSU staff authorized to carry weapons must receive training and retraining per approved procedures, covering when weapons may be carried and used as required by law and insurance.

Interpretation: Goal: Ensure CSU staff authorized to carry weapons receive proper training and retraining.

Additional info: DJJ Directive 18-004.1

Compliance: Review documentation if CSU staff are authorized, including training procedures, approval records, and training records.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

23

[TABLE 23-1] 6VAC35-150-230 (B). Weapons.

B. All CSU staff authorized to carry weapons shall have received training and retraining, in accordance with approved procedures, which shall include the limited circumstances when weapons may be carried and used as required by law and liability insurance coverage.

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• Page 24 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-240. Arrest of juvenile by staff.

6VAC35-150-240. Arrest of juvenile by staff.

Probation officers shall exercise arrest powers per approved procedures.

Interpretation: Goal: Ensure probation officers exercise arrest powers per approved procedures.

Additional information: Applicable DJJ CSU procedure: 9463.

Compliance Determination: Interview CSU director and staff: Inquire whether arrests have been made by probation officers.

Examine procedure components.

Review documentation: If arrests occurred, verify compliance with procedure requirements, including training.

If arrest documentation is missing, staff may be interviewed to verify compliance.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a).

24

[TABLE 24-1] 6VAC35-150-240. Arrest of juvenile by staff.

[/TABLE]

[TABLE 24-2] 6VAC35-150-240. Arrest of juvenile by staff.

Probation officers shall exercise their arrest powers in accordance with approved procedures.

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• Page 25 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-250. Absconders.

6VAC35-150-250. Absconders.

Unit staff shall cooperate with Department and law enforcement to locate and recover juveniles violating probation, parole, or who escape or run away from juvenile facilities.

Interpretation: Ensure cooperation between the Department and law enforcement.

CSUs are also subject to § 16.1-309.1 of the Code of Virginia.

Compliance: Interview CSU director and staff to inquire about absconded juveniles.

Examine case records for absconded juveniles' compliance if applicable.

The audit team may interview staff liaising with law enforcement to assess compliance.

Definitions: "Court service unit," "CSU," means a state or local unit per §§ 16.1-233, 16.1-235; "Department" is DJJ; "Juvenile" is under 18, delinquent, or in need of supervision/services per § 16.1-228, including those before the court or under supervision; "Parole" is supervision after release per §§ 16.1-285, 16.1-285.1, 16.1-285.2; "Probation" is court-ordered disposition per §§ 16.1-278.5, 16.1-278.8; "Supervision" involves contact, treatment, or services as court or officer directs.

25

[TABLE 25-1] 6VAC35-150-250. Absconders.

[/TABLE]

[TABLE 25-2] 6VAC35-150-250. Absconders.

Unit staff shall cooperate with Department personnel and state and local law-enforcement authorities to help locate and recover juveniles who violate the conditions of their probation or parole supervision and upon whom a detention order has been issued or who escape or run away from a juvenile correctional center, detention home, or other juvenile placement.

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• Page 26 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-260. Transportation of detained juveniles.

6VAC35-150-260 . Transportation of detained juveniles.

Detained juveniles shall be transported per "Guidelines for Transporting Juveniles in Detention" issued by the board per § 16.1-254.

Interpretation: Ensure transportation complies with the Board of Juvenile Justice guidelines.

Additional information: None.

Compliance: Interview CSU director and staff about transportation procedures.

Examine documentation for guideline availability during CSU transportation.

Compare interview practices with guideline requirements.

Definitions: "Board" is the Board of Juvenile Justice; "Juvenile" is under 18, delinquent, or in need of services per § 16.1-228, including those before the court or under supervision.

26

[TABLE 26-1] 6VAC35-150-260. Transportation of detained juveniles.

[/TABLE]

[TABLE 26-2] 6VAC35-150-260 . Transportation of detained juveniles.

Detained juveniles shall be transported in accord with "Guidelines for Transporting Juveniles in Detention," current edition issued by the board in accord with § 16.1-254 of the Code of Virginia.

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• Page 27 ---

Compliance Manual for Nonresidential Services 6VAC35-150, effective July 1, 2011, Article 3 Intake.

6VAC35-150-270 (A), (B), & (C). Intake duties.

6VAC35-150-270 (A). Intake duties.

A. When making an intake determination per § 16.1-260, in person, by phone, or video, the intake officer shall follow approved procedures:

1. Explain intake steps and options to each person as per approved procedures;
2. Enter all required data into the Department's electronic system per § 16.1-224 and approved procedures;
3. Consult with parents, guardians, or legal custodian to determine placement;
4. Notify parents, guardians, or custodian in detention cases.

Interpretation: Ensure intake determinations comply with this section and procedures.

Additional information: Applicable DJJ CSU procedure: 9115.

Compliance: Review procedures to ensure compliance with this section.

Interview intake officers to confirm procedures and requirements are followed.

Examine electronic data and case records for required entries.

Applicable definitions: (cid:1) "Approved procedures" include procedures issued by DJJ, modifications approved by the director, or locally approved procedures. (cid:1) "Department" means DJJ. (cid:1) "Intake" is the process for screening complaints within juvenile court jurisdiction per § 16.1-260. (cid:1) "Intake officer" is the probation officer authorized for intake per § 16.1-260. (cid:1) "Juvenile" means under 18, delinquent, in need of supervision or services per § 16.1-228; includes individuals under court or Department supervision, regardless of age.

27

[TABLE 27-1] 6VAC35-150-270 (A), (B), & (C). Intake duties.

[/TABLE]

[TABLE 27-2] 6VAC35-150-270 (A). Intake duties.

A. When making an intake determination as provided for by § 16.1-260 of the Code of Virginia, whether in person or by telephone or interactive video conferencing, the intake officer shall, in accordance with approved procedures:

1. Explain the steps and options in the intake process to each person present as provided for in approved procedures;
2. Make all required data entries into the Department's electronic data collection system in accordance with § 16.1-224 of the Code of Virginia and approved procedures;
3. Consult with available parents, guardians, legal custodian, or other person standing in loco parentis to determine the appropriate placement; and
4. Notify the juvenile's parents, guardians, legal custodian, or other person standing in loco parentis in cases involving the juvenile's detention.

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• Page 28 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 6VAC35-150-270 (B). Intake duties.

B. When making detention decisions per § 16.1-248.1 and recommendations per § 16.1-250, CSU personnel shall use the mandated uniform risk assessment instrument and procedure from Chapter 648 of 2002 Acts.

Interpretation: Ensure detention decisions use the uniform risk assessment instrument and related procedure.

Additional information: Applicable DJJ CSU procedures: 9115, 9131, and 9135.

Compliance: Interview intake officers to verify detention decisions comply with this section.

Examine case records or electronic data of detained juveniles to verify use of the risk assessment instrument complies with procedures.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

6VAC35-150-270 (C). Intake duties.

C. When the chief judge requests a replacement intake officer per § 16.1-235.1, CSU shall enter a written agreement covering duties, processing location, and face-to-face contact protocol.

Interpretation: Ensure provision of replacement intake officers as required by statute.

Additional information: None.

Compliance: Interview CSU director to verify if the chief judge requested replacement intake officers.

Examine agreement if a chief judge requested replacement officers for compliance with this section and § 16.1-235.1.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or local court service unit per §§ 16.1-233 and 16.1-235. (cid:1) "Intake" is the process for screening complaints per § 16.1-260. (cid:1) "Intake officer" is the probation officer authorized for intake per § 16.1-260. (cid:1) "Juvenile" means under 18, delinquent, in need of supervision or services per § 16.1-228; includes individuals under court or Department supervision, regardless of age. (cid:1) "Written" means information communicated in writing, either hard copy or electronic. 28

[TABLE 28-1] 6VAC35-150-270 (B). Intake duties.

B. When making a detention decision pursuant to § 16.1-248.1 of the Code of Virginia and when making recommendations to the court at a detention hearing pursuant to § 16.1-250 of the Code of Virginia, CSU personnel shall make use of the uniform risk assessment instrument and related procedure mandated by Chapter 648 of the 2002 Acts of Assembly.

[/TABLE]

[TABLE 28-2] 6VAC35-150-270 (C). Intake duties.

C. When the chief judge in a jurisdiction requests the provision of a replacement intake officer pursuant to § 16.1-235.1 of the Code of Virginia, the CSU shall enter into a written agreement with the requesting court that shall address, at a minimum, the scope of the intake duties, the location where intake cases will be processed, and the protocol for arranging any required face-to-face contact between the intake officer and juvenile.

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• Page 29 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-280. Medical and psychiatric emergencies at intake.

6VAC35-150-280. Medical and psychiatric emergencies at intake.

If during intake the officer suspects emergency medical or psychiatric care, the officer shall:

1. Immediately notify juvenile's parents or guardians of the emergency and their responsibilities;
2. Before placing a juvenile in a restrictive setting, the intake officer shall arrange emergency care;

Interpretation: Ensure intake officers comply when suspecting a juvenile needs emergency medical or psychiatric care.

Additional information: Applicable DJJ CSU procedure: 9125.

Compliance: Interview CSU director and intake officer to verify if any suspected emergencies during intake.

Examine case records or electronic data for emergencies during intake to verify compliance.

Applicable definitions: (cid:1) "Intake" is the process for screening complaints per § 16.1-260. (cid:1) "Intake officer" is the probation officer authorized per § 16.1-260. (cid:1) "Juvenile" means under 18, delinquent, in need of supervision or services per § 16.1-228; includes individuals under court or Department supervision, regardless of age.

29

[TABLE 29-1] 6VAC35-150-280. Medical and psychiatric emergencies at intake.

[/TABLE]

[TABLE 29-2] 6VAC35-150-280. Medical and psychiatric emergencies at intake.

If during the intake interview, the intake officer suspects that the juvenile requires emergency medical or psychiatric care, the intake officer shall:

1. Immediately contact the juvenile's parents or legal guardians to advise them of the emergency and any responsibilities they may have; and
2. Before placing a juvenile in a more restrictive setting, the intake officer shall arrange for the juvenile to receive the needed emergency care.

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• Page 30 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-290. Intake communication with detention.

6VAC35-150-290. Intake communication with detention.

When facilitating detention placement, CSU staff shall provide detention staff, by phone, written, or electronic means, at or before juvenile arrival, the detention reason, offenses, and, when available, medical info, guardians' contact info, prior records, suicide attempts, gang ties, and other required info.

Interpretation: Goal: Ensure CSU staff share necessary info to facilitate juvenile detention placement.

Additional information: Applicable DJJ CSU procedure: 9132.

Compliance Determination: Review procedure for required components.

Interview CSU staff: Inquire about CSU contacts with detention centers during juvenile placement.

Interview detention center staff: Contact the most used detention center; inquire about compliance with this section and procedures.

Examine documentation: Review case record or electronic system to verify info sharing with detention center complies with this section and procedures.

Applicable definitions: (cid:1) "Approved procedures" are procedures issued by DJJ applicable to all state or locally operated court service units, including approved modifications. (cid:1) "Court service unit," "CSU," or "unit" refers to a state or local court service unit per §§ 16.1-233 and 16.1-235. (cid:1) "Juvenile" means under 18, delinquent, in need of supervision or services as per § 16.1-228, including those before the court, under supervision, or committed. (cid:1) "Written" indicates information communicated in writing, either hard copy or electronic.

30

[TABLE 30-1] 6VAC35-150-290. Intake communication with detention.

[/TABLE]

[TABLE 30-2] 6VAC35-150-290. Intake communication with detention.

When CSU staff facilitate the placement of a juvenile in detention, they shall give detention staff, by telephone, in writing, or by electronic means, no later than the time the juvenile arrives at the detention facility, the reason for detention and the offenses for which the juvenile is being detained including any ancillary offenses. CSU staff shall also give detention staff the following information when available and applicable: medical information; parents' or guardians' names, addresses and phone numbers; prior record as regards sexual offenses, violence against persons, or arson; suicide attempts or self-injurious behaviors; gang membership and affiliation; and any other information as required by approved procedure.

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• Page 31 ---

Compliance Manual for Nonresidential Services 6VAC35-150, effective July 1, 2011, Article 4 Out-of-Home Placements.

6VAC35-150-300 (A), (B), & (C). Predispositionally placed juvenile.

6VAC35-150-300 (A). Predispositionally placed juvenile.

A. According to approved procedures, CSU must contact each juvenile in predispositional detention, jail, or shelter care within 5 days of placement, then at least every 10 days via face-to-face, phone, or videoconference, ensuring direct communication.

Interpretation: Goal: Ensure CSU maintains contact with predispositional juveniles in detention, jail, or shelter care as required.

Additional information:

• A CSU representative must inquire about adjustment and safety, answer questions, and provide necessary information to the detained juvenile. The visit may be private before transport. DJJ CSU procedure: 9134.
• This applies to juveniles transferred to circuit court for adult trial and confined in jail pending trial.

Compliance Determination: Review procedure components.

Examine documentation: Review case records of contacts with predispositional juveniles for compliance.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department.

31

[TABLE 31-1] 6VAC35-150-300 (A), (B), & (C). Predispositionally placed juvenile.

[/TABLE]

[TABLE 31-2] 6VAC35-150-300 (A). Predispositionally placed juvenile.

A. In accordance with approved procedures, a representative of the CSU shall make contact, either face-to-face or via videoconferencing, with each juvenile placed in predispositional detention, jail, or shelter care pursuant to § 16.1-248.1 of the Code of Virginia, within five days of the placement. A representative of the CSU shall make contact with the juvenile at least once every 10 days thereafter either face-to-face or by telephone or videoconferencing. All such contacts shall include direct communication between the CSU staff and the juvenile.

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• Page 32 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-300 (B). Predispositionally placed juvenile.

B. Each predispositional juvenile's case must be reviewed at least every 10 days per approved procedures to assess if a placement change is warranted.

Interpretation: Goal: Ensure each predispositional juvenile's case is reviewed as required.

Additional info: CSU staff should ensure continued detention is appropriate. Applicable DJJ CSU procedure: 9134.

Compliance Determination: Review procedural requirements.

Examine documentation: Review case records of juvenile reviews for compliance.

Applicable definitions: (cid:1) "Approved procedures" are DJJ-issued procedures for all court service units, including approved modifications. (cid:1) "Juvenile" means under 18, delinquent, in supervision, or receiving services as per § 16.1-228, including those before the court, under supervision, or committed. (cid:1) "Written" indicates info communicated in writing, either hard copy or electronic.

32

[TABLE 32-1] 6VAC35-150-300 (B). Predispositionally placed juvenile.

B. The case of each predispositionally placed juvenile shall be reviewed at least every 10 days in accordance with approved procedures to determine whether there has been a material change sufficient to warrant recommending a change in placement.

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• Page 33 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-300 (C). Predispositionally placed juvenile.

C. When the unit supervises a juvenile in a residential facility, designated CSU staff shall be available 24/7 for emergencies.

Interpretation: Ensure residential facility access to CSU personnel in emergencies.

Additional information: None.

Compliance: Interview staff about on-call/24-hour coverage practices.

Examine documentation: Review on-call/24-hour schedule for coverage.

Applicable definitions: "Agency" includes government entities and contracted private providers; "Approved procedures" are issued or approved by DJJ; "Court service unit," "CSU," or "unit" refers to state or local units established under §§ 16.1-233 and 16.1-235; "Juvenile" means under 18, delinquent, or in need of supervision/services, including those under court or Department supervision, regardless of age.

33

[TABLE 33-1] 6VAC35-150-300 (C). Predispositionally placed juvenile.

C. When the unit is the placing agency and is supervising a juvenile in a residential facility, designated staff of the CSU shall be available to the facility's staff 24 hours a day in case of emergency.

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• Page 34 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-310 (A) & (B). Postdispositional detention.

6VAC35-150-310 (A). Postdispositional detention.

A. When a court orders juvenile detention over 30 days under § 16.1-284.1, CSU staff shall develop a written plan with the facility for community treatment programs suitable for rehabilitation, which may occur at the facility or during temporary release, based on risk and other factors. CSU shall provide the juvenile's social history to the detention program upon request.

Interpretation: Ensure collaboration between CSU and postdispositional detention staff as per this section.

Additional information: None.

Compliance: Review case records of postdispositional juveniles for plan development and social history documentation, if requested.

Applicable definitions: "Court service unit," "CSU," or "unit" refers to state or local units under §§ 16.1-233 and 16.1-235; "Juvenile" means under 18, delinquent, or in need of supervision/services, including those under court or Department supervision, regardless of age; "Written" means information communicated in writing, in hard copy or electronic form.

34

[TABLE 34-1] 6VAC35-150-310 (A) & (B). Postdispositional detention.

[/TABLE]

[TABLE 34-2] 6VAC35-150-310 (A). Postdispositional detention.

A. When a court orders a juvenile to be detained postdispositionally for more than 30 days pursuant to subsection B of § 16.1-284.1 of the Code of Virginia, the CSU staff shall develop a written plan with the facility to enable such juvenile to take part in one or more community treatment programs appropriate for that juvenile's rehabilitation, which may be provided at the facility or while the juvenile is on temporary release status, as determined by that juvenile's risk to public safety and other relevant factors. The CSU shall provide a copy of the juvenile's social history to the postdispositional detention program upon request.

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• Page 35 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-310 (B). Postdispositional detention.

B. The case record of a juvenile in postdispositional detention under § 16.1-284.1 must contain:

1. Social history;
2. Court order;
3. Reason for placement; and
4. Current supervision plan, if applicable.

Interpretation: Ensure case records of postdispositional juveniles are maintained per this section.

Additional information: None.

Compliance: Review case records of postdispositional juveniles for compliance with this section.

Applicable definitions: "Case record" includes written/electronic info per procedures; "Individual supervision plan" is a written, updated plan with goals, objectives, strategies, and responsible persons, applicable during probation, parole, or treatment; "Juvenile" means under 18, delinquent, or in need of supervision/services, including those under court or Department supervision, regardless of age.

35

[TABLE 35-1] 6VAC35-150-310 (B). Postdispositional detention.

B. The case record of a juvenile placed in a postdispositional detention program pursuant to subsection B of § 16.1-284.1 of the Code of Virginia shall contain:

1. Social history;
2. Court order;
3. Reason for placement; and
4. Current supervision plan, if applicable.

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• Page 36 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-320. Notice of juvenile's transfer.

6VAC35-150-320. Notice of juvenile's transfer.

If CSU staff know a juvenile moved between facilities without parental/guardian notice, they must notify parents/guardians within 24 hours and document in the case record.

Interpretation: Ensure parents/guardians are notified of transfers, minimizing CSU workload.

Additional information: None.

Compliance: Review case records for move awareness, parental notification, and documentation of notice sent, as required.

Applicable definitions: "Case record" includes written/electronic info per procedures; "Court service unit," "CSU," or "unit" refers to state or local units under §§ 16.1-233 and 16.1-235; "Juvenile" means under 18, delinquent, or in need of supervision/services, including those under court or Department supervision, regardless of age.

36

[TABLE 36-1] 6VAC35-150-320. Notice of juvenile's transfer.

[/TABLE]

[TABLE 36-2] 6VAC35-150-320. Notice of juvenile's transfer.

When CSU staff have knowledge that a juvenile has been moved from one residential facility to another residential facility and do not have knowledge that the juvenile's parents or legal guardians have been advised of the transfer, CSU staff shall notify the juvenile's parents or legal guardians within 24 hours and shall document the notification in the juvenile's case record.

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• Page 37 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011 Article 5 Probation, Parole, and Other Supervision

6VAC35-150-335 (A), (B), & (C). Diversion.

6VAC35-150-335 (A). Diversion.

A. When an intake officer proceeds with diversion per subsection B of § 16.1-260, supervision shall not exceed 120 days; for truants per § 22.1-258, supervision is limited to 90 days.

Interpretation: Ensure diversions comply with this section and the Code of Virginia.

Additional information: Applicable DJJ CSU procedure: 9123.

Compliance: Review a sample of case records of diverted juveniles for compliance.

"Diversion" means counseling, supervision, programs, or services aligned with public safety and juvenile welfare per §§ 16.1-227 and 16.1-260. "Intake officer" is the probation officer authorized for intake per § 16.1-260. "Juvenile" is under 18, delinquent, in need of supervision or services per § 16.1-228, including those before the court or under supervision. "Supervision" involves contact, treatment, or services as required by court, officer, or for probation/parole.

37

[TABLE 37-1] 6VAC35-150-335 (A), (B), & (C). Diversion.

[/TABLE]

[TABLE 37-2] 6VAC35-150-335 (A). Diversion.

A. When an intake officer proceeds with diversion in accordance with subsection B of § 16.1-260 of the Code of Virginia, such supervision shall not exceed 120 days. For a juvenile alleged to be a truant pursuant to a complaint filed in accordance with § 22.1-258 of the Code of Virginia, such supervision shall be limited to 90 days.

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• Page 38 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-335 (B). Diversion.

B. When a new complaint is filed against a juvenile under supervision per subsection A, and qualifies for diversion per § 16.1-260, the intake officer may proceed with an additional 120 days of diversion from the complaint date.

Interpretation: Ensure subsequent diversions comply with this section and the Code of Virginia.

Additional info: This section is permissive; subsequent offenses need not be diverted, but if diverted, duration must not exceed 120 days.

Compliance: Review case records of juveniles with second or subsequent diversions for compliance.

Applicable definitions: (cid:1) "Diversion" means the provision of counseling, informal supervision, programs, or services, or a combination thereof, which is consistent with the protection of the public safety and the welfare of the juvenile as provided for in §§ 16.1-227 and 16.1-260 of the Code of Virginia. (cid:1) "Intake officer" means the probation officer who is authorized to perform the intake function as provided in § 16.1-260 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes.

6VAC35-150-335 (C). Diversion.

C. No petition shall be filed by CSU based on acts in the original complaint more than 120 days after initial referral.

Interpretation: Ensure diversion cases comply with this section.

Additional information: None.

Compliance: Review case records of diverted juveniles for compliance, including petitions filed beyond 120 days.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia.

38

[TABLE 38-1] 6VAC35-150-335 (B). Diversion.

B. When a new complaint is filed against a juvenile who is currently under supervision in accordance with subsection A of this section, and the juvenile qualifies for diversion in accordance with subsection B of § 16.1-260 of the Code of Virginia, then the intake officer may proceed with diversion for an additional 120 days from the date of the subsequent complaint.

[/TABLE]

[TABLE 38-2] 6VAC35-150-335 (C). Diversion.

C. In no case shall a petition be filed by the CSU based on acts or offenses in the original complaint after 120 days from the date of the initial referral on the original complaint.

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• Page 39 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-336 (A), (B), &(C). Social histories.

6VAC35-150-336 (A). Social histories.

A. A social history shall be prepared per approved procedures (i) when ordered by court, (ii) for each juvenile on probation, (iii) for each committed to the Department, (iv) for each in a postdispositional detention >30 days per § 16.1-284.1, or (v) upon written request with court order. Reports shall include the following information:

1. Juvenile's identifying and demographic info;
2. Current offense and prior court involvement;
3. Social, medical, psychological, and educational information about the juvenile;
4. Family information; and
5. Dispositional recommendations, if court permits.

Interpretation: Ensure social history reports comply with the Code of Virginia, this section, and procedures.

Additional info: CSU Director should develop internal procedures and format.

Applicable DJJ CSU procedure: 9230.

Compliance Determination: Review procedure: Examine required components and compliance with this section.

Examine documentation: Review case records for compliance with this section and the procedure.

Applicable definitions: (cid:1) "Approved procedures" are procedures issued by DJJ for all court service units, including modifications approved by the director or local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or local court service unit per §§ 16.1-233 and 16.1-235. (cid:1) "Juvenile" means an individual under 18, a delinquent child, or a child needing supervision or services as defined in § 16.1-228, including those before the court, under supervision, or committed to the Department. (cid:1) "Probation" means a court-ordered disposition per §§ 16.1-278.5, 16.1-278.8. (cid:1) "Supervision" involves contact, treatment, or services to a juvenile as required by court, intake, or for probation or parole.

39

[TABLE 39-1] 6VAC35-150-336 (A), (B), &(C). Social histories.

[/TABLE]

[TABLE 39-2] 6VAC35-150-336 (A). Social histories.

A. A social history shall be prepared in accordance with approved procedures (i) when ordered by the court, (ii) for each juvenile placed on probation supervision with the unit, (iii) for each juvenile committed to the Department, (iv) for each juvenile placed in a postdispositional detention program for more than 30 days pursuant to § 16.1-284.1 of the Code of Virginia, or (v) upon written request from another unit when accompanied by a court order. Social history reports shall include the following information:

1. Identifying and demographic information on the juvenile;
2. Current offense and prior court involvement;
3. Social, medical, psychological, and educational information about the juvenile;
4. Information about the family; and
5. Dispositional recommendations, if permitted by the court.

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• Page 40 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-336 (B). Social histories.

B. An existing social history under 12 months old may be used with an updated addendum. A new social history must be prepared as in subsection A or if ordered by the court when over 12 months old.

Interpretation: Goal: Ensure social history is current so judicial/service decisions are based on up-to-date information.

Additional information: Unit procedures may specify addendum format.

Compliance Determination: Interview CSU director and staff: Inquire regarding social histories and addendum practices.

Examine documentation: Review case files for compliance.

Applicable definitions: None.

6VAC35-150-336 (C). Social histories.

C. Social history reports on adults may be modified per procedures approved by the CSU director after consulting the court judges.

Interpretation: Goal: Ensure adult social histories follow approved procedures or formats approved by the CSU director after court consultation.

Additional information: CSU director should develop internal procedures and formats.

Applicable DJJ CSU procedure: 9230.

Compliance Determination: Interview CSU director about whether the format used is (1) in section 336 and approved procedures or (2) approved by the CSU director after court consultation.

Review procedure: If modified format is used, review procedure for required components.

Examine documentation: Examine adult case records for compliance with applicable format and content requirements.

Applicable definitions: (cid:1) "Adult" is a person 18 or older not a delinquent child per § 16.1-228. (cid:1) "Court service unit," "CSU," or "unit" means a state or local court service unit per §§ 16.1-233 and 16.1-235.

40

[TABLE 40-1] 6VAC35-150-336 (B). Social histories.

B. An existing social history that is less than 12 months old may be used provided an addendum is prepared updating all changed information. A new social history shall be prepared as required in subsection A of this section or when ordered by the court if the existing social history is more than 12 months old.

[/TABLE]

[TABLE 40-2] 6VAC35-150-336 (C). Social histories.

C. Social history reports on adults may be modified as provided for in procedures approved by the CSU director after consultation with the judge or judges of the court.

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• Page 41 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-340. Beginning supervision.

6VAC35-150-340. Beginning supervision.

Within the timeframes established by approved procedures for beginning supervision, a probation or parole officer shall:

1. See the juvenile face-to-face;
2. Provide written supervision rules, including conditions, and explain to juvenile and, when appropriate, parents or guardians;
3. Document actions in case record.

Interpretation: Goal: Ensure probation and parole officers follow approved procedures and this section when beginning supervision.

Additional information: The required time frames begin to run when the court order placing the individual under the supervision of the unit is received by the unit. Best practice is for the court order to be date stamped. If the court order is not date stamped, the time frames will begin to run on the date the court order was issued. Applicable DJJ CSU procedure: 9323.

Compliance Determination: Review procedure to determine applicable timeframes.

Examine documentation: Review case records for compliance with this section and procedure.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Case record" or "record" means written or electronic information regarding an individual and the individual's family, if applicable, that is maintained in accordance with approved procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Parole" means supervision of a juvenile released from commitment to the Department as provided for by §§ 16.1-285, 16.1-285.1, and 16.1-285.2 of the Code of Virginia. (cid:1) "Probation" means a court-ordered disposition of a juvenile or an adult as provided by §§ 16.1-278.5 (B)(2), 16.1-278.8 (A)(5), 16.1-278.8 (A)(7), and 16.1-278.8 (A)(7a). (cid:1) "Supervision" means visiting or making other contact with or providing treatment, rehabilitation, or services to a juvenile as required by the court, by an intake officer, or for probation or parole purposes. (cid:1) "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

41

[TABLE 41-1] 6VAC35-150-340. Beginning supervision.

[/TABLE]

[TABLE 41-2] 6VAC35-150-340. Beginning supervision.

Within the timeframes established by approved procedures for beginning supervision, a probation or parole officer shall:

1. See the juvenile face-to-face;
2. Give the juvenile the written rules of supervision, including any special conditions, and explain these to the juvenile and, when appropriate, to the juvenile's parents or guardians; and
3. Document these actions in the case record.

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• Page 42 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-350 (A) & (B). Supervision plans for juveniles.

6VAC35-150-350 (A). Supervision plans for juveniles.

A. To ensure public safety and address juvenile and family needs, a juvenile shall be supervised per a written individual supervision plan, developed per approved procedures and timeframes, detailing contacts with the juvenile, parents, guardians, and service providers.

Interpretation: Goal: Ensure juvenile supervision aligns with the individual supervision plan and procedures.

Additional information:

• Units may develop specific supervision plans that do not conflict with approved procedures. Juveniles must be supervised per established procedures.
• Applicable DJJ CSU procedures: 9324 and 9338.
• CSU must provide a list of levels to the audit team before the audit to determine contact frequency for supervision levels.

Compliance: Review procedure to determine applicable requirements and time frames.

Examine documentation: Review a sample of case records for compliance with the section and the procedure.

Definitions: "Agency" includes government entities and contractors; "Approved procedures" are issued by DJJ or approved modifications; "Individual supervision plan" is a written, adaptable plan with goals, objectives, strategies, and responsible persons, applicable during probation, parole, and services; "Juvenile" is under 18, including those under court supervision or committed to the Department; "Provider" is responsible for service compliance; "Supervision" involves contact or services as required; "Written" means documented in hard copy or electronic form. 42

[TABLE 42-1] 6VAC35-150-350 (A) & (B). Supervision plans for juveniles.

[/TABLE]

[TABLE 42-2] 6VAC35-150-350 (A). Supervision plans for juveniles.

A. To provide for the public safety and address the needs of a juvenile and that juvenile's family, a juvenile shall be supervised according to a written individual supervision plan, developed in accordance with approved procedures and timeframes, that describes the range and nature of field and office contact with the juvenile, with the parents or guardians of the juvenile, and with other agencies or providers providing treatment or services.

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• Page 43 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-350 (B). Supervision plans for juveniles.

B. Per approved procedures, each written supervision plan shall be reviewed (i) with the juvenile and family, and (ii) by supervisors from treatment and case management to confirm appropriateness.

Interpretation: Goal: Ensure supervision plan review complies with this section.

Additional information: Applicable DJJ CSU procedures: 9260, 9324, 9325, 9334, 9338, and 9339.

Compliance: Review procedure to determine requirements.

Examine documentation: Review case records or alternatives for compliance.

Definitions: "Approved procedures" include DJJ-issued or approved modifications; "Individual supervision plan" is a written, adaptable plan with goals, objectives, strategies, responsible persons, during probation, parole, and services; "Juvenile" is under 18, including those before court or committed; "Written" means documented in hard copy or electronic form.

43

[TABLE 43-1] 6VAC35-150-350 (B). Supervision plans for juveniles.

B. In accordance with approved procedures, each written individual supervision plan shall be reviewed (i) with the juvenile and the juvenile's family, and (ii) by a supervisor from both a treatment and a case management perspective to confirm the appropriateness of the plan.

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• Page 44 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-355. Supervision of juvenile on electronic monitoring.

6VAC35-150-355. Supervision of juvenile on electronic monitoring.

When a unit places a juvenile in an electronic monitoring program, use of the program shall be governed by approved procedures that shall provide for criteria for placement in the program, parental involvement, required contacts, consequences for tampering with and violating program requirements, and time limits.

Interpretation: Goal: To ensure electronic monitoring programs are governed by the requirements of approved procedures governing the components of this section.

Additional information: Applicable DJJ CSU procedure: 9467.

Compliance Determination: Review procedure: Examine procedure or description of the Electronic Monitoring Program used by the Unit to determine that the Unit and Program have agreed to the regulatory requirements.

Applicable definitions: (cid:1) "Approved procedures" means (i) procedures issued by the Department of Juvenile Justice, which apply to all state-operated court service units and which may be voluntarily observed by locally operated court service units; or (ii) modifications to the procedures approved by the director or his designee; or (iii) procedures for locally operated court service units approved in accordance with local procedures. (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit established pursuant to §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Electronic monitoring" means the use of electronic devices, including, but not limited to, voice recognition and global positioning systems, to verify a juvenile's or adult's compliance with certain judicial orders or conditions of release from incarceration, as an alternative to detention, or as a short-term sanction for noncompliance with rules of probation or parole. (cid:1) "Juvenile" means an individual less than 18 years of age, a delinquent child, a child in need of supervision, or a child in need of services as defined in § 16.1-228 of the Code of Virginia. For the purpose of this regulation, "juvenile" includes an individual, regardless of age, who is or has been before the court, who was under the age of 18 at the time of the offense or act, who is under supervision or receiving services from a court service unit or a program under contract with or monitored by the unit, or who is committed to the Department. (cid:1) "Tamper" means any purposeful alteration to electronic monitoring equipment that interferes with or weakens the monitoring system.

44

[TABLE 44-1] 6VAC35-150-355. Supervision of juvenile on electronic monitoring.

[/TABLE]

[TABLE 44-2] 6VAC35-150-355. Supervision of juvenile on electronic monitoring.

When a unit places a juvenile in an electronic monitoring program, use of the program shall be governed by approved procedures that shall provide for criteria for placement in the program, parental involvement, required contacts, consequences for tampering with and violating program requirements, and time limits.

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• Page 45 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-365. Supervision of adult on probation.

6VAC35-150-365. Supervision of adult on probation.

For an adult convicted of a criminal act under § 16.1-241 where juvenile court retains jurisdiction and no specific supervision conditions are ordered, a supervision plan must be prepared within 30 days, consulting the adult and family if appropriate.

Interpretation: Ensure supervision plans are developed for adult probationers per this section.

Additional information: None.

Compliance Determination: Review procedure to identify applicable requirements.

Review a sample of adult case records for compliance with this section and procedure.

Definitions: "Adult" is 18+ not a delinquent child per § 16.1-228. "Individual supervision plan" is a written, adaptable plan with goals, objectives, strategies, time frames, and responsible persons, applicable during probation, parole, and juvenile services. "Probation" is a court-ordered disposition per §§ 16.1-278.5 et seq. "Supervision" involves contact, treatment, or services as required by court or officers.

45

[TABLE 45-1] 6VAC35-150-365. Adult probation supervision.

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[TABLE 45-2] 6VAC35-150-365. Adult probation supervision.

For an adult convicted of a criminal act for which the juvenile court retained jurisdiction pursuant to § 16.1-241 of the Code of Virginia and the juvenile court does not order specific conditions of supervision, a supervision plan for the adult probationer shall be prepared within 30 days of the disposition. The adult and that adult's family, if appropriate, must be consulted in development of the supervision plan.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-380. Violation of probation or parole.

6VAC35-150-380. Violation of probation or parole.

When a probationer or parolee violates conditions, unit personnel shall act per approved procedures.

Interpretation: Ensure probation and parole violations are managed per approved procedures.

Additional information: Applicable DJJ CSU procedure: 9326.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Review case records for compliance with this section and procedure, including supervisor discussion if formal action is taken.

Definitions: "Approved procedures" are DJJ-issued, approved modifications, or locally approved procedures for court service units. "Court service unit" or "CSU" is a state or local court unit per §§ 16.1-233 and 16.1-235. "Parole" is supervision of a juvenile released from commitment per §§ 16.1-285 et seq. "Probation" is a court-ordered disposition per §§ 16.1-278.5 et seq.

46

[TABLE 46-1] 6VAC35-150-380. Violation of probation or parole.

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[TABLE 46-2] 6VAC35-150-380. Violation of probation or parole.

When a probationer or parolee violates the conditions of the individual's probation or parole, unit personnel shall take action in accordance with approved procedures.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-390 (A) & (B). Transfer of case supervision.

6VAC35-150-390 (A). Transfer of case supervision.

A. If an individual's residence under CSU supervision is outside the original CSU's jurisdiction, case transfer to another Virginia unit is permitted per § 16.1-295 and approved procedures.

Interpretation: Ensure case transfers within Virginia follow this section, statute, and procedure.

Additional info: Applicable DJJ CSU procedure: 9351. Excludes transfers between same CSU branch offices.

Compliance Determination: Interview CSU director: Inquire whether supervision was transferred on any cases.

Review procedure: Examine procedure to determine applicable requirements.

Review case records for compliance with statute, this section, and procedure.

Definitions: "Approved procedures" are DJJ-issued, approved modifications, or locally approved procedures for court service units. "Court service unit" or "CSU" is a state or local court unit per §§ 16.1-233 and 16.1-235. "Supervision" involves contact, treatment, or services as required by court or officers.

47

[TABLE 47-1] 6VAC35-150-390 (A) & (B). Transfer of case supervision.

[/TABLE]

[TABLE 47-2] 6VAC35-150-390 (A). Transfer of case supervision.

A. When the legal residence of an individual under the supervision of a CSU is not within the jurisdiction of the original CSU, the supervision of the case may be transferred to another unit in Virginia in accordance with § 16.1-295 of the Code of Virginia and approved procedures.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-390 (B). Transfer of case supervision.

B. When transferring supervision of a juvenile on probation or parole to/from another state CSU, staff shall follow the Interstate Compact Relating to Juveniles, Article 14 (§ 16.1-323) of Chapter 11, Title 16.1.

Interpretation: Goal: Ensure supervision of cases to and from another state transfers per applicable statutes.

Additional information: None.

Compliance Determination: Interview CSU director: Inquire whether supervision was transferred to or from another state on any cases.

Examine documentation: Review sample case records for compliance with statutes and this section.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or locally operated court service unit per §§ 16.1-233 and 16.1-235 of the Code of Virginia. (cid:1) "Juvenile" means an individual under 18, delinquent, in need of supervision or services as defined in § 16.1-228. "Juvenile" includes anyone, regardless of age, who was or is before the court, under 18 at the offense, under supervision or services, or committed to the Department. (cid:1) "Parole" means supervision of a juvenile released from commitment per §§ 16.1-285, 16.1-285.1, 16.1-285.2. (cid:1) "Probation" means court-ordered disposition per §§ 16.1-278.5, 16.1-278.8. (cid:1) "Supervision" means contact, treatment, or services to a juvenile as required by court, intake officer, or for probation or parole.

48

[TABLE 48-1] 6VAC35-150-390 (B). Transfer of case supervision.

B. When transferring or receiving supervision of a juvenile on probation or parole to or from another state CSU staff shall do so in accordance with the Interstate Compact Relating to Juveniles, Article 14 (§ 16.1-323 et seq.) of Chapter 11 of Title 16.1 of the Code of Virginia.

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• Page 49 ---

Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-400. Notice of release from supervision.

6VAC35-150-400. Notice of release from supervision.

Notice of release shall be in writing to the supervised individual and juvenile's parents or guardians, documented in the case record per approved procedures.

Interpretation: Goal: Ensure the supervised individual and juvenile's parents are notified in writing of release.

Additional info: DJJ CSU procedure 9327. Copies of notification or court orders shall be in the case file, with release documented in the case narrative.

Compliance Determination: Review procedure to determine documentation requirements.

Examine documentation: Review sample closed supervision case records for compliance.

Applicable definitions: (cid:1) "Approved procedures" are procedures issued by DJJ, applicable to all or locally operated court service units, or approved modifications. (cid:1) "Case record" is written or electronic info about an individual and family, maintained per approved procedures. (cid:1) "Court service unit," "CSU," or "unit" is a state or local court service unit per §§ 16.1-233 and 16.1-235. (cid:1) "Juvenile" is under 18, delinquent, in need of supervision or services as per § 16.1-228, including anyone before the court, under supervision, or committed to the Department. (cid:1) "Supervision" involves contact, treatment, or services to a juvenile as required by court, intake, or for probation or parole. (cid:1) "Written" means information communicated in writing, in hard copy or electronic form.

49

[TABLE 49-1] 6VAC35-150-400. Notice of release from supervision.

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[TABLE 49-2] 6VAC35-150-400. Notice of release from supervision.

Notice of release from supervision shall be given in writing to the individual under the supervision of a CSU and to the parents or guardians of juveniles. Such notification shall be appropriately documented in the case record in accordance with approved procedures.

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Compliance Manual for Nonresidential Services 6VAC35-150, effective July 1, 2011, Article 6 Juvenile in Direct Care.

6VAC35-150-410 (A) & (B). Commitment information.

6VAC35-150-410 (A). Commitment information.

A. When a juvenile is committed to the Department, they may not be transported to RDC until (i) required items and info per Virginia Code and procedures are received, and (ii) the case is accepted by RDC.

Interpretation: Goal: Ensure appropriate information is provided to RDC before transporting the juvenile.

Additional information: Applicable DJJ CSU procedure: 9332.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Interview director: Inquire about "drop offs"; review case records for compliance with statute, section, and procedure.

Applicable definitions: (cid:1) "Approved procedures" are those issued by DJJ, applicable to all or locally operated court service units, or approved modifications. (cid:1) "Department" is the Department of Juvenile Justice. (cid:1) "Direct care" is the time a resident committed to the Department, per §§ 16.1-272, 16.1-285.1, or subdivision A 14 or 17 of § 16.1-278.8, is under staff supervision in a juvenile correctional or residential facility. (cid:1) "Juvenile" is under 18, delinquent, in need of supervision or services as per § 16.1-228, including anyone before the court, under supervision, or committed to the Department.

50

[TABLE 50-1] 6VAC35-150-410 (A). Commitment information.

A. When a juvenile is committed to the Department, the juvenile may not be transported to the Reception and Diagnostic Center (RDC) until (i) the items and information required by the Code of Virginia and approved procedures have been received by RDC and (ii) the case is accepted by RDC.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-410 (B). Commitment information.

B. If a juvenile is transported to the Department directly from the court, in addition to ensuring the immediate delivery of the items required in subsection A of this section, unit staff shall immediately notify RDC by telephone of the juvenile's impending arrival.

Interpretation: Goal: To ensure RDC immediately receives notice of a juvenile's impending arrival and the appropriate information when transported to RDC directly from court.

Additional information: Applicable DJJ CSU procedure: 9351.

Compliance Determination: Interview CSU director: Inquire whether any juveniles were transported to RDC directly from court.

Review procedure: Examine procedure to determine applicable requirements (i.e., information to be provided to RDC).

Examine documentation: Review a sample of case records of juveniles transported directly from court for compliance with this section and procedure.

Applicable definitions: (cid:1) "Court service unit," "CSU," or "unit" means a state or local court service unit established under §§ 16.1-233 and 16.1-235. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Juvenile" means an individual under 18, a delinquent child, child in need of supervision or services as defined in § 16.1-228. For this regulation, "juvenile" includes anyone who was or is before the court, under 18 at the time of the offense, under supervision or receiving services from a court unit or program, or committed to the Department.

51

[TABLE 51-1] 6VAC35-150-410 (B). Commitment information.

B. If a juvenile is transported to the Department directly from the court, in addition to ensuring the immediate delivery of the items required in subsection A of this section, unit staff shall immediately notify RDC by telephone of the juvenile's impending arrival.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-415. Supervision of juvenile in direct care.

6VAC35-150-415. Supervision of juvenile in direct care.

For juveniles in direct care, probation or parole officers shall, per approved procedures, do the following:

1. Develop and implement a family involvement plan.
2. Develop a parole supervision plan: a. For juveniles indeterminately committed under subsection A (14) of § 16.1-278.8 and § 16.1-272, CSU staff shall complete a plan per approved procedures. b. For juveniles determinately committed under subdivision A (17) of § 16.1-278.8 or §§ 16.1-285.1, 16.1-272, a plan shall be prepared for all serious offender judicial review hearings as required by law and approved procedures.
3. Send a report on the family's progress toward the family involvement plan's goals to the juvenile's facility.

Interpretation: Goal: Ensure family involvement plans, supervision plans, and progress reports are completed per statutes, this section, and procedures.

Additional info: Quarterly means every 90 days after plan development. Applicable DJJ CSU procedures: 9332, 9334, 9338.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of commitment case records for compliance with statute, this section, and procedure.

Applicable definitions: (cid:1) "Approved procedures" are procedures issued by DJJ applying to all state court service units, possibly observed by local units, or approved modifications. (cid:1) "Court service unit," "CSU," or "unit" means a state or local court service unit established under §§ 16.1-233 and 16.1-235. (cid:1) "Department" means the Department of Juvenile Justice. (cid:1) "Direct care" is the supervision time in juvenile correctional or residential facilities operated or contracted by the Department. (cid:1) "Individual supervision plan" is a written, adaptable plan with goals, objectives, strategies, time frames, and responsible persons, applicable during probation, parole, and treatment, including services for the juvenile's family. (cid:1) "Juvenile" means a person under 18, a delinquent child, child in need of supervision or services as defined in § 16.1-228, including anyone who was or is before the court, under 18 at the time of the offense, under supervision or receiving services, or committed to the Department.

52

[TABLE 52-1] 6VAC35-150-415. Supervision of juvenile in direct care.

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[TABLE 52-2] 6VAC35-150-415. Supervision of juvenile in direct care.

For a juvenile placed in direct care, the probation or parole officer shall, in accordance with approved procedures, do the following:

1. Develop and implement a family involvement plan.
2. Develop a parole supervision plan. a. For a juvenile indeterminately committed to the Department pursuant to subsection A (14) of § 16.1-278.8 and § 16.1-272 of the Code of Virginia, CSU staff shall complete a parole supervision plan in accordance with approved procedure. b. For a juvenile determinately committed to the Department pursuant to subdivision A (17) of § 16.1-278.8 or §§ 16.1-285.1 or 16.1-272 of the Code of Virginia, a parole supervision plan shall be prepared for all serious offender judicial review hearings as required by law and in accordance with approved procedures.
3. Send a report on the family's progress toward planned goals of the family involvement plan to the facility at which the juvenile is housed.

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Compliance Manual for Nonresidential Services 6VAC35-150, effective July 1, 2011, covers juveniles under 18 at offense, under supervision, receiving services, or committed to the Department. (cid:1) "Parole" is supervision of juveniles released from commitment per §§ 16.1-285, 16.1-285.1, 16.1-285.2. (cid:1) "Probation" is court-ordered disposition per §§ 16.1-278.5, 16.1-278.8 (A)(5), (7), (7a). (cid:1) "Supervision" involves contact, treatment, or services as required by court or officer. (cid:1) "Written" means information communicated in writing, either hard copy or electronic.

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Compliance Manual for The Regulation For Nonresidential Services 6VAC35-150, effective July 1, 2011

6VAC35-150-420. Contacts during juvenile's commitment.

6VAC35-150-420. Contacts during juvenile's commitment.

During commitment, designated staff shall contact the juvenile, parents, guardians, custodians, and treatment staff as required by approved procedures, specifying face-to-face or remote contact methods.

Interpretation: Goal: Ensure CSU personnel contact (1) juvenile, (2) parents/guardians, and (3) treatment staff during commitment per this section and procedures.

Additional information: Applicable DJJ CSU procedures: 9332 and 9334.

Compliance Determination: Review procedure: Examine procedure to determine applicable requirements.

Examine documentation: Review a sample of committed juvenile case records for compliance with this section and procedure.

Applicable definitions: (cid:1) "Approved procedures" are DJJ-issued procedures for all state court units, possibly observed locally, or approved local modifications. (cid:1) "Direct care" is supervision time in juvenile correctional or residential facilities operated or contracted by the Department. (cid:1) "Juvenile" means under 18, a delinquent child, child in need of supervision or services as defined in § 16.1-228, including anyone who was or is before the court, under 18 at the offense, under supervision, receiving services, or committed to the Department.

DOCUMENTS INCORPORATED BY REFERENCE (6VAC35-150) "Guidelines for Transporting Juveniles in Detention," State Board of Juvenile Justice, September 2004.

54

[TABLE 54-1] 6VAC35-150-420. Contacts during juvenile's commitment.

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[TABLE 54-2] 6VAC35-150-420. Contacts during juvenile's commitment.

During the period of a juvenile's commitment, a designated staff person shall make contact with the committed juvenile, the juvenile's parents, guardians, or other custodians, and the treatment staff at the juvenile's direct care placement as required by approved procedures. The procedures shall specify when contact must be face-to-face contact and when contacts may be made by video conferencing or by telephone.

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• Page 1 ---

Department of Juvenile Justice Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

In ac cordance 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.

I. PURPOSE

This guidance document provides the process for the review and approval of four types of external data requests and research proposals. These include (1) external aggregate data requests, (2) Virginia Longitudinal Data System requests, (3) external case-specific data requests, and (4) human research proposals.

This guidance document implements and must be applied in conjunction with the Regulation Governing Juvenile Data Requests and Research Involving Human Subjects (6VAC35-170) issued by the Board of Juvenile Justice.

All research activities conducted within Virginia’s juvenile justice system shall comply with all applicable state and federal laws and regulations and with medical, societal, and professional ethics; guarantee the safety, health, privacy, and confidentiality of clients and staff; and prohibit unauthorized access to and publication of information that identifies individuals or families. Research activities must not impede rehabilitation and treatment of juveniles and must not compromise the security of juvenile facilities or place the public safety at risk.

II. SCOPE AND GENERAL INFORMATION

This guidance document describes how data requests and research proposals will be submitted, reviewed, approved, and coordinated. This guidance document does not apply to quality or process improvement projects.

The department may charge requestors reasonable fees to offset costs incurred in supporting

specific projects.

III. DEFINITION

The following words and terms, when used in this guidance document, shall have the following meanings unless the context clearly indicates otherwise:

Aggregate Data - Statistics that relate to broad classes, groups, or categories so that it is not possible to distinguish the properties of individuals within those classes, groups, or categories.

Case-specific Data - Nonaggregated data that provides information about individuals within a group.

Coordinator of External Research - The department employee in the research unit designated by the director to receive research proposals and data requests from external entities and to ensure that the proposals are reviewed in accordance with this guidance document and with 6VAC35-170.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

De-identified Data - Data with common identifiers, such as names, phone numbers, social security numbers, and addresses removed in order to eliminate the ability of an individual viewing the data to determine the identity of an individual.

Department - The Department of Juvenile Justice.

Director - The director of the department or the director's designee.

External Research - Research conducted at or using the resources of a facility, program, or organization that is owned, operated, or regulated by the department or the Board of Juvenile Justice by researchers who are not part of the department or under contract with the department, or who are not employees of another state agency conducting a study at the direction of the General Assembly.

Human Research - A systematic investigation, including research development, testing, and evaluation, utilizing human subjects that is designed to develop or contribute to generalized knowledge. Human research shall not be deemed to include research exempt from federal research regulation pursuant to 45 CFR 46.101(b).

Human Research Review Committee (HRRC) - The committee established by the department to oversee human research proposals and activities in accordance with 6VAC35-170-130 and § 32.1-162.19 of the Code of Virginia.

Human Subject - An individual who is under the department's care, custody, or supervision; under the care, custody, or supervision of a facility or program regulated by the department or the Board of Juvenile Justice; or a member of the family of such an individual and who is, or who is proposed to be, a subject of human research. For purposes of this definition, human subject also means an individual who is employed in or provides contractual services to a juvenile correctional center or other facility or program regulated by the department or the Board of Juvenile Justice and who is or who is proposed to be a subject of human research.

Informed Consent - The knowing and voluntary agreement without undue inducement or any element of force, fraud, deceit, duress, or other form of constraint or coercion of a person who is capable of exercising free choice. The basic elements necessary for informed consent regarding human research include:

1. A reasonable and comprehensible explanation to the person of the proposed procedures and protocols to be followed; their purposes, including descriptions of attendant discomforts; and the risks and benefits reasonably to be expected;
2. A disclosure of alternative procedures or therapies that might be helpful to the person;

1. An instruction that the person may withdraw consent and stop participating in the human research at any time without prejudice;
2. An explanation of costs or compensation that may accrue to the person and whether third party reimbursement is available for the proposed procedures or protocols; and
3. An offer to answer, and answers to, questions by the person about the procedures and protocols.

Internal Committee - The committee established by the department pursuant to 6VAC35-170-65 to oversee de-identified case specific data.

2

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

Legally Authorized Representative - The parent having custody of a prospective subject; the legal guardian of a prospective subject; or any person or judicial or other body authorized by law to consent on behalf of a prospective subject to such subject's participation in the particular human research, including an attorney in fact appointed under a durable power of attorney, provided the power grants the authority to make such a decision. For purposes of this guidance document, "legally authorized representative" shall not include an official or employee of the institution or agency conducting or authorizing the research.

Minimal Risk - The risks of harm anticipated in the proposed research are not greater, considering probability and magnitude, than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.

Nontherapeutic Research - Human research in which there is no reasonable expectation of direct benefit to the physical or mental condition of the human subject.

Organizational Unit Head - The person in charge of a juvenile correctional center, court service unit, or other organizational unit of the department or a Board of Juvenile Justice-regulated facility, program, or service.

Principal Researcher - The individual who is responsible for the research design, research implementation, supervision of research staff, and research findings.

Research - The systematic development of knowledge essential to effective planning and rational

decision-making. It involves the assessment of current knowledge on conceptual problems selected, the statement of those problems in researchable format, the design of methodologies appropriate to the problems, and the application of statistical techniques to organize and analyze data.

Researcher - An individual conducting research.

Research Project - The systematic collection of information, analysis of the data, and the preparation of a report of findings.

Sensitive Data - Data, the compromise of which, with respect to confidentiality, integrity, or availability, could have a material adverse effect on agency programs or the privacy to which individuals are entitled.

Virginia Longitudinal Data System (VLDS) - A data system that provides de-identified case-specific data from participating agencies to qualified researchers through a process that involves submission of requests and approval or denial by each sponsoring agency from which data are sought in an effort to create usable information for policy and generate cross-agency research.

Written - The required information is communicated in writing either in hard copy or electronic form.

3

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

IV. PROCEDURES

A. External Aggregate Data Requests

1. External aggregate data requests shall be submitted to the Research Manager or designee via a detailed email outlining the specific information requested.

1. The Research Manager or designee shall determine the following prior to approving aggregate data requests:

a. That the request meets the conditions for department approval of research identified in 6VAC35-170-30 and 6VAC35-170-50; b. Whether the data requested is accessible; c. An estimate of the time required to process the data request; and d. Based on staff workload, whether staff resources are available to process the data request.

1. The Research Manager or designee, as the director’s designee, may approve and coordinate the provision of data.

1. The Research Manager or designee, as the director’s designee, shall notify the requestor of the approval or denial of the data request with the rationale for the decision within 20 business days of receiving the request.

1. If the data request is approved, the Research Manager or designee shall provide the requestor with

an estimated timeline for receipt of the data.

B. VLDS Requests

1. If requesting the department as the sponsor agency of a VLDS data request, the forms and review process for external de-identified case-specific data requests, described in subsection C of this guidance document, shall be completed prior to submission using the VLDS portal. External case-specific data requests submitted through the VLDS with a different sponsor agency are not required to complete or submit the Research Proposal Form prior to submission using the VLDS portal.

1. All external case-specific data requests submitted through the VLDS shall be submitted to the department using the VLDS portal.

1. The researcher shall comply with all VLDS procedures in order to access data through the VLDS.

1. The chair of the HRRC shall have primary responsibility for reviewing and approving requests submitted through the VLDS portal. The chair of the HRRC may not approve an external case-specific data request unless the request meets the following requirements:

a. The request satisfies the conditions for department approval of research identified in 6VAC35-170-30 and 6VAC35-170-50; b. The request is not a human research proposal and does not require the HRRC's review; 4

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

c. The request is in the required format and includes all required information; d. The request complies with basic research standards and applicable laws; and e. The data requested are accessible and available in the VLDS.

1. Upon reviewing the data request, the chair of the HRRC may restrict the scope of the data, provided the data requested are unrelated to the purpose of the research study.

6. The following process shall be followed for requests to modify an approved VLDS project:

a. If sponsored by the department, the same process as described in this guidance document for modifications to external case-specific data requests shall be followed. Approval must occur prior to submitting an amendment in the VLDS portal. b. If sponsored by a different agency, the researcher is not required to receive approval prior to submitting an amendment in the VLDS portal.

C. General Requirements for External De-Identified Case-Specific Data Requests and Human Research Proposals

1. External data requestors, external researchers, and department personnel proposing to conduct human research all will follow the same steps in submitting proposals for the department’s consideration. If a project involves both an external de-identified case-specific data request and a human research proposal, the process for approving a human research proposal shall be followed to approve the project as a whole.

1. The department’s website shall include information on requesting data and conducting research with the department, including instructions and forms for use by external data requestors and researchers.

1. External data requestors and researchers to whom juvenile record information is disclosed may not redisclose or otherwise reveal the juvenile record information of an individual, beyond the purpose for which the original disclosure was made. The prohibition on redisclosure shall not prevent the external data requestors and researchers from publishing research findings based on juvenile information, provided the findings are presented using aggregate data or data from which individually identifying information has been removed, encoded, or encrypted.

1. External de-identified case-specific data requests and research proposals shall be submitted to the Coordinator of External Research using the Confidentiality Agreement Form, the Research Proposal Form, the Research Agreement Form, and any required attachments. The principal researcher shall provide the Coordinator of External Research an electronic copy of the forms via email.

1. The Research Agreement Form must be signed by the principal researcher(s) and the student researcher (if applicable) at the time of submission.

1. The Confidentiality Agreement Form must be signed by every individual who may access the data.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

7. The Research Proposal Form shall contain the following elements:

a. Name, address, telephone number, email address, title, and affiliation of the principal researcher(s) (for student projects, the principal researcher must be the academic advisor rather than the student); b. Name, telephone number, and email address of the person who will coordinate the project, if different from the principal researcher;

c. Resume or Curriculum Vitae for principal researcher(s) and students (if applicable); d. Funding source, if any; e. Date of the proposal’s submission to the department; f. Title or descriptive name of the proposed project; g. Statement of the specific purpose(s) of the proposed research project with anticipated results, including benefit to the department; h. A concise description of the research design and techniques for data collection and analysis and of the likely effects of the research methodology on existing programs and institutional operations; i. Timeframes indicating proposed beginning and ending dates for data collection, analysis, preliminary report, and final report; j. A list of resources the researcher will require from the department or its units, such as staff, supplies, materials, equipment, work spaces, or access to clients and files; k. Identification of the organizational unit where the research will be conducted and letter of support acknowledging the organizational unit’s agreement to participate in research-related activities, if applicable. i. Pursuant to the regulation, if the external research is proposed to take place in a

particular organizational unit, the principal researcher shall present a preliminary research proposal to the organizational unit head and get the organizational unit head’s written endorsement.

II. The organizational unit head supporting the project is responsible for requesting a written endorsement from the deputy director of the appropriate division prior to the submission of the proposal packet to the Coordinator of External Research.); l. Endorsement from the Institutional Review Board (IRB) of the institution or organization with which the researcher is affiliated; and m. A signed and dated statement that the principal researcher and the research staff have read and understand 6VAC35-170, this guidance document, and the Research Agreement Form.

1. The Research Agreement Form shall outline the respective responsibilities of the parties and shall specify the following:

a. The frequency with which progress reports shall be required; b. The department’s unrestricted authority to use the research findings in accordance with

professional standards of research; c. The principal researcher’s obligation to submit a formal final report electronically, with an executive summary to the Coordinator of External Research; d. Whether the department requires pre-review and approval by the department prior to external publications; e. That, unless waived by the director, all external articles, reports, presentations, and publications made from the data collected shall be submitted electronically to the Coordinator 6

[TABLE 6-1] The organizational unit head supporting the project is responsible for requesting a written endorsement from the deputy director of the appropriate division prior to the submission of the proposal packet to the Coordinator of External Research.);

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

of External Research within 30 days of the publication or presentation date, and all materials shall include the statement, “The findings of this study are the responsibility of the researchers, and cooperation by DJJ in facilitating this research should not be construed as an endorsement of the conclusions drawn by the researchers”; f. That, if the statement above is waived, all external articles, reports, presentations, and publications shall be reviewed and approved by the department prior to being released.

Materials shall be submitted to the Coordinator of External Research at least 30 days prior to

the anticipated submission date; and g. That the Research Agreement Form is not effective until signed by both the principal researcher and the director.

1. Industry standard levels of encryption shall be required to protect all juvenile record information provided to researchers.

10. The principal researcher must comply with the research plan stated in the Research Proposal Form, including the plan for disseminating findings. Requests for changes to the research plan must be submitted to the Coordinator of External Research and approved by the department before being implemented.

11. The Coordinator of External Research shall distribute the findings of all external research projects as appropriate.

D. External Case-Specific Data Requests

1. The department considers the following identifiers to be sensitive data and shall be removed from the data provided to researchers:

a. Names; b. Dates of birth; c. Postal street addresses; d. Telephone numbers; e. Email addresses; f. Social security numbers; g. Medical record numbers; h. Biometric identifiers, including finger and voice prints; and i. Full face photographic images and any comparable images.

1. The department may consider the following identifiers as sensitive data based on the details of the project and other information included in the data set, and may remove such identifiers from the data provided to researchers:

a. Dates (date of admission, date of release, etc.); b. Location information more detailed than town or city, state, and zip code; and c. Account numbers (Juvenile Number, Direct Care Number, etc.).

1. The director, on a case-by-case basis, may approve the dissemination of the identifiable data for research benefiting the department, provided the researcher agrees that any such information will 7

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

be released or published only in aggregate form or kept confidential in accordance with the following requirements:

a. Research findings shall not identify individual subjects. b. All records and all information given by research subjects or employees of the department shall be kept confidential in accordance with § 16.1-300 of the Code of Virginia and applicable rules and regulations regarding confidentiality of juvenile records. c. Persons who breach confidentiality shall be subject to sanctions in accordance with applicable laws, regulations, policies, and procedures. d. Confidentiality does not preclude reporting results utilizing de-identified data or giving raw data to the department for possible further analysis.

1. If sensitive data are provided, the researchers must follow the human research review process and must comply with appropriate security (e.g., Commonwealth’s Information Security Standard SEC-501) and non-disclosure requirements. The department may require completion of additional forms or agreements for sensitive data requests.
2. Within 10 business days of receiving the data request, the Coordinator of External Research shall

determine the following:

a. The request meets the conditions for department approval of research identified in 6VAC35-170-30; b. The proposal is not a human research proposal and is not required to be reviewed by the HRRC; however, requests that include sensitive data shall be reviewed by the HRRC; c. The principal researcher has the appropriate academic or professional standing or job-related experience in the area to be studied; d. The proposal is in the required format and includes all required information; e. The proposal complies with basic research standards and applicable laws; f. The data requested is accessible; g. Department staff and resources are available to process the data request; and h. An estimate of the time required to compile the data request.

1. The Research Manager shall assess staff workload and resources and determine if staff and resources are available to process the data request, as required.

1. An internal committee, chaired by the Research Manager who designates committee members, shall act on a research proposal within 20 business days. The internal committee may meet in person, by conference call, or via email. The internal committee shall determine that the proposal meets the following conditions set forth in 6VAC35-170-50:

a. The department has sufficient financial and staff resources to support the request, and that on balance the benefits of the request justify the department’s involvement; b. The request will not interfere significantly with the department’s programs or operations, particularly those of the operating units that would participate in the proposed research; and c. The request is compatible with the purposes and goals of the juvenile justice system and with the department's organization, operations, and resources.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

8. In addition, the internal committee shall:

a. Review the data requested and determine if it is necessary to restrict the scope of the information provided. The scope of information may be restricted for any reason. b. Determine if the project is beneficial to the department. c. Ensure juvenile confidential information will be protected adequately.

d. Make a written recommendation to the director to approve or disapprove the request.

1. The Coordinator of External Research shall submit the Research Proposal Form, the Research Agreement Form signed by the researcher, and the internal committee’s recommendation to the director for review.

10. The director shall approve or deny the proposal within 10 business days of receiving the recommendation and shall communicate the approval or denial to the Research Manager and the Coordinator of External Research.

11. Within five business days of receiving the director’s decision, the Coordinator of External Research shall:

a. Notify the researcher that the proposal was not approved and provide a rationale for the denial; or b. Provide the principal researcher a final copy of the Research Agreement Form containing the director’s signature if the research proposal is approved.

12. The following process shall be followed for requests to modify an approved project: a. The principal researcher shall submit a redline version (e.g., Track Changes) and clean version of the modified Research Proposal Form via email to the Coordinator of External Research. b. Within 10 business days of receiving the research proposal, the Coordinator of External Research shall consult with the Research Manager to determine if the requested modifications substantively change the criteria considered in the original review or alter the scope of the study. c. If the revision is substantive, a full review is required and shall follow the process described above for new proposals. If the revision is not substantive, the Research Manager may conduct an expedited review of the amendment. Additional review or approval by the internal committee or director shall not be required. d. The Coordinator of External Research shall notify the principal researcher of the decision.

E. Human Research General Provisions

1. The following categories of human research are not subject to 6VAC35-170 nor this guidance document. Except as otherwise provided by law or regulation, these activities shall be subject to the nonhuman research review and approval process established by the department. a. Activities of the Virginia Department of Health conducted pursuant to § 32.1-39 of the Code of Virginia. b. Research or student learning outcomes assessments conducted in educational settings involving regular or special education instructional strategies; the effectiveness of or the 9

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

comparison among instructional techniques, curricula, or classroom management methods; or the use of educational tests, whether cognitive, diagnostic, aptitude, or achievement, if the data from such tests are recorded in a manner so that subjects cannot be identified, directly or through identifiers linked to the subject. c. Research involving solely the observation of public behavior, including observation by participants, or research involving survey or interview procedures unless subjects can be identified from the data either directly or through identifiers linked to the subjects, and

either: i. The information about the subject, if it became known outside the research, reasonably could place the subject at risk of criminal or civil liability or be damaging to the subject's financial standing or employability; or II. The research deals with sensitive aspects of the subject's own behavior, such as sexual behavior, drug or alcohol use, or illegal conduct. d. The collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the subjects cannot be identified from the information either directly or through identifiers linked to the subjects.

e. Medical treatment of an experimental nature intended to save or prolong the life of the subject in danger of death, to prevent the subject from becoming disfigured or physically or mentally incapacitated, or to improve the quality of the subject's life. f. Pursuant to 45 CFR 46.101, the exemptions outlined in this section shall not apply to research conducted upon individuals involuntarily confined in a penal institution, including individuals committed to a juvenile correctional center or juvenile secure detention center. g. Pursuant to 45 CFR 46.101, the exemptions outlined in subdivision A(3) of this federal provision shall not apply to research conducted on children who have not attained age 18 years.

1. Human research that is not exempted by § 32.1-162.17 of the Code of Virginia requires endorsement from the IRB of the institution or organization with which the researcher is affiliated.

1. Human research involving known and substantive physical, mental, or emotional risk to subjects, including the withholding of any prescribed program of treatment, and all experimental medical, pharmaceutical or cosmetic research, are specifically prohibited.

1. No human research shall be conducted without the review of the HRRC and approval by the department.

1. At the request of the researcher, the HRRC may conduct an expedited review when the proposed research involves no more than minimal risk to the human subjects and the proposal has been reviewed and approved by another agency’s HRRC.

1. Offering incentives to participate in research is discouraged but not prohibited. Incentives shall be appropriate to the juveniles' custodial status and proportionate to the situation.

1. The principal researcher shall be responsible for the conduct of the research staff, the protection of the rights of subjects involved in the project, and the provision of information required by the coordinator of external research, organizational unit heads, and the HRRC.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

F. Human Research Review Committee

1. The department shall establish an HRRC composed of persons representing diverse backgrounds relative to both work and life experience as well as race, ethnicity, gender, and other characteristics. The HRRC shall ensure the competent, complete, and professional review of human research activities conducted or proposed to be conducted or authorized by the department.

1. The Research Manager shall keep a current listing of members of the HRRC.

3. The HRRC shall consist of at least seven persons, including:

a. The Research Manager, who will serve as chair; b. The Chief Psychologist of the department’s Behavioral Services Unit; c. At least three persons who are not employed by the department; d. At least one person from a non-scientific profession (e.g., lawyer, ethicist, clergyperson); and e. At least one person with the background and experience to advocate for the welfare of human research subjects.

1. Committee members shall be chosen by the chair of the HRRC with input provided by current HRRC members and other department staff. Committee members shall serve two-year terms with the option to renew.

5. HRRC Operation:

a. The HRRC shall meet as often as necessary to give timely consideration to human research proposals. Whenever practicable, proposals shall be emailed to the HRRC members, who shall act on a research proposal within thirty business days of receipt. b. An HRRC member who is directly involved in a research project or has administrative authority over a research project apart from the member’s role on the HRRC may not vote on such research. c. A simple majority of HRRC members constitutes a quorum. The HRRC may meet in person, by conference call, or via email. d. The HRRC may consult with any person who has expertise or competence pertinent to the proposed research. Such persons may offer their opinions but may not vote when the HRRC makes its decision. e. The HRRC may require additional information from the researcher before making a recommendation to the director.

G. Review of Human Research Proposals

1. Within 10 business days of receiving the research proposal, the Coordinator of External Research shall determine the following:

a. The proposal is in the required format and includes all required information;

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

b. The principal researcher has appropriate academic or professional standing or job-related experience in the area to be studied, or is directly supervised by a person with such standing or experience; c. The research conforms to generally accepted ethical standards of professional societies such as the American Correctional Association, the American Psychological Association, the American Sociological Association, the National Association of Social Workers, the American Evaluation Association, or their equivalent;

d. The proposal complies with basic research standards and applicable laws; e. The proposal supports the mission and goals of the department; f. The proposal could reasonably comply with the criteria to be examined by the HRRC; and g. The data requested is accessible, if applicable.

1. If the Coordinator of External Research, after consulting with the Research Manager, determines that these criteria cannot be satisfied through reasonable modifications to the proposal, the proposal will be denied and written notification sent to the principal researcher.
2. If the proposal is not denied, the Coordinator of External Research will notify the principal researcher of any necessary changes, additional information, or clarifications.

1. Within 10 business days of receiving a research proposal that complies with all criteria considered by the Coordinator of External Researcher, the proposal shall be distributed via email to the HRRC.

1. The HRRC shall review the proposal within 30 business days and make a recommendation to the director.

1. In reviewing a human research proposal, the HRRC must determine that the proposal meets the following conditions set forth in 6VAC35-170-50:

a. The department has sufficient financial and staff resources to support the request, and that on balance the benefits of the request justify the department’s involvement; b. The request will not interfere significantly with the department’s programs or operations, particularly those of the operating units that would participate in the proposed research; and c. The request is compatible with the purposes and goals of the juvenile justice system and with the department's organization, operations, and resources.

7. In reviewing a human research proposal, the HRRC also shall consider whether:

a. The research’s potential risks and benefits are adequately described; b. The benefits to the human subjects outweigh the risks; c. The methodology is adequate for the proposed research; d. The nontherapeutic research presents more than a minimal risk to the human subjects;

e. The rights and welfare of the human subjects are adequately protected; f. The researchers are appropriately competent and qualified; g. The criteria for selecting subjects are valid and equitable; h. The research complies with the requirements set out in 6VAC35-170 and this guidance document; and

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

i. Informed consent will be obtained by methods that are adequate, appropriate, and in accordance with the requirements of § 32.1-162.18 of the Code of Virginia, 6VAC35-170-80, and 6VAC35-170-160. Any form used must be understandable to potential participants.

1. Informed Consent

a. Virginia law sets out the following requirements regarding informed consent for research

involving human subjects: i. Except as provided elsewhere in Chapter 5.1 of Title 32.1 (§ 32.1-162.16 et seq), no researcher may involve a human subject in human research without first obtaining the informed consent of the human subject or his legally authorized representative. A researcher shall seek such consent only under circumstances that provide the human subject or the legally authorized representative sufficient opportunity to consider whether to participate and that minimize the possibility of coercion or undue influence.

II. If a human subject is competent, informed consent shall be given in writing by the subject and witnessed.

III. If a human subject is not competent, informed consent shall be given in writing by the subject's legally authorized representative and witnessed.

IV. If a human subject is a minor who is otherwise capable of giving informed consent, informed consent shall be given in writing by both the minor and his legally authorized representative. v. If two or more persons who qualify as legally authorized representatives with decision-making authority inform the researcher that they disagree as to the participation of the human subject, the subject shall not be enrolled in the human research that is the subject

of the consent.

VI. Notwithstanding consent by a legally authorized representative, no person who is otherwise capable of giving informed consent shall be forced to participate in human research.

VII. A legally authorized representative may not consent to nontherapeutic research unless the HRRC determines that the research will present no more than a minimal risk to the human subject.

b. The informed consent form shall not include any language through which the human subject waives or appears to waive any legal right, including the release of an individual, institution, or agency or any agent thereof from liability for negligence.

c. The HRRC:

i. Shall review and approve the consent process and all required consent forms for each proposed human research project before recommending approval to the director.

II. May approve a consent procedure that omits or alters some or all of the basic elements of

informed consent or waives the requirement to get informed consent if the HRRC finds and documents that:

a. The research involves no more than a minimal risk to the subjects;

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

b. The omission, alteration, or waiver will not adversely affect the rights and welfare of the subjects; c. The research could not be performed practicably without the omission, alteration, or waiver; and d. After participation, the subjects will be given additional pertinent information when appropriate.

III. May waive the requirement that the researcher get written informed consent for some or all subjects if the principal risk would be potential harm resulting from a breach of confidentiality and the only record linking the subject and the research would be the consent document. The HRRC may require the researcher to give the subjects and legally authorized representatives a written statement explaining the research. Further, the researcher shall ask each subject whether he wants documentation linking him to the research, and the subject's wishes shall govern.

9. After reviewing the human research proposal, the HRRC may:

a. Recommend that the director approve the research; b. Recommend that the director reject the research proposal as inconsistent with the provisions of §§ 32.1-162.16, et seq. of the Code of Virginia, inconsistent with the department’s procedures, or incompatible with available resources; or c. Defer a recommendation pending receipt of additional information or modification of the proposal by the principal researcher.

10. The Coordinator of External Research shall submit the Research Proposal Form, the Research Agreement Form signed by the researcher, and the HRRC’s recommendation to the director.

11. The director shall approve or deny the proposal within 10 business days of receiving the recommendation and shall communicate the approval or denial to the Research Manager and the Coordinator of External Research. The director may reject the approval recommendation upon finding the research proposal is inconsistent with any of the provisions of §§ 32.1-162.16, et seq. of the Code of Virginia or the department’s procedures, or is incompatible with available resources. The director also may set conditions on the research, which shall be put in writing.

12. Within five business days of receiving the director’s decision, the Coordinator of External Research shall:

a. Notify the principal researcher of the director’s final decision; b. If the research proposal was approved, send the signed Research Agreement Form to the principal researcher.

H. Review of Modifications to Approved Human Research

1. The following process shall be followed to request and approve a modification to an approved project:

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

a. The principal researcher shall submit a redline version (e.g., Track Changes) and clean version of the modified Research Proposal Form via email to the Coordinator of External Research.

b. Within 10 business days of receiving the research proposal, the Coordinator of External Research shall consult the Research Manager to determine if the requested modifications substantively change the criteria considered in the original review or alter the scope of the study.

c. If the revision is substantive, a full review is required and shall follow the process described above for new proposals. If the revision is not substantive, the chair of the HRRC may conduct an expedited review of the amendment. Additional review or approval by the HRRC or director shall not be required.

d. The Coordinator of External Researcher shall notify the principal researcher of the final decision.

I. Review of Human Research in Progress

1. In accordance with § 32.1-162.19 of the Code of Virginia and 6VAC35-170-180, the HRRC shall review all human research activities at least annually to ensure that the project is conducted in conformance with the proposal as approved by the director.

1. The principal researcher shall report to the Coordinator of External Research all protocol violations, including (but not limited to) the reporting of adverse events, sponsor-imposed or IRB-

imposed protocol suspensions, protocol deviations/violations, confidentiality breaches, and participant complaints. Reports must be submitted within five business days of the principal researcher’s knowledge of the incident. The report shall include relevant dates, times, locations, personnel involved, event details, and actions taken and planned.

a. Within five business days of receiving the report, the Coordinator of External Research shall disseminate the report via email to the HRRC for review. b. Within ten business days of receiving the report, the HRRC shall recommend further action to the director. c. Within ten business days of the HRRC’s recommendation, the director shall make a final determination of further action. d. Within five business days of the director’s determination, the Coordinator of External Research shall notify the principal researcher of the decision.

1. The following actions may be taken at any time if a research project deviates significantly from the proposal as approved or from any conditions imposed by the director or increases the level of

harm to participants or others:

a. Require the investigator to submit a report to their IRB, copying the Coordinator of External Research on all correspondence; b. Temporarily halt research activities until a corrective action plan can be approved and implemented; and c. Revoke approval of the research in whole or part. 15

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

J. Researcher Non-Compliance

1. The researcher shall report noncompliance with the approved research proposal to the HRRC and the IRB.
2. If the HRRC determines that the research activities fail to comply with the approved proposal or violate the Code of Virginia or the Virginia Administrative Code, the department may restrict or

terminate further research, prohibit the researcher from presenting or publishing the research results, and/or bar the researcher from conducting future studies.

K. Annual Reporting

The HRRC shall submit to the Governor, the General Assembly, the Board of Juvenile Justice, and the director at least annually a report on human research projects approved by the HRRC and the status of such research, including any significant deviation from the proposals as approved. The report shall include a summary of approved human research projects and the results of such projects and be posted on the department’s website unless otherwise exempt from disclosure under the Virginia Freedom of Information Act (§ 2.2-3700 et seq. of the Code of Virginia).

V. RESPONSIBILITY

All organizational unit heads shall have primary responsibility for referring requestors to this guidance document. The Coordinator of External Research shall have primary responsibility for implementing and ensuring compliance with this guidance document.

VI. INTERPRETATION

The Deputy Director of Administration and Finance or designee shall be responsible for interpreting and granting any exceptions to this guidance document.

VII. REVIEW DATE

This guidance document shall remain in effect until rescinded or otherwise modified by the Board of Juvenile Justice.

Approved by: Date: June 24, 2021

Effective Date: June 24, 2021 Office of Primary Responsibility: Research

Manager; Data Manager; Coordinator of External Research

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[TABLE 16-1] Approved by: | Date: June 24, 2021 Effective Date: June 24, 2021 | Office of Primary Responsibility: Research Manager; Data Manager; Coordinator of External Research

[/TABLE]

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Department of Juvenile Justice Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

In accordance with § 2.2-4002.1 of the Code of Virginia, this guidance conforms to the definition in § 2.2-4101.

I. PURPOSE

This guidance details review and approval of four external data request types: (1) aggregate data, (2) Virginia Longitudinal Data System, (3) case-specific data, and (4) human research proposals.

This guidance implements and must be used with the Regulation Governing Juvenile Data Requests and Human Subjects Research (6VAC35-170) issued by the Board of Juvenile Justice.

All research within Virginia’s juvenile justice system must comply with applicable laws, ethics, ensure safety, privacy, confidentiality, and prohibit unauthorized access or publication of identifying info. It must not hinder rehabilitation, treatment, or compromise facility security or public safety.

II. SCOPE AND GENERAL INFORMATION

This guidance outlines submission, review, approval, and coordination of data requests and research proposals. It does not apply to quality or process improvement projects.

The department may charge requestors reasonable fees to offset costs incurred in supporting

specific projects.

III. DEFINITION

The following terms in this guidance have these meanings unless context indicates otherwise:

Aggregate Data - Statistics related to broad classes or categories that prevent identifying individuals within them.

Case-specific Data - Nonaggregated data about individuals within a group.

Coordinator of External Research - Department employee designated by the director to receive and review external research proposals and data requests per this guidance and 6VAC35-170.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

De-identified Data - Data with identifiers like names, phone numbers, SSNs, and addresses removed to prevent individual identification.

Department - The Department of Juvenile Justice.

Director - The director of the department or the director's designee.

External Research - Research at or using resources of a department or Board facility, conducted by non-department researchers or contractors, not employed by another state agency under the General Assembly.

Human Research - Systematic investigation involving human subjects to develop or contribute to general knowledge, excluding federally exempt research (45 CFR 46.101(b)).

Human Research Review Committee (HRRC) - The committee established by the department to oversee human research proposals and activities in accordance with 6VAC35-170-130 and § 32.1-162.19 of the Code of Virginia.

Human Subject - An individual who is under the department's care, custody, or supervision; under the care, custody, or supervision of a facility or program regulated by the department or the Board of Juvenile Justice; or a member of the family of such an individual and who is, or who is proposed to be, a subject of human research. For purposes of this definition, human subject also means an individual who is employed in or provides contractual services to a juvenile correctional center or other facility or program regulated by the department or the Board of Juvenile Justice and who is or who is proposed to be a subject of human research.

Informed Consent - Knowing, voluntary agreement without undue inducement, force, fraud, deceit, duress, or coercion from a capable person. Basic elements include:

1. A clear explanation to the person of proposed procedures, purposes, discomforts, risks, and benefits;
2. Disclosure of alternative procedures or therapies that may help the person;

1. Instruction that the person may withdraw consent and stop participating at any time without prejudice;
2. Explanation of costs, compensation, and third-party reimbursement for procedures or protocols;
3. Offer to answer questions about procedures and protocols;

Internal Committee - Department-established committee overseeing de-identified case-specific data per 6VAC35-170-65.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

Legally Authorized Representative - The parent having custody of a prospective subject; the legal guardian of a prospective subject; or any person or judicial or other body authorized by law to consent on behalf of a prospective subject to such subject's participation in the particular human research, including an attorney in fact appointed under a durable power of attorney, provided the power grants the authority to make such a decision. For purposes of this guidance document, "legally authorized representative" shall not include an official or employee of the institution or agency conducting or authorizing the research.

Minimal Risk - Risks in the research are no greater than those encountered in daily life or routine exams/tests, considering probability and magnitude.

Nontherapeutic Research - Human research with no reasonable expectation of direct benefit to subjects' physical or mental health.

Organizational Unit Head - Person in charge of juvenile correctional, court, or other department or Board-regulated unit.

Principal Researcher - Person responsible for research design, implementation, staff supervision, and findings.

Research - Systematic development of knowledge for effective planning and decision-making.

decision-making. It involves the assessment of current knowledge on conceptual problems selected, the statement of those problems in researchable format, the design of methodologies appropriate to the problems, and the application of statistical techniques to organize and analyze data.

Researcher - An individual conducting research.

Research Project - Systematic data collection, analysis, and report preparation.

Sensitive Data - Data whose compromise could adversely affect agency programs or individual privacy.

Virginia Longitudinal Data System (VLDS) - Provides de-identified case data from agencies to qualified researchers via request submission and approval, enabling policy use and cross-agency research.

Written - Information communicated in hard copy or electronic form.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

IV. PROCEDURES

A. External Aggregate Data Requests

1. External aggregate data requests shall be submitted to the Research Manager or designee via a detailed email outlining the specific information requested.

1. The Research Manager or designee shall determine the following prior to approving aggregate data requests:

a. Request meets department approval conditions in 6VAC35-170-30 and 6VAC35-170-50; b. Data accessibility; c. Estimated processing time; d. Staff resource availability based on workload.

1. The Research Manager or designee, as the director’s designee, may approve and coordinate data provision.

1. The Research Manager or designee shall notify the requestor of approval or denial, with rationale, within 20 business days of receiving the request.

1. If approved, the Research Manager or designee shall provide the requestor with

Estimated timeline for data receipt.

B. VLDS Requests

1. For VLDS data requests with the department as sponsor, forms and review in subsection C must be completed before submission via the VLDS portal. Requests with different sponsors do not require the Research Proposal Form before submission.

1. All external case-specific data requests must be submitted to the department via the VLDS portal.

1. The researcher shall comply with all VLDS procedures to access data.

1. The HRRC chair shall review and approve requests via the VLDS portal and may not approve requests unless they meet the following requirements:

a. The request satisfies the conditions for department approval of research identified in 6VAC35-170-30 and 6VAC35-170-50; b. The request is not a human research proposal and does not require the HRRC's review; 4

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

c. Request in proper format with all info; d. Complies with research standards and laws; e. Data accessible and available in VLDS.

1. Upon review, the HRRC chair may restrict data scope if unrelated to the research purpose;

6. The process for requests to modify an approved VLDS project:

a. Department-sponsored requests follow the same modification process; approval required before VLDS amendment. b. Other agency-sponsored requests do not require prior approval for amendments.

C. General Requirements for External De-Identified Case-Specific Data Requests and Human Research Proposals

1. External requestors, researchers, and department personnel follow the same steps for proposals. If both data request and human research are involved, the human research process must be followed for approval.

1. The department’s website shall provide info, instructions, and forms for requesting data and conducting research.

1. Requestors and researchers may not redisclose juvenile records beyond original purpose. They can publish findings using aggregate or de-identified data.

1. Requests and proposals must be submitted to the Coordinator of External Research using the required forms, with the principal researcher providing an electronic copy via email.

1. The Research Agreement Form must be signed by principal and student researchers (if applicable) at submission.

1. Every individual accessing data must sign the Confidentiality Agreement Form.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

7. The Research Proposal Form shall contain the following elements:

a. Principal researcher’s name, address, phone, email, title, affiliation (for students, advisor); b. Coordinator’s contact info if different.

c. CVs for principal researchers and students; d. Funding info; e. Submission date; f. Project title; g. Purpose, results, and benefits; h. Research design and impact; i. Data collection and analysis timelines; j. Resources needed; k. Organizational unit and support letter; l. If in a specific unit, present proposal to unit head for endorsement.

particular organizational unit, the principal researcher shall present a preliminary research proposal to the organizational unit head and get the organizational unit head’s written endorsement.

The unit head must request IRB endorsement and a signed statement confirming understanding of 6VAC35-170, guidance, and the Research Agreement before submission.

1. The Research Agreement Form shall outline the respective responsibilities of the parties and shall specify the following:

a. Required progress report frequency; b. Department’s unrestricted use of findings per

c. Final report and executive summary submission; d. Department pre-review for external publications; e. Unless waived, all external outputs must be submitted electronically to the Coordinator.

[TABLE 6-1] Unit head must request deputy director endorsement before proposal submission.);

[/TABLE]

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

Within 30 days of publication/presentation, materials must include the statement attributing responsibility; if waived, all external outputs require department review before release.

Materials must be submitted to the Coordinator at least 30 days before

the submission date; and g. The Research Agreement is effective only when signed by both principal researcher and director.

1. Industry-standard encryption levels are required to protect juvenile record information provided to researchers.

10. The researcher must follow the research plan; changes require prior approval from the Coordinator and department.

11. The Coordinator shall distribute all research findings as appropriate.

D. External Case-Specific Data Requests

1. The department considers the following identifiers sensitive data and shall remove them from data provided to researchers:

a. Names; b. Birth dates; c. Addresses; d. Phone numbers; e. Emails; f. SSNs; g. Medical record numbers; h. Biometric identifiers; i. Face images.

1. The department may consider project-related identifiers as sensitive data and remove them from data provided to researchers.

a. Dates (admission, release); b. Detailed location info; c. Account numbers (Juvenile, Direct Care).

1. The director may approve dissemination of identifiable data for research benefiting the department if the researcher agrees.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

be released or published only in aggregate form or kept confidential per the following requirements:

a. Research findings shall not identify subjects. b. All records and info from research subjects or department employees shall be kept confidential per § 16.1-300 and juvenile record rules. c. Breaching confidentiality subjects persons to sanctions per laws, regulations, policies, and procedures. d. Confidentiality does not prevent reporting de-identified data or providing raw data for further analysis.

1. Researchers must follow the human research review, security standards (e.g., SEC-501), and non-disclosure requirements; department may require additional forms for sensitive data.
2. Within 10 business days of receiving the data request, the Coordinator of External Research shall

determine the following:

a. The request meets conditions for department approval per 6VAC35-170-30; b. The proposal is not human research and not subject to HRRC review, except for requests with sensitive data; c. The principal researcher has appropriate standing or experience; d. The proposal is in the required format with all info; e. It complies with research standards and laws; f. The data is accessible; g. Staff and resources are available; h. An estimated time to compile data.

1. The Research Manager shall assess staff workload and resources to determine availability for processing the data request.

1. An internal committee, chaired by the Research Manager, shall review proposals within 20 business days, meeting in person, by call, or email, to ensure they meet 6VAC35-170-50 conditions.

a. The department has sufficient financial and staff resources to support the request, and that on balance the benefits of the request justify the department’s involvement; b. The request will not interfere significantly with the department’s programs or operations, particularly those of the operating units that would participate in the proposed research; and c. The request is compatible with the purposes and goals of the juvenile justice system and with the department's organization, operations, and resources.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

8. In addition, the internal committee shall:

a. Review the data requested and decide if scope restrictions are needed; restrictions may be for any reason. b. Assess if the project benefits the department. c. Ensure juvenile confidential info is adequately protected.

d. Provide a written recommendation to the director to approve or disapprove.

1. The Coordinator of External Research shall submit the Research Proposal Form, signed Research Agreement, and committee recommendation to the director for review.

10. The director shall approve or deny within 10 business days of receiving the recommendation and notify the Research Manager and External Research Coordinator.

11. Within five business days of the director’s decision, the External Research Coordinator shall:

a. Notify the researcher of denial with reasons; or b. Provide the principal researcher a final signed Research Agreement Form if approved.

12. The following process shall be followed for requests to modify an approved project: a. The principal researcher shall submit a redline and clean version of the modified Research Proposal via email to the Coordinator. b. Within 10 business days of receiving the research proposal, the Coordinator of External Research shall consult with the Research Manager to determine if the requested modifications substantively change the criteria considered in the original review or alter the scope of the study. c. If the revision is substantive, a full review is required and shall follow the process described above for new proposals. If the revision is not substantive, the Research Manager may conduct an expedited review of the amendment. Additional review or approval by the internal committee or director shall not be required. d. The Coordinator of External Research shall notify the principal researcher of the decision.

E. Human Research General Provisions

1. Activities exempt from 6VAC35-170 include: a. VDH activities under § 32.1-39; b. educational research or assessments involving instructional strategies; the effectiveness of or the

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

comparison of instructional techniques, curricula, classroom management, or use of educational tests if data are recorded anonymously; or research involving only public behavior observation or surveys/interviews unless subjects can be identified from data.

either: i. The information about the subject, if it became known outside the research, reasonably could place the subject at risk of criminal or civil liability or be damaging to the subject's financial standing or employability; or II. The research deals with sensitive aspects of the subject's own behavior, such as sexual behavior, drug or alcohol use, or illegal conduct. d. The collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the subjects cannot be identified from the information either directly or through identifiers linked to the subjects.

e. Medical treatment of an experimental nature intended to save or prolong the life of the subject in danger of death, to prevent the subject from becoming disfigured or physically or mentally incapacitated, or to improve the quality of the subject's life. f. Pursuant to 45 CFR 46.101, the exemptions outlined in this section shall not apply to research conducted upon individuals involuntarily confined in a penal institution, including individuals committed to a juvenile correctional center or juvenile secure detention center. g. Pursuant to 45 CFR 46.101, the exemptions outlined in subdivision A(3) of this federal provision shall not apply to research conducted on children who have not attained age 18 years.

1. Non-exempt human research under § 32.1-162.17 requires IRB endorsement from the affiliated institution.

1. Research involving significant physical, mental, emotional risks, withholding treatment, or experimental medical, pharmaceutical, or cosmetic research is prohibited.

1. Human research requires HRRC review and department approval before conduct.

1. HRRC may conduct expedited review if research involves minimal risk and has prior approval by another agency’s HRRC.

1. Offering incentives to participate in research is discouraged but not prohibited. Incentives shall be appropriate to the juveniles' custodial status and proportionate to the situation.

1. Principal researcher is responsible for staff conduct, subject rights, and providing required information to the coordinator, unit heads, and HRRC.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

F. Human Research Review Committee

1. The department shall establish an HRRC with diverse backgrounds to ensure competent, complete, and professional review of human research activities.

1. The Research Manager shall maintain an up-to-date HRRC member list.

3. HRRC shall include at least seven persons, including:

a. The Research Manager (chair); b. The Chief Psychologist of Behavioral Services; c. At least three non-departmental members; d. At least one non-scientist (e.g., lawyer, ethicist, clergyperson); e. At least one advocate for research subjects' welfare.

1. HRRC chair, with input from members and staff, shall select members for two-year terms, renewable.

5. HRRC Operation:

a. The HRRC shall meet as needed; proposals emailed and acted on within 30 days. b. Members involved in a project cannot vote on it. c. Quorum is a simple majority; meetings can be in person, call, or email. d. The HRRC may consult experts who cannot vote. e. Additional info may be requested before recommending to the director.

G. Review of Human Research Proposals

1. Within 10 business days of receiving the research proposal, the Coordinator of External Research shall determine the following:

a. The proposal is in the required format with all info;

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

b. The principal researcher has appropriate standing or experience, or is supervised by someone who does; c. The research meets accepted ethical standards of relevant professional societies;

d. It complies with research standards and laws; e. Supports department mission and goals; f. Meets HRRC criteria; g. Data is accessible if needed.

1. If criteria cannot be met after consultation, the proposal will be denied with written notification to the principal researcher.
2. If not denied, the Coordinator will notify the principal researcher of required changes or clarifications.

1. Within 10 business days of receiving a compliant proposal, the Coordinator shall email it to the HRRC.

1. The HRRC shall review the proposal within 30 days and recommend to the director.

1. In review, the HRRC must ensure the proposal meets conditions in 6VAC35-170-50.

a. The department has sufficient financial and staff resources to support the request, and that on balance the benefits of the request justify the department’s involvement; b. The request will not interfere significantly with the department’s programs or operations, particularly those of the operating units that would participate in the proposed research; and c. The request is compatible with the purposes and goals of the juvenile justice system and with the department's organization, operations, and resources.

7. When reviewing a human research proposal, HRRC shall consider whether:

a. Risks and benefits are adequately described; b. Benefits outweigh risks; c. Methodology is adequate; d. Nontherapeutic research involves more than minimal risk;

e. Rights and welfare are protected; f. Researchers are qualified; g. Subject selection is valid and fair; h. It complies with 6VAC35-170 and guidance.

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

i. Informed consent will be obtained using adequate, appropriate methods per § 32.1-162.18, 6VAC35-170-80, and 6VAC35-170-160, with understandable forms.

1. Informed Consent

a. Virginia law requires informed consent for research involving human subjects:

involving human subjects: i. Except as in Chapter 5.1 of Title 32.1 (§ 32.1-162.16), no researcher may involve a human subject without prior informed consent from the subject or legal representative, obtained under conditions allowing consideration and minimizing coercion.

II. If a human subject is competent, informed consent shall be given in writing by the subject and witnessed.

III. If a human subject is not competent, informed consent shall be given in writing by the subject's legally authorized representative and witnessed.

IV. If a human subject is a minor who is otherwise capable of giving informed consent, informed consent shall be given in writing by both the minor and his legally authorized representative. v. If two or more persons who qualify as legally authorized representatives with decision-making authority inform the researcher that they disagree as to the participation of the human subject, the subject shall not be enrolled in the human research that is the subject

of the consent.

VI. Notwithstanding a legally authorized representative's consent, capable persons shall not be forced to participate in research.

VII. A legally authorized representative may not consent to nontherapeutic research unless HRRC determines it presents no more than minimal risk.

b. The informed consent form shall not include language waiving any legal right, including liability for negligence.

c. The HRRC:

i. Shall review and approve the consent process and forms for each proposed human research before recommending approval to the director.

II. May approve a consent procedure that omits or alters some or all of the basic elements of

informed consent or waives the requirement to get informed consent if the HRRC finds and documents that:

a. The research involves no more than minimal risk to subjects;

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

b. The omission, alteration, or waiver will not adversely affect subjects' rights and welfare; c. the research cannot practicably be done without it; and d. subjects will receive additional pertinent info after participation when appropriate.

III. May waive the requirement that the researcher get written informed consent for some or all subjects if the principal risk would be potential harm resulting from a breach of confidentiality and the only record linking the subject and the research would be the consent document. The HRRC may require the researcher to give the subjects and legally authorized representatives a written statement explaining the research. Further, the researcher shall ask each subject whether he wants documentation linking him to the research, and the subject's wishes shall govern.

9. After review, HRRC may:

a. Recommend director approval; b. Recommend rejection for inconsistency with §§ 32.1-162.16, procedures, or resources; or c. Defer pending more info or modifications.

10. The Coordinator of External Research shall submit the Research Proposal, signed Research Agreement, and HRRC recommendation to the director.

11. The director shall approve or deny within 10 business days of recommendation, notify the Research Manager and Coordinator, may reject if inconsistent with §§ 32.1-162.16, procedures, or resources, and may set written conditions.

12. Within five business days of the director’s decision, the Coordinator shall:

a. Notify the principal researcher of the decision; b. If approved, send the signed Research Agreement.

H. Review of Modifications to Approved Human Research

1. The process for requesting and approving modifications to an approved project shall be followed:

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

a. The principal researcher shall submit a redline version (e.g., Track Changes) and clean version of the modified Research Proposal Form via email to the Coordinator of External Research.

b. Within 10 days, the Coordinator shall consult the Research Manager to determine if modifications substantively change review criteria or scope.

c. If substantive, a full review follows the process for new proposals; if not, the HRRC chair may conduct an expedited review. No further review needed.

d. The Coordinator shall notify the principal researcher of the final decision.

I. Review of Human Research in Progress

1. Per § 32.1-162.19 of Virginia Code and 6VAC35-170-180, HRRC shall review all human research annually to ensure compliance with the approved proposal.

1. The principal researcher shall report protocol violations, including adverse events, sponsor-imposed, or IRB- to the Coordinator of External Research.

imposed protocol suspensions, protocol deviations/violations, confidentiality breaches, and participant complaints. Reports must be submitted within five business days of the principal researcher’s knowledge of the incident. The report shall include relevant dates, times, locations, personnel involved, event details, and actions taken and planned.

a. Within five business days of receiving the report, the Coordinator of External Research shall disseminate the report via email to the HRRC for review. b. Within ten business days of receiving the report, the HRRC shall recommend further action to the director. c. Within ten business days of the HRRC’s recommendation, the director shall make a final determination of further action. d. Within five business days of the director’s determination, the Coordinator of External Research shall notify the principal researcher of the decision.

1. Actions may be taken at any time if a research project significantly deviates from the approved proposal, conditions imposed by the director, or increases the level of

harm to participants or others:

a. Require the investigator to submit a report to their IRB, copying the Coordinator of External Research on all correspondence; b. Temporarily halt research activities until a corrective action plan can be approved and implemented; and c. Revoke approval of the research in whole or part. 15

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Guidance Document Interpreting 6VAC35-170 Review and Approval of Data Requests and Research Proposals

J. Researcher Non-Compliance

1. The researcher shall report noncompliance with the approved proposal to HRRC and IRB.
2. If HRRC finds noncompliance with the approved proposal or violations of Virginia law or regulations, the department may restrict or

Terminate further research, prohibit researcher from presenting, publishing results, or conducting future studies.

K. Annual Reporting

HRRC shall annually report to the Governor, General Assembly, Board of Juvenile Justice, and director on approved research, deviations, summaries, results, and post on the website unless FOIA-exempt.

V. RESPONSIBILITY

Organizational heads shall refer requestors to this guidance; the Coordinator of External Research shall implement and ensure compliance.

VI. INTERPRETATION

Deputy Director of Administration and Finance or designee shall interpret and grant exceptions.

VII. REVIEW DATE

This guidance remains in effect until rescinded or modified by the Board of Juvenile Justice.

Approved by: Date: June 24, 2021

Effective Date: June 24, 2021 Office of Primary Responsibility: Research

Manager; Data Manager; Coordinator of External Research

16

[TABLE 16-1] Approved by: | Date: June 24, 2021 Effective Date: June 24, 2021 | Office of Primary Responsibility: Research Manager; Data Manager; Coordinator of External Research

[/TABLE]

Department of Juvenile Justice Guidance Document

COMPLIANCE MANUAL

REGULATION GOVERNING JUVENILE GROUP HOMES AND HALFWAY HOUSES

6VAC35-41

This document shall serve as the compliance manual for the Regulation Governing Juvenile Group Homes and Halfway Houses (6VAC35-41) and is effective beginning January 1, 2014. This document shall govern all compliance audits of state and locally operated juvenile group homes and halfway houses, established pursuant to § 66-13 of the Code of Virginia and Chapter 2.1 of Title 66 (Juvenile Corrections Private Management Act), conducted by the Department of Juvenile Justice. ______________________________________________________________________________

Part I General Provisions ............................................................................................................ 5 6VAC35-41-40 (A), (B), & (C). Certification. ...................................................................... 5 6VAC35-41-50 (A) & (B). Age of residents. ........................................................................ 7 6VAC35-41-60 (A) & (B). Relationship to the regulatory authority......................................... 9 6VAC35-41-70 (A) & (B). Relationship with the department. ...............................................10 6VAC35-41-80 (A) & (B). Variances. ................................................................................11 6VAC35-41-90 (A), (B), (C), (D), (E), & (F). Serious incident reports. ..................................12 6VAC35-41-100 (A), (B), & (C). Suspected child abuse or neglect. .......................................17 6VAC35-41-105 (A), (B), & (C). Reporting criminal activity. ...............................................19 6VAC35-41-110 (A), (B), (C), & (D). Grievance procedure. .................................................21 Part II Administrative and Personnel .........................................................................................23 Article 1 General Provisions .......................................................................................................23 6VAC35-41-120 (A), (B), (C), (D), & (E). Responsibilities of the provider or governing authority. ........................................................................................................................23 6VAC35-41-130 (A) & (B). Insurance. ...............................................................................26 6VAC35-41-140 (A), (B), & (C). Participation of residents in human research. .......................27 6VAC35-41-145. Operational procedures. ..........................................................................29 Article 2 Hiring ..........................................................................................................................30 6VAC35-41-150 (A) & (B). Job descriptions. ......................................................................30 6VAC35-41-160 (A), (B), & (C). Qualifications. .................................................................31 6VAC35-41-165 (A), (B), (C), (D), (E), (F), & (G). Employee tuberculosis screening and follow-up. .................................................................................................................................33 6VAC35-41-170. Physical examination. .............................................................................36 6VAC35-41-180 (A), (B), (C), & (D). Employee and volunteer background checks. ................37 Article 3 Employee Orientation and Training .............................................................................40 6VAC35-41-190 (A), (B), & (C). Required initial orientation. ...............................................40 6VAC35-41-200 (A), (B), (C), (D), (E), & (F). Required initial training. ................................42 6VAC35-41-210 (A), (B), (C), (D), (E), (F), (G), & (H). Required retraining. .........................46 Article 4 Personnel .....................................................................................................................50 6VAC35-41-220. Written personnel procedures. ..................................................................50 6VAC35-41-230. Code of ethics. .......................................................................................51 6VAC35-41-250. Notification of change in driver's license status. .........................................52 6VAC35-41-260. Physical or mental health of personnel. .....................................................53 Article 5 Volunteers ...................................................................................................................54 6VAC35-41-270. Definition of volunteers or interns. ...........................................................54 6VAC35-41-280 (A), (B), (C), & (D). Selection and duties of volunteers or interns. ................55 6VAC35-41-290 (A), (B), & (C). Background checks for volunteers or interns. ......................57 6VAC35-41-300 (A) & (B). Orientation and training for volunteers or interns. ........................59 October 1, 2013

Article 6 Records .......................................................................................................................61 6VAC35-41-310 (A), (B), (C), & (D). Personnel records. .....................................................61 6VAC35-41-330 (A), (B), (C), (D), (E), (F), & (G). Maintenance of records. ..........................63 6VAC35-41-340 (A), (B), & (C). Face sheet. ......................................................................68 Part III Physical Environment ...................................................................................................70 6VAC35-41-350 (A), (B), & (C). Buildings and inspections. .................................................70 6VAC35-41-360 (A) & (B). Equipment and systems inspections and maintenance. .................72 6VAC35-41-370 (A) & (B). Heating and cooling systems and ventilation. ..............................74 6VAC35-41-380 (A), (B), (C), (D), & (E). Lighting. ............................................................75 6VAC35-41-390 (A), (B), & (C). Plumbing and water supply; temperature. ............................77 6VAC35-41-400 (A), (B), (C), (D), (E), (F), & (G). Toilet facilities. ......................................78 6VAC35-41-410 (A), (B), (C), (D), (E), (F), (G), & (H). Sleeping areas. ................................81 6VAC35-41-420. Furnishings. ...........................................................................................84 6VAC35-41-430 (A) & (B). Disposal of garbage and management of hazardous materials........85 6VAC35-41-440. Smoking prohibitions. .............................................................................86 6VAC35-41-450 (A) & (B). Space utilization. .....................................................................87 6VAC35-41-460 (A), (B), & (C). Maintenance of the buildings and grounds. ..........................89 6VAC35-41-470 (A), (B), (C), & (D). Animals on the premises. ...........................................91 Part IV Safety and Security ........................................................................................................93 6VAC35-41-480. Fire prevention plan. ...............................................................................93 6VAC35-41-490 (A), (B), (C), (D), (E), (F), (G), (H), (I), (J), (K), & (L). Emergency and evacuation procedures. .....................................................................................................94 6VAC35-41-500. Contraband. ......................................................................................... 102 6VAC35-41-510 (A), (B), (C), (D), & (E). Searches of residents. ........................................ 103 6VAC35-41-520 (A), (B), & (C). Telephone access and emergency numbers. ....................... 106 6VAC35-41-530. Internet access...................................................................................... 108 6VAC35-41-540 (A) & (B). Weapons. ............................................................................. 109 6VAC35-41-550 (A), (B), & (C). Transportation. .............................................................. 110 Part V Residents' Rights .......................................................................................................... 112 6VAC35-41-560. Prohibited actions. ................................................................................ 112 6VAC35-71-565 (A), (B), & (C). Vulnerable populations. .................................................. 113 6VAC35-41-570 (A), (B), (C), (D), (E), (F), (G), (H), (I) & (J). Residents' mail. ................... 114 6VAC35-41-580. Telephone calls. ................................................................................... 120 6VAC35-41-590 (A) & (B). Visitation. ............................................................................ 121 6VAC35-41-600 (A), (B), & (C). Contact with attorneys, courts, and law enforcement. ......... 123 6VAC35-41-610 (A), (B), (C), (D), & (E). Personal necessities and hygiene. ........................ 125 6VAC35-41-620. Showers. ............................................................................................. 127 6VAC35-41-630 (A), (B), (C), & (D). Clothing. ................................................................ 128 6VAC35-41-640. Residents' privacy. ................................................................................ 130 6VAC35-41-650 (A), (B), (C), (D), (E), & (F). Nutrition. ................................................... 131 6VAC35-41-660 (A) & (B). School enrollment and study time. ........................................... 134 6VAC35-41-670 (A) & (B). Religion. .............................................................................. 136 6VAC35-41-680 (A), (B), (C), & (D). Recreation. ............................................................. 138 6VAC35-41-690 (A) & (B). Residents' funds. ................................................................... 142 6VAC35-41-700. Fundraising.......................................................................................... 143 Part VI Program Operation ..................................................................................................... 144 Article 1 Admission, Transfer, and Discharge ........................................................................... 144 6VAC35-41-710. Placement pursuant to a court order. ....................................................... 144 6VAC35-41-720 (A) & (B). Readmission to a shelter care program. .................................... 145 6VAC35-41-730 (A), (B), & (C). Application for admission. .............................................. 147

2 October 1, 2013

6VAC35-41-740 (A) & (B). Admission procedures. ........................................................... 149 6VAC35-41-750 (A) & (B). Written placement agreement. ................................................. 151 6VAC35-41-760 (A) & (B). Admission. ........................................................................... 153 6VAC35-41-770 (A) & (B). Orientation to facility rules and disciplinary procedures. ............ 155 6VAC35-41-780. Emergency admissions. ......................................................................... 156 6VAC35-41-790 (A) & (B). Resident transfer between residential facilities located in Virginia and operated by the same governing authority. .................................................................. 158 6VAC35-41-800. Placement of residents outside the facility. .............................................. 160 6VAC35-41-810 (A), (B), (C), & (D). Discharge procedures. .............................................. 161 6VAC35-41-820 (A) & (B). Discharge documentation. ...................................................... 164 Article 2 Programs and Services ............................................................................................... 166 6VAC35-41-840 (A), (B), & (C). Structured programming. ................................................ 166 6VAC35-41-850 (A), (B), & (C). Daily log. ...................................................................... 168 6VAC35-41-860 (A), (B), (C), (D), (E), (F), & (G). Individual service plan. ......................... 170 6VAC35-41-870 (A), (B), & (C). Quarterly reports. ........................................................... 175 6VAC35-41-880. Therapy .............................................................................................. 177 6VAC35-41-890 (A), (B), (C), & (D). Community relationships. ......................................... 178 6VAC35-41-900. Resident visitation at the homes of staff. ................................................. 180 Article 3 Supervision ................................................................................................................ 181 6VAC35-41-910. Additional assignments of direct care staff. .............................................. 181 6VAC35-41-920 (A), (B), (C), (D), (E), & (F). Staff supervision of residents. ....................... 182 6VAC35-41-930 (A), (B), (C), & (D). Staffing pattern. ...................................................... 186 6VAC35-41-940 (A) & (B). Outside personnel working in the facility.................................. 189 Part VII Work Programs ......................................................................................................... 190 6VAC35-41-950 (A), (B), (C), & (D). Work and employment. ............................................ 190 Part VIII Independent Living Programs ................................................................................... 192 6VAC35-41-960 (A) & (B). Independent living programs. .................................................. 192 6VAC35-41-970 (A), (B), & (C). Independent living programs curriculum and assessment. ... 193 6VAC35-41-980. Employee training in independent living programs. .................................. 195 6VAC35-41-990. Medication management in independent living programs. ......................... 196 6VAC35-41-1000. Nutrition procedure in independent living programs. ............................... 197 Part IX Wilderness Programs and Adventure Activities ............................................................ 198 6VAC35-41-1010 (A), (B), & (C). Wilderness program. ..................................................... 198 6VAC35-41-1020 (A) & (B). Wilderness programs or adventure activities. .......................... 200 6VAC35-41-1030. Initial physical for wilderness programs or adventure activities. ............... 202 6VAC35-41-1040 (A), (B), (C), (D), (E), & (F). Physical environment of wilderness programs or adventure activities......................................................................................................... 203 6VAC35-41-1050 (A), (B), (C), (D), (E), (F), (G), (H), & (I). Sleeping areas of wilderness programs or adventure activities. ..................................................................................... 206 6VAC35-41-1060 (A) & (B). Personal necessities in wilderness programs or adventure activities. .................................................................................................................................... 209 6VAC35-41-1070 (A), (B), (C), (D), (E), & (F). Trip or activity coordination for wilderness programs or adventure activities. ..................................................................................... 210 Part X Family Oriented Group Homes ..................................................................................... 213 6VAC35-41-1080. Requirements of family oriented group home systems. ............................ 213 6VAC35-41-1090. Examination by physician. ................................................................... 215 6VAC35-41-1100. Requirements of family group homes. ................................................... 216 6VAC35-41-1110. Other applicable regulations. ................................................................ 217 Part XI Respite Care ................................................................................................................ 218 6VAC35-41-1120. Definition of respite care. .................................................................... 218

3 October 1, 2013

6VAC35-41-1130 (A) & (B). Admission and discharge from respite care. ............................ 219 6VAC35-41-1140. Updating health records in respite care. ................................................. 220 Part XII Health Care Services .................................................................................................. 221 6VAC35-41-1150. Definitions applicable to health care services. ........................................ 221 6VAC35-41-1160. Provision of health care services. .......................................................... 222 6VAC35-41-1170 (A), (B), & (C). Health care procedures. ................................................. 223 6VAC35-41-1180 (A) & (B). Health-trained personnel. ...................................................... 225 6VAC35-41-1190 (A), (B), (C), & (D). Consent to and refusal of health care services. ........... 226 6VAC35-41-1200. Health screening at admission. ............................................................. 229 6VAC35-41-1210 (A), (B), & (C). Tuberculosis screening. ................................................. 230 6VAC35-41-1220 (A) & (B). Medical examinations and treatment. ..................................... 232 6VAC35-41-1230 (A) & (B). Infectious or communicable diseases. ..................................... 233 6VAC35-41-1240. Suicide prevention. ............................................................................. 235 6VAC35-41-1250 (A), (B), (C), (D), (E), & (F). Residents' health records. ........................... 236 6VAC35-41-1260 (A) & (B). First aid kits. ....................................................................... 240 6VAC35-41-1270 (A) & (B). Hospitalization and other outside medical treatment of residents. .................................................................................................................................... 241 6VAC35-41-1280 (A), (B), (C), (D), (E), (F), (G), (H), (I), (J), (K), (L), & (M). Medication. .. 243 Part XIII Behavior Support and Management .......................................................................... 249 6VAC35-41-1290 (A), (B), (C), (D), (E), & (F). Behavior management. .............................. 249 6VAC35-41-1300 (A), (B), & (C). Behavior support. ......................................................... 253 6VAC35-41-1310 (A) & (B). Timeout. ............................................................................. 255 6VAC35-41-1320 (A), (B), (C), & (D). Physical restraint. .................................................. 257 6VAC35-41-1330. Chemical agents. ................................................................................ 259

4 October 1, 2013

Part I General Provisions

6VAC35-41-40 (A), (B), & (C). Certification.

6VAC35-41-40 (A). Certification.

A. The provider shall comply with the provisions of the Regulations Governing the Monitoring, Approval, and Certification of Juvenile Justice Programs (6VAC35-20). The provider shall:

1. Demonstrate compliance with this chapter, other applicable regulations issued by the board, and applicable statutes and regulations;
2. Implement approved plans of action to correct findings of noncompliance; and
3. Ensure no noncompliance may pose any immediate and direct danger to residents.

Interpretation: Goal: To ensure that the provider operates in compliance with established regulations.

Additional information: None

Compliance Determination:  Examine documentation: Review Board of Juvenile Justice Certification Certificate and corrective action plans as applicable. Examine any documentation of identified non-compliance issues that have not been corrected through a corrective action plan.

Applicable definitions:  "Board" means Board of Juvenile Justice.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-40 (B). Certification.

B. The provider shall maintain the documentation necessary to demonstrate compliance with this chapter for a minimum of three years.

Interpretation: Goal: To ensure documentation is available to evaluate compliance.

Additional information: The regulation requires documentation to be maintained for a minimum of three years. It is the responsibility of the facility to establish compliance with all regulatory requirements. While the regulation does not require maintaining specific lists or sample groups or separate files of certain documents, facility administrators should consider implementing such processes as a best practice to facilitate the audit and certification process. Documentation may be maintained longer but not for a shorter period of time. The audit team will examine documentation for the audit period (which may be three years or less).

Compliance Determination: Examine documentation covering the audit period.

5 October 1, 2013

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

6VAC35-41-40 (C). Certification.

C. The current certificate shall be posted at all times in each facility in a place conspicuous to the public.

Interpretation: Goal: To ensure the public has knowledge of the certification status of the facility.

Additional information: A conspicuous place is a place where the public may view the certificate outside the secure areas (e.g. the lobby, visitation registration area).

Additional information: None

Compliance Determination: Observe location of posted certificate.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6 October 1, 2013

6VAC35-41-50 (A) & (B). Age of residents.

6VAC35-41-50 (A). Age of residents.

A. Facilities shall admit residents only in compliance with the age limitations approved by the board in establishing the facility's certification capacity, except as provided in subsection B of this section.

Interpretation: Goal: To ensure the proper placement of residents.

Additional information: None

Compliance Determination: Examine documentation of ages and gender of residents.

Applicable definitions:  "Board" means Board of Juvenile Justice.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-50 (B). Age of residents.

B. A facility shall not admit a resident who is above the age approved for certification. A child may remain in the facility above the age of certified capacity (i) to allow the resident to complete a program identified in the resident's individual service plan and (ii) if a discharge plan has been established. This subsection does not apply to shelter care programs.

Interpretation: Goal: To ensure that only appropriate residents are placed in the facility.

Additional information: None

Compliance Determination: Examine documentation in a sample of case files

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is

7 October 1, 2013

not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

8 October 1, 2013

6VAC35-41-60 (A) & (B). Relationship to the regulatory authority.

6VAC35-41-60 (A). Relationship to the regulatory authority.

A. All reports and information as the regulatory authority may require to establish compliance with this chapter and other applicable regulations and statutes shall be submitted to or made available to the regulatory authority.

Interpretation: Goal: To ensure documentation is available to evaluate compliance.

Additional information: None.

Compliance Determination: Examine documentation covering the audit period.

Applicable definitions:  "Regulatory authority" means the board or the department as designated by the board.

6VAC35-41-60 (B). Relationship to the regulatory authority.

B. A written report of any contemplated changes in operation that would affect the terms of the certificate or the continuing eligibility for certification shall be submitted to the regulatory authority. A change may not be implemented prior to approval by the regulatory authority.

Interpretation: Goal: To ensure that the facility operated to the approval granted by the Board.

Additional information: None

Compliance Determination: Review any written reports submitted to the regulatory authority.

Applicable definitions:  "Regulatory authority" means the board or the department as designated by the board.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

9 October 1, 2013

6VAC35-41-70 (A) & (B). Relationship with the department.

6VAC35-41-70 (A). Relationship with the department.

A. The director or designee shall be notified within five working days of any significant change in administrative structure or newly hired facility administrator.

Interpretation: Goal: To ensure that the director is aware of any administrative changes.

Additional information: Notification to the DJJ Certification Unit is required in this matter.

Compliance Determination: Review the timeliness of notifications that were submitted.

Applicable definitions:  "Department" or "DJJ" means the Department of Juvenile Justice.  "Director" means the Director of the Department of Juvenile Justice.  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.

6VAC35-41-70 (B). Relationship with the department.

B. Any of the following that may be related to the health, safety, or human rights of residents shall be reported to the director or designee within 10 days: (i) lawsuits against the facility or its governing authority and (ii) settlements with the facility or its governing authority.

Interpretation: Goal: To ensure that the Department is made aware events that might affect the operations of the facility and care of residents.

Additional information: Notification to the DJJ Certification Unit is required in this matter.

Compliance Determination: Review the timeliness of the notification that was submitted.

Applicable definitions:  "Department" or "DJJ" means the Department of Juvenile Justice.  "Director" means the Director of the Department of Juvenile Justice.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

10 October 1, 2013

6VAC35-41-80 (A) & (B). Variances.

6VAC35-41-80 (A). Variances.

A. Board action may be requested by the facility administrator to relieve a facility from having to meet or develop a plan of action for the requirements of a specific section or subsection of this regulation, either permanently or for a determined period of time, as provided in the Regulations Governing the Monitoring, Approval, and Certification of Juvenile Justice Programs (6VAC35-20).

Interpretation: Goal: To define variance.

Additional information: None

Compliance Determination: None

Applicable definitions:  "Board" means Board of Juvenile Justice.  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-80 (B). Variances.

B. Any such variance may not be implemented prior to approval of the board.

Interpretation: Goal: To ensure variances are requested in accordance with the Certification Regulation and are not implemented prior to approval of the Board of Juvenile Justice.

Additional information: None

Compliance Determination:

 Interview staff: Interview superintendent regarding the timeframe for implementation.  Examine documentation: Examine any requests for variances for required components. .

Applicable definitions:  "Board" means Board of Juvenile Justice.

11 October 1, 2013

6VAC35-41-90 (A), (B), (C), (D), (E), & (F). Serious incident reports.

6VAC35-41-90 (A). Serious incident reports.

A. The following events shall be reported within 24 hours to: (i) to the placing agency, (ii) to the parent or legal guardian, or both, as applicable and appropriate, and (iii) the director or designee:

1. Any serious incident, accident, illness, or injury to the resident;
2. Any overnight absence from the facility without permission;
3. Any runaway;
4. Any fire, hostage or emergency situation, or natural disaster that jeopardizes the health, safety, and welfare of the residents; and
5. Any suspected case of child abuse or neglect at the facility, on a facility event or excursion, or involving facility center staff as provided in 6VAC35-41-100 (suspected child abuse or neglect).

The 24-hour reporting requirement may be extended when the emergency situation or natural disaster has made such communication impossible (e.g., modes of communication are not functioning). In such cases, notice shall be provided as soon as feasible thereafter.

Interpretation: Goal: To ensure serious incidents are reported to the director or designee.

Additional information: What constitutes a serious illness, incident, injury, or accident is defined in Department procedures.

Compliance Determination:  Review the procedure.  Review a sample of incident reports in BADGE to determine compliance with this section.

Applicable definitions:  "Director" means the Director of the Department of Juvenile Justice.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.

12 October 1, 2013

 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-90 (B). Serious incident reports.

B. The provider shall notify the director or designee within 24 hours of any events detailed in subsection A of this section and all other situations required by the regulatory authority of which the facility has been notified.

Interpretation: Goal: To ensure serious incidents are reported to (1) the parent or legal guardian and (2) the supervising CSU or agency.

Additional information:  What constitutes a serious illness, incidents, or accidents are defined in Department procedures.  Note: The regulatory requirement does not mandate notification of a resident’s parent or legal guardian when the resident is 18 years of age or older. In such cases, notification shall be made in accordance with Department procedures.

Compliance Determination: Review the procedure.

Review a sample of incident reports in BADGE to determine compliance with this section.

Applicable definitions:  "Director" means the Director of the Department of Juvenile Justice.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Regulatory authority" means the board or the department as designated by the board.

6VAC35-41-90 (C). Serious incident reports.

C. Any incident involving the death of a resident shall be reported to the individuals specified in subsections A and B without undue delay. If an incident involving the death of a resident occurs at the facility, the facility shall notify the parents or legal guardians, as appropriate and applicable, of all residents in the facility provided such notice does not violate any confidentiality requirements or jeopardize any law enforcement or child protective services investigation or the prosecution of any criminal cases related to the incident.

Interpretation: Goal: To ensure incidents involving the death of a resident are reported to the director or designee, the parent or legal guardian, and the CSU or supervising agency.

13 October 1, 2013

Additional information: When concerns exist regarding confidentiality the legal representative for the facility should be consulted.

Compliance Determination: Review any applicable SIR found in BADGE.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-90 (D). Serious incident reports.

D. The facility shall (i) prepare and maintain a written report of the events listed in subsections A and B of this section and (ii) submit a copy of the written report to the director or designee. The report shall contain the following information:

1. The date and time the incident occurred;
2. A brief description of the incident;
3. The action taken as a result of the incident;
4. The name of the person who completed the report;
5. The name or identifying information of the person who made the report to the placing agency and to either the parent or legal guardian, as appropriate and applicable; and
6. The name of or identifying information provided by the person to whom the report was made, including any law enforcement or child protective service personnel.

Interpretation: Goal: To ensure incident reports contain the listed information.

Additional information: None

Compliance Determination: Examine a sample of serious incident reports in BADGE to determine compliance with this section.

Applicable definitions:  "Director" means the Director of the Department of Juvenile Justice.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes,

14 October 1, 2013

but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-90 (E). Serious incident reports.

E. The resident's record shall contain a written reference (i) that an incident occurred and (ii) of all applicable reporting.

Interpretation: Goal: To ensure documentation of any serious incidents in the resident’s record.

Additional information: The written reference may be (1) a copy of the incident report in the resident’s case record; (2) documentation in the resident’s record in the facility’s electronic database; or (3) a notation/cross-reference in either the resident’s hard copy or electronic case record.

Compliance Determination: Compare the sample of serious incident reports with the case record to determine compliance with this subsection.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-90 (F). Serious incident reports.

F. In addition to the requirements of this section, any serious incident involving an allegation of child abuse or neglect at the facility, at a facility sponsored event, or involving facility staff shall be governed by 6VAC35-41-100 (suspected child abuse or neglect).

Interpretation:

15 October 1, 2013

Goal: To ensure suspected child abuse or neglect complaints are reported in accordance with section 100.

Additional information: None

Compliance Determination:  Inquire whether the facility had any incidents involving suspected child abuse and neglect during the audit period.  Review a sample of CPS incident reports for compliance with requirements in section 100.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

16 October 1, 2013

6VAC35-41-100 (A), (B), & (C). Suspected child abuse or neglect.

6VAC35-41-100 (A). Suspected child abuse or neglect.

A. When there is a reason to suspect that a child is an abused or neglected child, the matter shall be reported immediately to the local department of social services as required by § 63.2-1509 of the Code of Virginia and in accordance with the written procedures.

Interpretation: Goal: To ensure suspected child abuse or neglect is reported to the local department of social services as required by the Code of Virginia.

Additional information: The Code of Virginia mandates immediate reporting to the local department of social services (DSS) or toll free hotline when that person has “reason to suspect that a child is an abused or neglected child.” This applies when there is reason to suspect that the resident has been or is being subject to any kind of child abuse or neglect by any person. DSS will evaluate the report to determine whether it is a valid complaint. The facility should make the report immediately (and not wait for absolute proof of the allegation). It is not the facility’s job to validate the abuse; this is the job of DSS employees or law enforcement officers who have been trained to undertake this type of investigation. In all cases, the report must be made within 24 hours of the first suspicion of child abuse or neglect.

Compliance Determination:  Interview staff: Inquire whether the facility had any incidents involving suspected child abuse and neglect during the audit period.  Examine documentation: Review a sample of CPS incident reports in BADGE for compliance with this subsection.

Applicable definitions:  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-100 (B). Suspected child abuse or neglect.

B. Written procedures shall be distributed to all staff members and shall at a minimum provide for the following:

1. Handling accusations against staff;
2. Reporting and documenting suspected cases of child abuse and neglect;
3. Cooperating during any investigation; and
4. Measures to be taken to ensure the safety of the resident and the staff.

Interpretation: Goal: To ensure procedures for the reporting of suspected child abuse or neglect contain the required components and are accessible to staff.

Additional information: None

Compliance Determination:  Review procedure for compliance with this section.  Interview staff regarding the accessibility of the procedures.

17 October 1, 2013

 Observe the location and accessibility of the procedure.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-100 (C). Suspected child abuse or neglect.

C. Any case of suspected child abuse or neglect shall be reported and documented as required in 6VAC35-41-90 (serious incident reports). The resident's record shall contain a written reference that a report was made.

Interpretation: Goal: To ensure that documentation of the reporting of suspected child abuse is contained in the resident’s case record.

Additional information: None

Compliance Determination:  Interview staff to determine if the facility had any incidents involving suspected child abuse and neglect during the audit period.  Examine documentation: Compare sample CPS reports with resident’s case record for compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

18 October 1, 2013

6VAC35-41-105 (A), (B), & (C). Reporting criminal activity.

6VAC35-41-105 (A). Reporting criminal activity.

A. Staff shall be required to report all known criminal activity by residents or staff including, but not limited to any physical abuse, sexual abuse, or sexual harassment, to the facility administrator for appropriate action.

Interpretation: Goal: To ensure staff is required to report applicable criminal activity.

Additional information: None

Compliance Determination:  Interview superintendent regarding the requirements of this section

Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-105 (B). Reporting criminal activity.

B. The facility administrator, in accordance with written procedures, shall notify the appropriate persons or agencies, including law enforcement, child protective services, and the department as appropriate and applicable, of suspected criminal violations by residents or staff. Suspected criminal violations relating to the health and safety or human rights of residents shall be reported to the director or designee.

Interpretation: Goal: To ensure the proper reporting of suspected criminal violations relating to the health and safety or human rights of residents.

Additional information: SIRs in Badge related to child abuse would be a relevant topic to review.

Compliance Determination:  Examine procedure  Interview facility administrator for any reported violations.  Review any available documentation.

Applicable definitions:  "Department" or "DJJ" means the Department of Juvenile Justice.  "Director" means the Director of the Department of Juvenile Justice.  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

19 October 1, 2013

6VAC35-41-105 (C). Reporting criminal activity.

C. The facility shall assist and cooperate with the investigation of any such complaints and allegations as necessary.

Interpretation: Goal: To ensure the facility administration cooperates with investigations.

Additional information: This subsection does not apply to criminal defendant’s invoking their Constitutional rights.

Compliance Determination: Interview facility administrator to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

20 October 1, 2013

6VAC35-41-110 (A), (B), (C), & (D). Grievance procedure.

6VAC35-41-110 (A). Grievance procedure.

A. Written procedure shall provide that residents are oriented to and have continuing access to a grievance procedure that provides for:

1. Resident participation in the grievance process with assistance from staff upon request;
2. Investigation of the grievance by an objective employee who is not the subject of the grievance;
3. Documented, timely responses to all grievances with the reasons for the decision;
4. At least one level of appeal;
5. Administrative review of grievances;
6. Protection from retaliation or threat of retaliation for filing a grievance; and
7. Hearing of an emergency grievance within eight hours.

Interpretation: Goal: To ensure there is a means for residents express a grievance.

Additional information: None

Compliance Determination:  Review procedure for each required element.  Review a sample of grievances to ensure compliance with the procedures required elements.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-110 (B). Grievance procedure.

B. Each resident shall be oriented to the grievance procedure in an age or developmentally appropriate manner.

Interpretation: Goal: To ensure there is a means for residents express a grievance and residents have been made aware of the process upon arrival.

Additional information: Age or developmentally appropriate manner should take into account literacy level and any disabilities.

Compliance Determination:  Review a sample of orientation forms found in case files.  Inquire regarding orientation process (i.e.: was it explained in a way the resident understood).

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

21 October 1, 2013

6VAC35-41-110 (C). Grievance procedure.

C. The grievance procedure shall be (i) written in clear and simple language and (ii) posted in an area easily accessible to residents and their parents and legal guardians.

Interpretation: Goal: To ensure the grievance procedure is accessible to residents and parents.

Additional information: Posted means secured (i.e.: taped) to a wall, window, door, or other surface.

Compliance Determination:  Review procedure to determine whether it is in clear and simple language.  Observe location where the grievance procedure is posted.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-110 (D). Grievance procedure.

D. Staff shall assist and work cooperatively with other employees in facilitating the grievance process.

Interpretation: Goal: To ensure staff assist and work cooperatively in facilitating the grievance process.

Additional information: None

Compliance Determination:  Ask staff how they help implement the grievance process.  Ask residents how staff helps them with the grievance process.

Applicable definition: None.

22 October 1, 2013

Part II Administrative and Personnel Article 1 General Provisions

6VAC35-41-120 (A), (B), (C), (D), & (E). Responsibilities of the provider or governing authority.

6VAC35-41-120 (A). Responsibilities of the provider or governing authority.

A. The provider shall clearly identify the corporation, association, partnership, individual, or public agency that is the holder of the certificate (governing authority). Any change in the identity or corporate status of the governing authority or provider shall be reported to the director or designee.

Interpretation: Goal: To clearly identify the governing authority for the facility.

Additional information: This could be a written statement, an organizational chart, or other forms of documentation.

Compliance Determination:  Examine documentation

Applicable definitions:  "Director" means the Director of the Department of Juvenile Justice.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

6VAC35-41-120 (B). Responsibilities of the provider or governing authority.

B. The governing authority shall appoint a facility administrator to whom it delegates the authority and responsibility for administrative direction of the facility.

Interpretation: Goal: To ensure there is an administrator with authority to provide direction for the facility.

Additional information: Examples of documentation would include a letter of appointment or a job description.

Compliance Determination:  Review available documentation

Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

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6VAC35-41-120 (C). Responsibilities of the provider or governing authority.

C. A written decision-making plan shall be developed and implemented and shall provide for a staff person with the qualifications of a facility administrator to be designated to assume the temporary responsibility for the operation of the facility. Each plan shall include an organizational chart.

Interpretation: Goal: To ensure that lines of decision making are clearly identified and there is always a qualified administrator available to direct the facility.

Additional information: None

Compliance Determination:  Review the written decision-making plan.  Review organizational chart  Interview facility administrator to determine the qualified person  Review qualifications of designee

Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-120 (D). Responsibilities of the provider or governing authority.

D. The provider shall have a written statement of its (i) purpose, (ii) population served, and (iii) available services for each facility subject to this regulation.

Interpretation: Goal: To ensure that applicants for admission know the purpose and programs of the facility.

Additional information: None

Compliance Determination: Examine written statement

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes,

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but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-120 (E). Responsibilities of the provider or governing authority.

E. Written procedures shall be developed and implemented to monitor and evaluate quality assurance in each facility. Improvements shall be implemented when indicated.

Interpretation: Goal: To ensure there is an ongoing evaluation of services and effectiveness.

Additional information: None

Compliance Determination: Examine procedure

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-130 (A) & (B). Insurance.

6VAC35-41-130 (A). Insurance.

A. Documentation of the following insurance coverage shall be maintained:

1. Liability insurance covering the premises and the facility's operations, including all employees and volunteers, if applicable.
2. Insurance necessary to comply with Virginia's minimum insurance requirements for all vehicles used to transport residents.

Interpretation: Goal: To ensure that all facility operations are properly insured.

Additional information: Copies of insurance documentation showing effective dates. If staff uses personal vehicles to transport residents their documentation must be maintained.

Compliance Determination:  Ask program administrator if staff transport residents in their personal vehicles.  Review required documentation for current effective dates.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-130 (B). Insurance.

B. Staff, who use personal vehicles for official business, including transporting residents, shall be informed of the requirements to provide and document insurance coverage for such purposes.

Interpretation: Goal: To ensure that the facility operations are properly insured.

Additional information: This does not apply to attending training. If staff are asked to use their personal vehicle documentation must be obtained. If staff does not use personal vehicles for facility business there is no need to inform them of the requirements.

Compliance Determination: Ask staff if they use personal vehicles for facility business.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-140 (A), (B), & (C). Participation of residents in human research.

6VAC35-41-140 (A). Participation of residents in human research.

A. The provider shall have procedures, approved by its governing authority, to govern the review, approval, and monitoring of human research. Human research means any systematic investigation, including research development, testing, and evaluating, involving human subjects, including but not limited to a resident or his parents, guardians, or family members, that is designed to develop or contribute to generalized knowledge. Human research does not include statistical analysis of information readily available on the subject that does not contain any identifying information or research exempted by federal research regulations pursuant to 45 CFR 46.101(b).

Interpretation: Goal: To ensure resident participation in human research is performed in accordance with applicable statutes and regulations.

Additional information: Questions regarding this area can be referred to DJJ Research Unit.

Compliance Determination:  Review procedure  Inquire of the program administrator whether any human research has been conducted on residents.  If any human research occurred during the audit period, inquire with central office staff whether the regulatory and statutory requirements for research were met.

Applicable definitions:

 "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-140 (B). Participation of residents in human research.

B. Information on residents shall be maintained as provided in 6VAC35-41-330 (maintenance of residents' records) and all records and information related to the human research shall be kept confidential in accordance with applicable laws and regulations.

Interpretation: Goal: To ensure the confidentiality of residents.

Additional information: None

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Compliance Determination:  If research occurred review the retention of the records for confidentiality.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-140 (C). Participation of residents in human research.

C. The provider may require periodic progress reports of any research project and a formal final report of all completed research projects.

Interpretation: Goal: To ensure resident participation in human research is performed in accordance with applicable statutes and regulations.

Additional information: None

Compliance Determination:  Examine procedure

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-145. Operational procedures.

6VAC35-41-145. Operational procedures.

Current operational procedures shall be accessible to all staff.

Interpretation: Goal: To ensure that all staff has access to procedure that defines the operations of the facility so there is consistent implementation of procedures.

Additional information: None

Compliance Determination: Examine procedure Interview staff

Applicable definitions: None.

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Article 2 Hiring

6VAC35-41-150 (A) & (B). Job descriptions.

6VAC35-41-150 (A). Job descriptions.

A. There shall be a written job description for each position that, at a minimum, includes the:

1. Job title or position;
2. Duties and responsibilities of the incumbent;
3. Job title or identification of the immediate supervisor; and
4. Minimum education, experience, knowledge, skills, and abilities required for entry level performance of the job.

Interpretation: Goal: To ensure that positions are clearly defined and responsibilities are identified.

Additional information: None

Compliance Determination:  Review a written job description for each position for the elements.

Applicable definitions:  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-150 (B). Job descriptions.

B. A copy of the job description shall be given to each person assigned to a position prior to assuming that position's duties.

Interpretation: Goal: To ensure that positions are clearly defined and responsibilities are identified.

Additional information: None

Compliance Determination:  Ask newly hired staff if they were given a job description prior to assuming that position’s duties.

Applicable definitions: None.

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6VAC35-41-160 (A), (B), & (C). Qualifications.

6VAC35-41-160 (A). Qualifications.

A. Facilities subject to (i) the rules and regulations of a governing authority or (ii) the rules and regulations of a local government personnel office shall develop written minimum entry-level qualifications in accordance with the rules and regulations of the supervising personnel authority.

Facilities not subject to rules and regulations of the governing authority or a local government personnel office shall follow the minimum entry-level qualifications of the Virginia Department of Human Resource Management.

Interpretation: Goal: To ensure that employees have the knowledge, skills, and abilities to perform their jobs.

Additional information: A determination regarding authority for the employee qualification is necessary.

Compliance Determination:  Interview facility administrator  Review entry level position requirements for each position

Applicable definitions:  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-160 (B). Qualifications.

B. When services or consultations are obtained on a contractual basis, they shall be provided by professionally qualified personnel.

Interpretation: Goal: To ensure services are provided by professionally qualified personnel.

Additional information: For example, a contractor who serves as the program director must meet the program director's qualification requirements. A contractor who provides medical, nursing or psychological services must meet the appropriate licensure requirements imposed by state law.

Compliance Determination:  Interview facility administrator about process for determining qualifications of personnel  Review documentation of appropriate licensure or certification, as applicable.

Applicable definitions: None.

6VAC35-41-160 (C). Qualifications.

C. Each facility shall provide documentation of contractual agreements or staff expertise to provide educational services, counseling services, psychological services, medical services, or any other services needed to serve the residents in accordance with the facility's program description as defined by the facility's criteria of admission, required by 6VAC35-41-730 B (application for admission).

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Interpretation: Goal: To ensure that qualified persons provide services to residents.

Additional information: None

Compliance Determination: Examine contracts.

Examine documentation of staff expertise (include licensure and certification, as applicable)

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-165 (A), (B), (C), (D), (E), (F), & (G). Employee tuberculosis screening and follow-up.

6VAC35-41-165 (A). Employee tuberculosis screening and follow-up.

A. On or before the employee's start date at the facility each employee shall submit evidence of freedom from tuberculosis in a communicable form that is no older than 30 days. The documentation shall indicate the screening results as to whether there is an absence of tuberculosis in a communicable form.

Interpretation: Goal: To ensure staff at the facility have submitted the required tuberculosis screening assessments indicating whether there is an absence of tuberculosis in a communicable form.

Additional information: The “employee’s start date at the facility” is the date that the employee starts his or her position responsibilities at the facility, which includes orientation and training if conducted at the facility.

Compliance Determination:  Examine documentation: Review documentation of the tuberculosis screening assessment for compliance with this section. Review documentation in sample of staff files

Applicable definitions: None.

6VAC35-41-165 (B). Employee tuberculosis screening and follow-up.

B. Each employee shall submit evidence of an annual evaluation of freedom from tuberculosis in a communicable form.

Interpretation: Goal: Protect staff and residents from exposure to TB.

Additional information: None

Compliance Determination:  Examine documentation: Review documentation of the tuberculosis screening assessment for compliance with this section.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-165 (C). Employee tuberculosis screening and follow-up.

C. Employees shall undergo a subsequent tuberculosis screening or evaluation, as applicable, in the following circumstances:

1. The employee comes into contact with a known case of infectious tuberculosis; or
2. The employee develops chronic respiratory symptoms of three weeks duration.

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Interpretation: Goal: Protect staff and residents from exposure to TB.

Additional information: None

Compliance Determination:  Interview program administrator to determine whether any such instances occurred during the audit period.  If such an instance occurred, examine documentation of the required screening or evaluation.

Applicable definitions: None.

6VAC35-41-165 (D). Employee tuberculosis screening and follow-up.

D. Employees suspected of having tuberculosis in a communicable form shall not be permitted to return to work or have contact with staff or residents until a physician has determined that the individual does not have tuberculosis in a communicable form.

Interpretation: Goal: Protect staff and residents from exposure to TB.

Additional information: None

Compliance Determination:  Interview facility administrator to determine whether any such instances occurred during the audit period.  If such an instance occurred, examine documentation of the employee’s leave of absence and subsequent medical clearance to return to work.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-165 (E). Employee tuberculosis screening and follow-up.

E. Any active case of tuberculosis developed by an employee or a resident shall be reported to the local health department in accordance with the requirements of the Commonwealth of Virginia State Board of Health Regulations for Disease Reporting and Control (12VAC5-90).

Interpretation: Goal: To ensure that active cases are reported as required.

Additional information: None

Compliance Determination:

 Interview facility administrator to determine if any such cases occurred during the audit period.  Review the personnel file and/or resident medical file to determine compliance with this section.

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Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-165 (F). Employee tuberculosis screening and follow-up.

F. Documentation of any screening results shall be retained in a manner that maintains the confidentiality of information.

Interpretation: Goal: To protect staff confidentiality of medical records.

Additional information: None

Compliance Determination:  Interview the program administrator to determine practices relating to the maintenance of the applicable documentation.  Observe the location of the documentation.

Applicable definitions: None.

6VAC35-41-165 (G). Employee tuberculosis screening and follow-up.

G. The detection, diagnosis, prophylaxis, and treatment of pulmonary tuberculosis shall be performed consistent with the current requirements of the Virginia Department of Health's Division of Tuberculosis Prevention and Control and the Department of Health and Human Services Centers for Disease Control and Prevention.

Interpretation: Goal: To provide for consistency of current requirements.

Additional information: The Department’s health administrator will provide facilities with up to date information regarding the current requirements. Use of the current screening form of the Virginia Department of Health contains all the requirements.

Compliance Determination:  Review a sample of tuberculosis screening and assessment forms to ensure all sections were properly completed.

Applicable definitions: None.

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6VAC35-41-170. Physical examination.

6VAC35-41-170. Physical examination.

When the qualifications for a position require a given set of physical abilities, all persons selected for such positions shall be examined by a physician at the time of employment to ensure that they have the level of medical health or physical ability required to perform assigned duties. Persons hired into positions that require a given set of physical abilities may be reexamined annually in accordance with written procedures. .

Interpretation: Goal: To ensure employees have the level of medical health or physical ability required to perform assigned duties.

Additional information: A given set of physical abilities must be described in the position description.

Compliance Determination:  Review the position description  Review procedure  Review documentation of initial exam in staff files.  Review documentation of annual exam in staff files if required.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-180 (A), (B), (C), & (D). Employee and volunteer background checks.

6VAC35-41-180 (A). Employee and volunteer background checks.

A. Except as provided in subsection B, all persons who (i) accept a position of employment at, (ii) volunteer on a regular basis and will be alone with a resident in the performance of their duties, or (iii) provide contractual services directly to a resident on a regular basis and will be alone with a resident in the performance of their duties in a juvenile residential facility shall undergo the following background checks, in accordance with § 63.2-1726 of the Code of Virginia, to ascertain whether there are criminal acts or other circumstances that would be detrimental to the safety of residents in the facility:

1. A reference check;
2. A criminal history check;
3. A fingerprint check with the Virginia State Police and Federal Bureau of Investigations (FBI);
4. A central registry check with Child Protective Services; and
5. A driving record check if applicable to the individual's job duties.

Interpretation: Goal: To ensure background checks are performed on required individuals working at the facility.

Additional information: Individuals who provide contractual services directly to a resident includes, but is not limited to, any contracted medical, mental health, culinary, and occupational services. The individual must work directly with and be alone with a resident in order to be subject to this requirement. Regular basis means the contract provider provides services more than twice per month. If the individual contract services for two times or less per month, the contract provider is subject to the requirements of the procedure for supervising individual without background checks required by subsection 180 (D).

Compliance Determination:  Review a sample of personnel records of new staff and applicable contract providers hired since the last audit for documentation of background checks.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-180 (B). Employee and volunteer background checks.

B. To minimize vacancy time when the fingerprint checks required by subdivision A 3 have been requested, employees may be hired, pending the results of the fingerprint checks, provided:

1. All of the other applicable components of subsection A have been completed;
2. The applicant is given written notice that continued employment is contingent on the fingerprint check results as required by subdivision A 3 of this section; and
3. Employees hired under this exception shall not be allowed to be alone with residents and may work with residents only when under the direct supervision of staff whose background checks have been completed, until such time as all background checks are completed.

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Interpretation: Goal: To ensure the provisions of this section are followed when employees are hired contingent upon the receipt of the fingerprint checks.

Additional information: None

Compliance Determination:  Inquire facility administrator what the facility process is for new employees hired on contingency.  Interview facility administer regarding staff/post assignments.  Review the sample of employees hired under this contingency during the audit period. Review duty rosters for compliance with this subsection.

Applicable definitions:  "Direct supervision" means that the staff may work with residents while not in the presence of direct care staff. Staff members who provide direct supervision are responsible for maintaining the safety, care, and well-being of the residents in addition to providing services or performing the primary responsibilities of that position.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-180 (C). Employee and volunteer background checks.

C. Documentation of compliance with this section shall be retained in the individual's personnel record as provided in 6VAC35-41-310 (personnel records).

Interpretation: Goal: To ensure proper retention of background checks.

Additional information: None

Compliance Determination:  Review a sample of employee and volunteer personnel files

Applicable definitions: None.

6VAC35-41-180 (D). Employee and volunteer background checks.

D. Written procedures shall provide for the supervision of nonemployee persons, who are not subject to the provisions of subsection A and who have contact with residents.

Interpretation: Goal: To ensure that nonemployees who do not have background checks are not alone with residents and under the supervision of staff.

Additional information: None

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Compliance Determination:  Examine procedure

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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Article 3 Employee Orientation and Training

6VAC35-41-190 (A), (B), & (C). Required initial orientation.

6VAC35-41-190 (A). Required initial orientation.

A. Before the expiration of the employee's seventh work day at the facility, each employee shall be provided with a basic orientation on the following:

1. The facility;
2. The population served;
3. The basic objectives of the program;
4. The facility's organizational structure;
5. Security, population control, emergency preparedness, and evacuation procedures in accordance with 6VAC35-41-490 (emergency and evacuation procedures);
6. The practices of confidentiality;
7. The residents' rights; and
8. The basic requirements of and competencies necessary to perform in the positions.

Interpretation: Goal: To ensure that all employees and contractors have an understanding of their functions at the facility.

Additional information: If the training requirement is cited elsewhere in the regulation (i.e.: disciplinary process), the facility will be cited for noncompliance for that section only.

Compliance Determination:  Review a sample of training records for newly hired employees to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-190 (B). Required initial orientation.

B. Prior to working with residents while not under the direct supervision of staff who have completed all applicable orientations and training, each direct care staff shall receive a basic orientation on the following:

1. The facility's program philosophy and services;
2. The facility's behavior management program;
3. The facility's behavior intervention procedures and techniques, including the use of least restrictive interventions and physical restraint;

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1. The residents' rules of conduct and responsibilities;
2. The residents' disciplinary and grievance procedures;
3. Child abuse and neglect and mandatory reporting;
4. Standard precautions; and
5. Documentation requirements as applicable to the position's duties.

Interpretation: Goal: To ensure that before staff work with residents they are properly trained.

Additional information: Teachers employed by local school divisions are not considered staff.

Teachers are not referenced in the regulation. They provide a contractual service and are under the supervision of local educational agencies. They are not “direct supervision” staff.

Compliance Determination: Examine documentation in training records

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Direct supervision" means that the staff may work with residents while not in the presence of direct care staff. Staff members who provide direct supervision are responsible for maintaining the safety, care, and well-being of the residents in addition to providing services or performing the primary responsibilities of that position.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Rules of conduct" means a listing of a facility's rules or regulations that is maintained to inform residents and others of the behavioral expectations of the behavior management program, about behaviors that are not permitted, and about the sanctions that may be applied when impermissible behaviors occur.

6VAC35-41-190 (C). Required initial orientation.

C. Volunteers shall be oriented in accordance with 6VAC35-41-300 (orientation and training for volunteers or interns).

Interpretation: Goal: To ensure that all volunteers and interns have an understanding of their functions at the facility.

Additional information: Compliance will be determined under subsection 300.

Compliance Determination:  Review a sample of volunteer files in subsection 300.

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Applicable definitions: None.

6VAC35-41-200 (A), (B), (C), (D), (E), & (F). Required initial training.

6VAC35-41-200 (A). Required initial training.

A. Each full-time and part-time employee and relief staff shall complete initial, comprehensive training that is specific to the individual's occupational class, is based on the needs of the population served, and ensures that the individual has the competencies to perform in the position.

1. Direct care staff shall receive at least 40 hours of training, inclusive of all training required by this section, in their first year of employment.
2. Contractors shall receive training required to perform their position responsibilities in a juvenile residential facility.

Interpretation: Goal: To ensure that all direct care staff and contractors are adequately trained.

Additional information: None

Compliance Determination:  Review sample of training files for the completion of required training, as applicable.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-200 (B). Required initial training.

B. Within 30 days following the employee's start date at the facility or before the employee is responsible for the direct supervision of a resident, all direct care staff and staff who provide direct supervision of the residents while delivering services, with the exception of workers employed by contract to provide behavioral health or health care services, shall complete training in the following areas:

1. Emergency preparedness and response;
2. First aid and cardiopulmonary resuscitation, unless the individual is currently certified, with certification required as applicable to their duties;
3. The facility's behavior management program;
4. The residents' rules of conduct and the rationale for the rules;
5. The facility's behavior intervention procedures, with physical and mechanical restraint training required as applicable to their duties;
6. Child abuse and neglect;
7. Mandatory reporting;
8. Maintaining appropriate professional relationships;
9. Interaction among staff and residents; 10. Suicide prevention;

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11. Residents' rights, including, but not limited to, the prohibited actions provided for in 6VAC35-41-560 (prohibited actions); 12. Standard precautions; and 13. Procedures applicable to the employees' position and consistent with their work profiles.

Interpretation: Goal: To ensure that all staff is adequately trained to meet the needs of the resident.

Additional information: Each element listed above is a separate regulatory requirement. The audit team will review training records to determine compliance with each element individually

Compliance Determination:  Review a sample of training files for the provision of training in the proper time frame and before being left alone with residents.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Direct supervision" means that the staff may work with residents while not in the presence of direct care staff. Staff members who provide direct supervision are responsible for maintaining the safety, care, and well-being of the residents in addition to providing services or performing the primary responsibilities of that position.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Rules of conduct" means a listing of a facility's rules or regulations that is maintained to inform residents and others of the behavioral expectations of the behavior management program, about behaviors that are not permitted, and about the sanctions that may be applied when impermissible behaviors occur.

6VAC35-41-200 (C). Required initial training.

C. Employees who administer medication shall have, prior to such administration, successfully completed a medication training program approved by the Board of Nursing or be licensed by the Commonwealth of Virginia to administer medication.

Interpretation: Goal: To ensure employees who administer medications have the required training prior to such administration.

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Additional information: If medications are administered by nursing personnel, confirmation of this practice will be sufficient to meet the requirement of this section. This does not include professional medical staff.

Compliance Determination:  Inquire as to which employees administer medications.  Review training records. Compare training completion date with dates medication is administered.

Applicable definitions: None.

6VAC35-41-200 (D). Required initial training.

D. Training shall be required by and provided as appropriate to the individual's job duties and in accordance with the provider's training plan.

Interpretation: Goal: To ensure the training needs of staff are met.

Additional information: The training plan may be specific to an individual staff or group of staff.

Compliance Determination: Examine training plan Examine documentation in training records

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

6VAC35-41-200 (E). Required initial training.

E. When an individual is employed by contract to provide services for which licensure by a professional organization is required, documentation of current licensure shall constitute compliance with this section.

Interpretation: Goal: To ensure that employees are qualified to provide services.

Additional information: None

Compliance Determination:  Review status of licensure of applicable staff

Applicable definitions: None.

6VAC35-41-200 (F). Required initial training.

F. Volunteers and interns shall be trained in accordance 6VAC35-41-300 (orientation and training for volunteers or interns).

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Interpretation: Goal: To ensure proper training of volunteers and interns.

Additional information: Compliance will be determined in subsection 300.

Compliance Determination: Review a sample of training records for volunteers and interns.

Applicable definitions: None.

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6VAC35-41-210 (A), (B), (C), (D), (E), (F), (G), & (H). Required retraining.

6VAC35-41-210 (A). Required retraining.

A. Each employee, relief staff, and contractor shall complete retraining that is specific to the individual's occupational class and the position's job description and addresses any professional development needs.

Interpretation: Goal: To ensure there is a training programs that is continuous to keep staff current on training needs.

Additional information: None

Compliance Determination:  Examine documentation: Review training records for the required number of hours and trainings.

Applicable definitions: None.

6VAC35-41-210 (B). Required retraining.

B. All staff shall complete an annual training refresher on the facility's emergency preparedness and response plan and procedures.

Interpretation: Goal: To ensure that the staff is trained to respond to emergencies.

Additional information: None

Compliance Determination:  Examine training records for annual emergency preparedness training.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-210 (C). Required retraining.

C. All direct care staff and staff who provide direct supervision of the residents while delivering services, with the exception of workers who are employed by contract to provide behavioral health or health care services, shall complete at least 40 hours of training annually that shall include training in the following areas:

1. Suicide prevention;

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1. Child abuse and neglect;
2. Mandatory reporting;
3. Residents' rights, including, but not limited to, the prohibited actions provided for in 6VAC35-41-560 (prohibited actions);
4. Standard precautions; and
5. Behavior intervention procedures.

Interpretation: Goal: To ensure direct care staff and employees who provide direct supervision complete required annual trainings.

Additional information: This section contains seven individual regulatory requirements.

Compliance Determination:  Review a sample of training files for each component and a total of at least 40 hours.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Direct supervision" means that the staff may work with residents while not in the presence of direct care staff. Staff members who provide direct supervision are responsible for maintaining the safety, care, and well-being of the residents in addition to providing services or performing the primary responsibilities of that position.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-210 (D). Required retraining.

D. Staff required by their position to have certification in cardiopulmonary resuscitation and first aid shall receive training sufficient to maintain current certifications.

Interpretation: Goal: To ensure that properly trained staff is available to meet the emergency needs of residents.

Additional information: None

Compliance Determination: Examine sample of training records to ensure staff have current certifications.

Applicable definitions: None.

6VAC35-41-210 (E). Required retraining.

E. Employees who administer medication shall complete annual refresher training on the administration of medication.

Interpretation:

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Goal: To ensure that staff administering medication is properly trained.

Additional information: None

Compliance Determination: Examine sample of training records to ensure that staff who administer medication have an annual refresher.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.

6VAC35-41-210 (F). Required retraining.

F. Retraining shall (i) be required by and provided as appropriate to the individual's job duties, (ii) address any needs identified by the individual and the supervisor, if applicable, and (iii) be in accordance with the provider's training plan.

Interpretation: Goal: To ensure the ongoing training needs of staff are addressed

Additional information: The training plan may be specific to a staff or to a group of staffs.

Compliance Determination: Examine the training plan.

Examine documentation of training records

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

6VAC35-41-210 (G). Required retraining.

G. When an individual is employed by contract to provide services for which licensure by a professional organization is required, documentation of current licensure shall constitute compliance with this section.

Interpretation: Goal: To ensure that contract service provides are qualified.

Additional information: None

Compliance Determination:  Review status of staff licensure to ensure compliance with this section.

Applicable definitions: None.

6VAC35-41-210 (H). Required retraining.

H. Staff who have not timely completed required retraining shall not be allowed to have direct care responsibilities pending completion of the retraining requirements.

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Interpretation: Goal: To ensure that only properly trained staff supervise resident.

Additional information:  If annual training is not completed within the applicable time period or the training for required certifications or licensure is not completed before the expiration of the certificate/licensure period, that individual cannot be responsible for the direct care of residents, until the required training is completed.  Staff without required trainings may work in a non-direct care capacity during this period.  If any staff has not timely completed required retraining, the certification unit will examine staffing documents to determine whether staff had any direct care responsibilities during this period.

Compliance Determination:  Review a sample of the training files for compliance with the training requirements. Review documentation of staffing patterns to determine compliance with this section.

Applicable definitions: ”Timely” means completion of required training in accordance with regulatory and procedural changes.

49 October 1, 2013

Article 4 Personnel

6VAC35-41-220. Written personnel procedures.

6VAC35-41-220. Written personnel procedures.

The provider shall have and implement provider approved written personnel procedures and make these readily accessible to each staff member.

Interpretation: Goal: To ensure there are personnel procedures for the program staff.

Additional information: Accessible to the staff may be an individual hard copy, a copy that is available to staff, or an electronic copy.

Compliance Determination:  Interview staff to determine accessibility of the personnel procedures.  Observe location and accessibility of the personnel procedures.  Review the procedures  Review the approval

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-230. Code of ethics.

6VAC35-41-230. Code of ethics.

A written code of ethics shall be available to all employees.

Interpretation:

Goal: Ensure that each employee has knowledge of an established Code of Ethics.

Additional information: Accessible to the staff may be an individual hard copy, a copy that is available to staff, or an electronic copy.

Compliance Determination:  Interview staff regarding availability of the code of ethics.  Review the code of conduct.  Observe location and availability of the code of ethics.

Applicable definitions:  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-250. Notification of change in driver's license status.

6VAC35-41-250. Notification of change in driver's license status.

Staff whose job responsibilities may involve transporting residents shall (i) maintain a valid driver's license and (ii) report to the facility administrator or designee any change in their driver's license status including but not limited to suspensions, restrictions, and revocations.

Interpretation: Goal: To ensure that staff that provides transportation for residents is properly licensed.

Additional information: Determine those persons who transport residents.

Compliance Determination:  Examine a sample of personnel records to ensure valid driver’s license on file.  Interview the facility administrator to ensure staff is properly reporting changes in the status of their driver’s license, as applicable.

Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

52 October 1, 2013

6VAC35-41-260. Physical or mental health of personnel.

6VAC35-41-260. Physical or mental health of personnel.

When an individual poses a direct threat to the health and safety of a resident, others at the facility, or the public or is unable to perform essential job-related functions, that individual shall be removed immediately from all duties involved in the direct care or direct supervision of residents. The facility may require a medical or mental health evaluation to determine the individual's fitness for duty prior to returning to duties involving the direct care or direct supervision of residents. The results of any medical information or documentation of any disability related inquiries shall be maintained separately from the employee's personnel records maintained in accordance with 6VAC35-41-310 (personnel records). For the purpose of this section a direct threat means a significant risk of substantial harm.

Interpretation: Goal: To ensure the health and safety of residents.

Additional information: This section provides a method for dealing with an employee’s fitness for duty. Concern may focus on the staff member's mental or physical fitness for duty whenever he has experienced an illness, injury, or contagious disease that may reasonably be expected to expose residents or other staff to harm, including the risk of diminished ability to perform assigned duties.

Compliance Determination:  Interview facility administrator if there has been any applicable instances during the audit period.  Review documentation of leaves of absence or disciplinary records, as appropriate.  Review documentation of medical or mental health evaluations to determine the individual’s fitness for duty prior to returning to direct care duties, as applicable.  Ensure that the results of any employee medical information or documentation of any disability related to inquiries are maintained separate from the employee’s personnel records.

Applicable definitions:  "Direct supervision" means that the staff may work with residents while not in the presence of direct care staff. Staff members who provide direct supervision are responsible for maintaining the safety, care, and well-being of the residents in addition to providing services or performing the primary responsibilities of that position.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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Article 5 Volunteers

6VAC35-41-270. Definition of volunteers or interns.

6VAC35-41-270. Definition of volunteers or interns.

For the purpose of this chapter, volunteer or intern means any individual or group who of their own free will provides goods and services without competitive compensation.

Interpretation: Goal: Define volunteer and intern.

Additional information: None

Compliance Determination: None

Applicable definitions: None.

54 October 1, 2013

6VAC35-41-280 (A), (B), (C), & (D). Selection and duties of volunteers or interns.

6VAC35-41-280 (A). Selection and duties of volunteers or interns.

A. Any facility that uses volunteers or interns shall develop and implement written procedures governing their selection and use. Such procedures shall provide for the objective evaluation of persons and organizations in the community who wish to associate with the residents.

Interpretation:

Goal: To ensure that volunteers are appropriate to provide services.

Additional information: None

Compliance Determination:  Examine procedure for required elements.  Review selection criteria and volunteer files to ensure that the procedure is implemented (i.e.: that persons and organizations are evaluated).

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-280 (B). Selection and duties of volunteers or interns.

B. Volunteers and interns shall have qualifications appropriate for the services provided.

Interpretation: Goal: To ensure that volunteers are appropriate to provide services.

Additional information: The audit team will review the information available on volunteers (e.g. some facilities may use a regular employment application form while others may develop a separate tool to determine whether the facility has appropriate information on which to base assignments and whether that information is used appropriately in assigning volunteers and interns).

Compliance Determination:  Compare job duties (as required in subsection C) with the volunteer’s or intern’s application and qualifications (i.e.: degrees, licenses, references).  Review a sample of volunteer/intern files.

Applicable definitions: None.

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6VAC35-41-280 (C). Selection and duties of volunteers or interns.

C. The responsibilities of interns and individuals who volunteer on a regular basis shall be clearly defined in writing.

Interpretation: Goal: To ensure that responsibilities are clearly identified.

Additional information: “Regular basis” means the volunteer provides services more than twice per month.

Compliance Determination:  Review a sample of volunteer/intern files for written descriptions of duties and responsibilities.

Applicable definitions: None.

6VAC35-41-280 (D). Selection and duties of volunteers or interns.

D. Volunteers and interns shall neither be responsible for the duties of direct care staff nor for the direct supervision of the residents.

Interpretation: Goal: To ensure that only properly trained staff supervises residents.

Additional information: None

Compliance Determination:  Interview facility administrator to determine if volunteers or interns are responsible for the duties of direct care staff.  If available, interview volunteers/interns to determine if they are or have ever been assigned direct care staff duties.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Direct supervision" means that the staff may work with residents while not in the presence of direct care staff. Staff members who provide direct supervision are responsible for maintaining the safety, care, and well-being of the residents in addition to providing services or performing the primary responsibilities of that position.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

56 October 1, 2013

6VAC35-41-290 (A), (B), & (C). Background checks for volunteers or interns.

6VAC35-41-290 (A). Background checks for volunteers or interns.

A. Any individual who (i) volunteers on a regular basis or is an intern and (ii) will be alone with a resident in the performance of that position's duties shall be subject to the background check requirements provided for in 6VAC35-41-180 A (employee and volunteer background checks).

Interpretation: Goal: To ensure that volunteers have proper background checks.

Additional information: None

Compliance Determination: Interview facility administrator to determine if any volunteers or interns are subject to this requirement.

If applicable, examine a sample of volunteer/intern files for documentation of any required background checks prior to being alone with a resident.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-290 (B). Background checks for volunteers or interns.

B. Documentation of compliance with the background check requirements shall be maintained for each intern and each volunteer for whom a background investigation is required. Such records shall be kept in accordance with 6VAC35-41-310 (personnel records).

Interpretation: Goal: To ensure maintenance of proper documentation.

Additional information: None

Compliance Determination: Examine sample of volunteer/intern files to ensure compliance with this requirement.

Applicable definitions: None.

6VAC35-41-290 (C). Background checks for volunteers or interns.

C. A facility that uses volunteers shall have procedures for supervising volunteers, on whom background checks are not required or whose background checks have not been completed, who have contact with residents.

Interpretation: Goal: To ensure proper supervision of volunteers.

Additional information: None

Compliance Determination: Examine procedures for compliance with this requirement.

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Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

58 October 1, 2013

6VAC35-41-300 (A) & (B). Orientation and training for volunteers or interns.

6VAC35-41-300 (A). Orientation and training for volunteers or interns.

A. Volunteers and interns shall be provided with a basic orientation on the following:

1. The facility;
2. The population served;
3. The basic objectives of the facility;
4. The facility's organizational structure;
5. Security, population control, emergency, emergency preparedness, and evacuation procedures;
6. The practices of confidentiality;
7. The residents' rights including, but not limited to the prohibited actions provided for in 6VAC35-41-560 (prohibited actions); and
8. The basic requirements of and competencies necessary to perform their duties and responsibilities.

Interpretation: Goal: To ensure the proper orientation of volunteers.

Additional information: None

Compliance Determination:

 Interview facility administrator to determine if any volunteers or interns are subject to this requirement.  Examine documentation of orientation in a sample of volunteer files for compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-300 (B). Orientation and training for volunteers or interns.

B. Volunteers and interns shall be trained within 30 days from their start date at the facility in the following:

1. Any procedures that are applicable to their duties and responsibilities; and
2. Their duties and responsibilities in the event of a facility evacuation.

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Interpretation: Goal: To ensure the proper orientation of volunteers.

Additional information: None

Compliance Determination:  Examine documentation:  Review sample of volunteer/intern files and compare start date and the dates the volunteer or intern received the required trainings.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

60 October 1, 2013

Article 6 Records

6VAC35-41-310 (A), (B), (C), & (D). Personnel records.

6VAC35-41-310 (A). Personnel records.

A. Separate up-to-date written or automated personnel records shall be maintained on each (i) employee and (ii) volunteer or intern on whom a background check is required.

Interpretation: Goal: To ensure proper maintenance of personnel records.

Additional information: Up-to-date is that information should be immediately on file.

Compliance Determination: Examine a sample of personnel records to determine compliance with this section.

Applicable definitions:  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-310 (B). Personnel records.

B. The records of each employee shall include:

1. A completed employment application form or other written material providing the individual's name, address, phone number, and social security number or other unique identifier;
2. Educational background and employment history;
3. Documentation of required reference check;
4. Annual performance evaluations;
5. Date of employment for each position held and date of separation;
6. Documentation of compliance with requirements of Virginia law regarding child protective services and criminal history background investigations;
7. Documentation of the verification of any educational requirements and of professional certification or licensure if required by the position;
8. Documentation of all training required by this chapter and any other training received by individual staff; and
9. A current job description.

Interpretation: Goal: To ensure proper maintenance of personnel records.

Additional information: None

Compliance Determination: Examine a sample of personnel records since the last audit to determine compliance with this section.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-310 (C). Personnel records.

C. If applicable, health records, including reports of any required health examinations, shall be maintained separately from the other records required by this section.

Interpretation: Goal: To ensure proper maintenance of personnel records.

Additional information: Separately is in another folder, file or drawer.

Compliance Determination: Examine a sample of personnel records to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-310 (D). Personnel records.

D. The personnel records of volunteers and contractual service providers may be limited to documentation of compliance with the background checks as required by 6VAC35-41-180 (employee and volunteer background checks).

Interpretation: Goal: To ensure the completion of background checks on volunteers/intern.

Additional information: Compliance for this subsection will be assessed in subsection 180.

Compliance Determination:  None

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

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6VAC35-41-330 (A), (B), (C), (D), (E), (F), & (G). Maintenance of records.

6VAC35-41-330 (A). Maintenance of records.

A. A separate written or automated case record shall be maintained for each resident that shall include all correspondence and documents received by the facility relating to the care of that resident and documentation of all case management services provided.

Interpretation:

Goal: To ensure the proper documentation of case management services.

Additional information: Records should be maintained in standard format.

Compliance Determination:  Review a sample of resident case records to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-330 (B). Maintenance of records.

B. A separate health record may be kept on each resident. The resident's active health records shall be readily accessible in case of emergency and shall be made available to authorized staff consistent with applicable state and federal statutes and regulations.

Interpretation: Goal: To ensure the proper documentation of healthcare records and services.

Additional information: The audit team will evaluate whether the health care records are maintained separately. The requirements of 6VAC35-71-1320 will be evaluated under that section. A separate case record means that the information for an individual resident must be kept separately from information on all other residents. Sections of individual records such as allegations of child abuse, medical and educational information, etc. may be retained in separate locations on the premises provided they are kept individually, confidentiality is protected and the location of the information is noted in the master record.

Compliance Determination:

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 Review a sample of resident health records to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-330 (C). Maintenance of records.

C. Each case record and health record shall be kept (i) up to date, (ii) in a uniform manner, and (ii) confidential from unauthorized access.

Interpretation:

Goal: To ensure that records are maintained in accordance with written procedures.

Additional information: Review schematic (or other documentation) on requirements for maintaining records uniformly (if a schematic is not available, the audit team will inquire of staff how information is kept in the records).

Compliance Determination:  Ask the facility administrator what the facility’s process for the release of case records and whether the process is in compliance with the procedure required in subsection D and the applicable statutes and regulations.  Review sample of case records to determine compliance with this section.  Interview staff

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.

6VAC35-41-330 (D). Maintenance of records.

D. Written procedures shall provide for the management of all records, written and automated, and shall describe confidentiality, accessibility, security, and retention of records pertaining to residents, including:

1. Access, duplication, dissemination, and acquisition of information only to persons legally authorized according to federal and state laws;
2. Facilities using automated records shall address procedures that include: a. How records are protected from unauthorized access; b. How records are protected from unauthorized Internet access; c. How records are protected from loss;

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d. How records are protected from unauthorized alteration; and e. How records are backed up.

1. Security measures to protect records (i) from loss, unauthorized alteration, inadvertent or unauthorized access, or disclosure of information; and (ii) during transportation of records between service sites;
2. Designation of person responsible for records management; and
3. Disposition of records in the event the facility ceases to operate.

Interpretation: Goal: To ensure that records are maintained in accordance with written procedures.

Additional information: None

Compliance Determination:  Review the procedure to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-330 (E). Maintenance of records.

E. Written procedure shall specify what information is available to the resident.

Interpretation: Goal: To define information that is available to the resident.

Additional information: None

Compliance Determination:  Review procedure to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.

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 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-330 (F). Maintenance of records.

F. Active and closed written records shall be kept in secure locations or compartments that are accessible to authorized staff and shall be protected from unauthorized access, fire, and flood.

Interpretation: Goal: To ensure the confidentiality of records and safe protection of those records.

Additional information: o Protected from unauthorized access means locked or in a locked room (or the equivalent thereof). o Protected from fire means the records are kept in a fire retardant container (i.e.: metal file cabinet or the equivalent thereof) o Protected from flood means the records are not placed in an area prone to flooding (i.e.: the audit team will look for evidence of leaks, water seepage, water damage, or prior flooding).

Compliance Determination:  Observe location of the active and closed case records for compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-330 (G). Maintenance of records.

G. All case records shall be retained as governed by The Library of Virginia.

Interpretation: Goal: To ensure that records are maintained according to requirements of the Library of Virginia.

Additional information: Auditors may need to refer specific information on requirements to the Records Retention Manager at DJJ Central Office.

Compliance Determination:  Inquire of the facility administrator to determine the facility’s practice, process, or procedure for retention of inactive records.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical,

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psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.

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6VAC35-41-340 (A), (B), & (C). Face sheet.

6VAC35-41-340 (A). Face sheet.

A. At the time of admission each resident's record shall include, at a minimum, a completed face sheet that contains the following:

1. The resident's full name, last known residence, birth date, gender, race, unique numerical identifier, and admission date; and
2. Names, addresses, and telephone numbers of the resident's placing agency, emergency contacts, legal guardians, and parents, as applicable and appropriate.

Interpretation: Goal: To ensure proper documentation of identifying information.

Additional information: At the time of admission means the date the resident physically arrives at the facility. “Not applicable” and “unknown” are not acceptable entries on the face sheet, except when no information is available on a biological parent. “None” may be used as an entry for religious preference and telephone number.

Compliance Determination:  Review a sample of face sheets for the required components to determine compliance with this

section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-340 (B). Face sheet.

B. Upon discharge, the date of and reason for discharge, names and addresses of persons to whom the resident was discharged, and forwarding address of the resident, if known, shall be recorded on the face sheet.

Interpretation:

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Goal: To ensure current information is available and accurate.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section.  Examine a sample of face sheets to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-340 (C). Face sheet.

C. Information shall be updated when changes occur.

Interpretation: Goal: To ensure the retention of information relevant to the discharge of the resident.

Additional information: The information may be added to the face sheet or an addendum to the face sheet.

Compliance Determination:  Review sample of files for discharge information to determine compliance with this section.

Applicable definitions: None.

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Part III Physical Environment

6VAC35-41-350 (A), (B), & (C). Buildings and inspections.

6VAC35-41-350 (A). Buildings and inspections.

A. All newly constructed buildings, major renovations to buildings, and temporary structures shall be inspected and approved by the local building official. Approval shall be documented by a certificate of occupancy.

Interpretation: Goal: To ensure that all building are properly inspected and approved.

Additional information: None

Compliance Determination:  Interview facility administrator regarding renovations or new construction.  Review the certificate of occupancy and documentation of other required inspections (i.e.: building officials, fire marshal, and health department).

Applicable definitions: None.

6VAC35-41-350 (B). Buildings and inspections.

B. A current copy of the facility's annual inspection by fire prevention authorities indicating that all buildings and equipment are maintained in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51) shall be maintained. If the fire prevention authorities have failed to timely inspect the facility's buildings and equipment, documentation of the facility's request to schedule the annual inspection as well as documentation of any necessary follow-up with fire prevention authorities shall be maintained.

Interpretation: Goal: To ensure that residents are in a safe environment.

Additional information: Timely means within thirteen months from the date of the previous fire inspection. The facility’s request to schedule the annual inspection must be made a reasonable period of time prior to the expiration of the fire inspection. Reasonable period of time is the amount of time the fire marshal requires for scheduling an inspection. Any necessary follow-up means contact with the fire marshal before the expiration date to schedule the inspection if there was no response to the initial request (i.e.: 3-4 weeks before the expiration).

Compliance Determination:  Review documentation of annual fire inspection to determine compliance with this section.  If the fire inspection was not completed by the end of the thirteenth month after the previous fire inspection (unless it is defined differently by the Virginia Department of Fire Programs), review documentation of the request for the inspection and any follow-up.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.

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 "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-350 (C). Buildings and inspections.

C. The facility shall maintain a current copy of its annual inspection and approval, in accordance with state and local inspection laws, regulations, and ordinances, of the following:

1. General sanitation;
2. Sewage disposal system;
3. Water supply;
4. Food service operations; and
5. Swimming pools, if applicable.

Interpretation: Goal: To ensure that residents are in a safe environment.

Additional information: None

Compliance Determination:  Review documentation of any required annual inspections to determine compliance with this section.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-360 (A) & (B). Equipment and systems inspections and maintenance.

6VAC35-41-360 (A). Equipment and systems inspections and maintenance.

A. All safety, emergency, and communications equipment and systems shall be inspected, tested, and maintained by designated staff in accordance with the manufacturer's recommendations or instruction manuals or, absent such requirements, in accordance with a schedule that is approved by the facility administrator. Testing of such equipment and systems shall, at a minimum, be conducted quarterly.

Interpretation: Goal: To ensure that all required equipment functions properly.

Additional information: Safety, emergency, and communications equipment and systems includes, but not limited to, such equipment and systems as: computerized or electronic egress, intercoms, two-way radios, locks, fire extinguishers, sprinkler systems, hood systems. Fire detection and sprinkler system testing are evaluated by the fire authority during that inspection. “Testing” of fire extinguishers would only be an inspection of the gauge showing the status of the equipment

Compliance Determination:  Review approved schedule and documentation of testing and inspections to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.

6VAC35-41-360 (B). Equipment and systems inspections and maintenance.

B. Whenever safety, emergency, and communications equipment or a system is found to be defective, corrective action shall be taken to rectify the situation and to repair, remove, or replace the defective equipment.

Interpretation: Goal: To ensure that equipment functions and provides for a safe environment for residents and staff.

Additional information: None

Compliance Determination:  Interview the facility administrator to determine if there were any instances of defective safety, emergency, or communications equipment during the audit period.  If applicable, examine documentation of any requests for repair, removal, or replacement (i.e.: purchase order) and review for any follow-up needed.

Applicable definitions:

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 "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.

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6VAC35-41-370 (A) & (B). Heating and cooling systems and ventilation.

6VAC35-41-370 (A). Heating and cooling systems and ventilation.

A. Heat shall be distributed in all rooms occupied by the residents such that a temperature no less than 68°F is maintained, unless otherwise mandated by state or federal authorities.

Interpretation:

Goal: To ensure healthy environment for residents.

Additional information: None

Compliance Determination:  The audit team will (i) observe the thermostat and (ii) measure the temperature of a sample of rooms to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-370 (B). Heating and cooling systems and ventilation.

B. Air conditioning or mechanical ventilating systems, such as electric fans, shall be provided in all rooms occupied by residents when the temperature in those rooms exceeds 80°F.

Interpretation: Goal: Additional information:

Compliance Determination:

Interview facility administrator to determine if there were any instances of rooms occupied by residents exceeding temperature requirements during the audit period.

If applicable, determine if alternate cooling system were provided.

Examine procedure.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-380 (A), (B), (C), (D), & (E). Lighting.

6VAC35-41-380 (A). Lighting.

A. Sleeping and activity areas in the facility shall provide natural lighting.

Interpretation: Goal: To ensure healthy environment for residents.

Additional information: None

Compliance Determination:  Observe natural lighting in the sleeping and activity areas.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-380 (B). Lighting.

B. All areas within buildings shall be lighted for safety and the lighting shall be sufficient for the activities being performed.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: None

Compliance Determination:  Observe building areas and lighting to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-380 (C). Lighting.

C. There shall be night lighting sufficient to observe residents.

Interpretation: Goal: To ensure a safe environment for residents.

Additional information: Lighting should be sufficient for staff to observe residents during sleeping hours and for resident to perform toileting.

Compliance Determination:  Observe building areas and lighting to determine compliance with this section.

Applicable definitions:

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 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-380 (D). Lighting.

D. Each facility shall have a plan for providing alternative lighting in case of emergencies.

Interpretation: Goal: To ensure the safety of residents during a power loss.

Additional information: None

Compliance Determination:  Observe flashlights or lanterns; compare with the number of direct care staff on duty.  The audit team should test for proper functioning.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-380 (E). Lighting.

E. Outside entrances and parking areas shall be lighted.

Interpretation: Goal: To ensure safety of resident, staff and general public.

Additional information: None

Compliance Determination:  Observe outside lighting during the night hours.

Applicable definitions: None.

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6VAC35-41-390 (A), (B), & (C). Plumbing and water supply; temperature.

6VAC35-41-390 (A). Plumbing and water supply; temperature.

A. Plumbing shall be maintained in operational condition, as designed.

Interpretation: Goal: To ensure healthy environment for residents and staff.

Additional information:  There should be an adequate flow of water.  There should be proper draining and discharge.  Plumbing should be free of rust.  Plumbing should be drip free.

Compliance Determination:  Observe and test plumbing to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-390 (B). Plumbing and water supply; temperature.

B. An adequate supply of hot and cold running water shall be available at all times.

Interpretation: Goal: To ensure healthy and safe environment for residents.

Additional information: None

Compliance Determination:  Observe and test the water to determine compliance with this section.  Interview residents to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-390 (C). Plumbing and water supply; temperature.

C. Precautions shall be taken to prevent scalding from running water. Water temperatures should be maintained at 100°F to 120°F.

Interpretation: Goal: To ensure healthy and safe environment for residents.

Additional information: None

Compliance Determination:  Interview residents and ask if they have ever been scalded by hot water.  Audit team will check the hot water temperature to determine compliance with this section.

Applicable definitions: None.

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6VAC35-41-400 (A), (B), (C), (D), (E), (F), & (G). Toilet facilities.

6VAC35-41-400 (A). Toilet facilities.

A. There shall be at least one bathtub or bathtub alternative in each facility.

Interpretation:

Goal: To ensure a safe and healthy environment for residents.

Additional information: None

Compliance Determination:  Observe toilet facilities in the sleeping areas to determine compliance with this section.  Test for proper function.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-400 (B). Toilet facilities.

B. There shall be at least one toilet, one hand basin, and one shower or tub for every eight residents for facilities certified before July 1, 1981.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: Review date of construction and use as a determining factor of requirement.

Compliance Determination:  Ask facility administrator when buildings were constructed to determine number of toilet facilities required.  Observe the toilets, hand basins, and shower/tubs.  Compare with number required based on number of residents in the building or living units to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-400 (C). Toilet facilities.

C. There shall be one toilet, one hand basin, and one shower or tub for every four residents in any building constructed or structurally modified after July 1, 1981. Facilities certified after December 28, 2007, shall comply with the one-to-four ratio.

Interpretation:

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Goal: To ensure a safe and healthy environment for residents.

Additional information: Review date of construction and use as a determining factor of requirement.

Compliance Determination:  Ask facility administrator when buildings were constructed to determine number of toilet facilities required.  Observe the toilets, hand basins, and shower/tubs.  Compare with number required based on number of residents in the building or living units to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-400 (D). Toilet facilities.

D. The maximum number of staff members on duty in the living unit shall be counted in determining the required number of toilets and hand basins when a separate bathroom is not provided for staff.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: None

Compliance Determination:  Observe if there are separate bathrooms for staff.  If a staff bathroom is not available, the maximum number of staff on duty in the living units will be used to determine compliance with this section.

Applicable definitions:  "Living unit" means the space in which a particular group of residents in care of a juvenile residential facility reside. A living unit contains sleeping areas, bath and toilet facilities, and a living room or its equivalent for use by the residents of the living unit. Depending upon its design, a building may contain one living unit or several separate living units.  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.

6VAC35-41-400 (E). Toilet facilities.

E. There shall be at least one mirror securely fastened to the wall at a height appropriate for use in each room where hand basins are located.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: None

Compliance Determination:

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Observe mirrors

Applicable definitions: None.

6VAC35-41-400 (F). Toilet facilities.

F. When bathrooms are not designated for individual use:

1. Each toilet shall be enclosed for privacy, and
2. Bathtubs and showers shall provide visual privacy for bathing by use of enclosures, curtains, or other appropriate means.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: None

Compliance Determination: Observe bathrooms

Applicable definitions: None.

6VAC35-41-400 (G). Toilet facilities.

G. Windows in bathrooms and dressing areas shall provide for privacy.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: None

Compliance Determination: Observe windows

Applicable definitions: None.

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6VAC35-41-410 (A), (B), (C), (D), (E), (F), (G), & (H). Sleeping areas.

6VAC35-41-410 (A). Sleeping areas.

A. Males and females shall have separate sleeping areas.

Interpretation: Goal: To ensure privacy for male and female residents.

Additional information: Sleeping areas refer to sleeping rooms. Residents can sleep on the same wing or loaded corridor provided there are adequate provisions for privacy.

Compliance Determination:  Observe sleeping areas and the sex of the residents housed therein to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-410 (B). Sleeping areas.

B. No more than four residents shall share a bedroom or sleeping area.

Interpretation: Goal: To provide an environment conducive to sleep and rest.

Additional information: None

Compliance Determination: Observe sleeping areas to determine compliance with this section

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-410 (C). Sleeping areas.

C. Beds shall be at least three feet apart at the head, foot, and sides; and double-decker beds shall be at least five feet apart at the head, foot, and sides.

Interpretation: Goal: To ensure that space is safe and conducive to rest and sleep.

Additional information: Studies have shown that cold germs, viruses and similar contagious diseases are dispelled to a distance of slightly less than three feet. Placement of beds a minimum of three feet apart assists in reducing the spread of disease and the likelihood of residents being accidentally injured by rowdy play in an overcrowded area. Additional space is needed to allow adequate room when there are double-decker beds. It is a violation of this section if the specified distances are not maintained.

Compliance Determination:

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 The audit team will observe and/or measure the sleeping areas for facilities constructed after 1981. The audit team will observe the bed placement plan, and director or designee authorization, for facilities constructed before 1981.

Applicable definitions: None.

6VAC35-41-410 (D). Sleeping areas.

D. Sleeping quarters in facilities established, constructed, or structurally modified after July 1, 1981, shall have:

1. At least 80 square feet of floor area in a bedroom accommodating one person;
2. At least 60 square feet of floor area per person in rooms accommodating two or more persons; and
3. Ceilings with a primary height at least 7-1/2 feet in height exclusive of protrusions, duct work, or dormers.

Interpretation: Goal: To provide an environment conducive to sleep and rest.

Additional information: None

Compliance Determination: Observe sleeping areas Determine date Calculate space

Applicable definitions: None.

6VAC35-41-410 (E). Sleeping areas.

E. Mattresses shall be fire retardant as evidenced by documentation from the manufacturer except in buildings equipped with an automated sprinkler system as required by the Virginia Uniform Statewide Building Code (13VAC5-63).

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: The Consumer Product Safety Commission’s standard, 16 CRF 1633 became effective July 2007; mattress sets are required to meet the federal safety standard for open-flame fire resistance.

Compliance Determination:  Examine documentation from the manufacturer or observe the automated sprinkler system to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-410 (F). Sleeping areas.

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F. Each resident shall be assigned drawer space and closet space, or their equivalent that is accessible to the sleeping area for storage of clothing and personal belongings.

Interpretation: Goal: To provide space for personal items.

Additional information: Stand-a-lone units may replace closets.

Compliance Determination: Observe space to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-410 (G). Sleeping areas.

G. Windows in sleeping areas and dressing areas shall provide for privacy.

Interpretation: Goal: To provide for the privacy of residents.

Additional information: None

Compliance Determination: Observe windows to determine compliance with this section

Applicable definitions: None.

6VAC35-41-410 (H). Sleeping areas.

H. Every sleeping area shall have a door that may be closed for privacy or quiet and this door shall be readily opened in case of fire or other emergency.

Interpretation: Goal: To provide an environment conducive to privacy, sleep and rest.

Additional information: None

Compliance Determination:  Observe doors  Check to ensure that residents cannot be locked in their rooms to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.

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6VAC35-41-420. Furnishings.

6VAC35-41-420. Furnishings.

All furnishings and equipment shall be safe, clean, and suitable to the ages and number of residents.

Interpretation: Goal: To ensure a safe and healthy environment for residents

Additional information: None

Compliance Determination:  Observe the furnishings and equipment to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-430 (A) & (B). Disposal of garbage and management of hazardous materials.

6VAC35-41-430 (A). Disposal of garbage and management of hazardous materials.

A. Provision shall be made for the collection and legal disposal of all garbage and waste materials.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: None

Compliance Determination:   Observe provisions for the collection and disposal of garbage and waste to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-430 (B). Disposal of garbage and management of hazardous materials.

B. All flammable, toxic, medical, and caustic materials within the facility shall be stored, used, and disposed of in appropriate receptacles and in accordance with federal, state, and local requirements.

Interpretation: Goal: To ensure a safe and healthy environment for residents and staff.

Additional information: None

Compliance Determination:   Observe the receptacles in which flammable, toxic, medical, and caustic materials within the facility are stored, used, and disposed of to determine compliance with this section.  Review the hazard communication plan for the required components.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-440. Smoking prohibitions.

6VAC35-41-440. Smoking prohibitions.

Smoking shall be prohibited in living areas and in areas where residents participate in programs.

Interpretation: Goal: To ensure a safe and healthy environment for residents.

Additional information: Staff may not use tobacco products where residents may see or smell the use. The smell prohibition does not apply if staff returns to the facility with the scent of tobacco on his or her person after smoking.

Compliance Determination:

 Interview residents and ask about the facility’s procedures and practices regarding smoking  Interview staff to determine if there have been any instances of smoking in the living areas or areas where residents participate in programs during the audit period.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-450 (A) & (B). Space utilization.

6VAC35-41-450 (A). Space utilization.

A. Each facility shall provide for the following:

1. A living room;
2. An indoor recreation area with appropriate recreation materials;
3. An outdoor recreation area;
4. A dining area, where meals are served, that is equipped with tables and benches or chairs;
5. A visitation area that permits informal communication between residents and visitors, including the opportunity for physical contact in accordance with written procedures;
6. Kitchen facilities and equipment for the preparation and service of meals with any walk-in refrigerators or freezers equipped to permit emergency exits;
7. Space and equipment for laundry equipment, if laundry is done at the facility;
8. Space for the storage of items such as first aid equipment, household supplies, recreational equipment, luggage, out-of-season clothing, and other materials; and
9. Space for administrative activities including, as appropriate to the program, confidential conversations and provision for storage of records and materials.

Interpretation: Goal: To ensure that each facility maintain appropriate space and equipment to implement a program that meets the needs of the population being served.

Additional information: This subsection contains nine separate regulatory requirements. The facility will be assessed for each numerical subdivision as a separate standard.

Compliance Determination:  Observe the physical plant for compliance with each separate regulatory requirement.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-450 (B). Space utilization.

B. Spaces or areas may be interchangeably utilized but shall be in functional condition for the designated purposes.

Interpretation: Goal: Provides for the most cost effective use of space.

Additional information: None

Compliance Determination:

Interview staff regarding the functional condition of interchangeable spaces to determine compliance with this section.

Applicable definitions: None.

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6VAC35-41-460 (A), (B), & (C). Maintenance of the buildings and grounds.

6VAC35-41-460 (A). Maintenance of the buildings and grounds.

A. The interior and exterior of all buildings and grounds shall be safe, maintained, and reasonably free of clutter and rubbish. This includes, but is not limited to, (i) required locks, mechanical devices, indoor and outdoor equipment, and furnishings; and (ii) all areas where residents, staff, and visitors may reasonably be expected to have access.

Interpretation: Goal: To ensure a safe and secure environment for residents, staff and visitors.

Additional information: None

Compliance Determination:  Inspect the interior and exterior of the buildings and grounds for safety and cleanliness.  Inspect the condition of equipment and furnishings for safety and cleanliness.  Determine if mechanical devices are functioning properly and inspect for safety.  Determine if locks are functioning properly and inspect for safety.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-460 (B). Maintenance of the buildings and grounds.

B. All buildings shall be reasonably free of stale, musty, or foul odors.

Interpretation: Goal: To ensure a healthy environment.

Additional information: None

Compliance Determination:  Inspect the inside the buildings including closets and storage areas to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-460 (C). Maintenance of the buildings and grounds.

C. Buildings shall be kept reasonably free of flies, roaches, rats, and other vermin.

Interpretation: Goal: To ensure a safe and healthy environment.

Additional information: None

Compliance Determination:

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 Inspect the buildings for evidence of any condition conducive to harboring or breeding of flies, roaches, rats, and vermin.

Applicable definitions: None.

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6VAC35-41-470 (A), (B), (C), & (D). Animals on the premises.

6VAC35-41-470 (A). Animals on the premises.

A. Animals maintained on the premises shall be housed at a reasonable distance from sleeping, living, eating, and food preparation areas, as well as a safe distance from water supplies.

Interpretation: Goal: To ensure a safe and healthy environment.

Additional information: None

Compliance Determination:  Interview facility administrator and ask whether animals are maintained on the premises.  If applicable, determine if any animals maintained on the premises are housed at a reasonable distance to determine compliance with this section.

Applicable definitions:  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.

6VAC35-41-470 (B). Animals on the premises.

B. Animals maintained on the premises shall be tested, inoculated, and licensed as required by law.

Interpretation: Goal: To ensure a safe and healthy environment.

Additional information: None

Compliance Determination:  Review documentation of required testing, inoculations, and licensure to determine compliance with this section.

Applicable definitions:  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.

6VAC35-41-470 (C). Animals on the premises.

C. The premises shall be kept reasonably free of stray domestic animals.

Interpretation: Goal: To ensure a safe and healthy environment.

Additional information: Reasonably free means that stray animals are not housed, do not live, are not fed, or are not habitually present on the premises. Stray domestic animals include, but are not limited to, dogs, cats, etc.

Compliance Determination:  Inspect premises for evidence of stray domestic animals.

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Applicable definitions:  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.

6VAC35-41-470 (D). Animals on the premises.

D. Pets shall be provided with clean sleeping areas and adequate food and water.

Interpretation: Goal: To ensure a safe and healthy environment.

Additional information: None

Compliance Determination:  Interview facility administrator and ask whether the facility has any pets.  Observe sleeping areas and inspect for adequate food and water supplies.

Applicable definitions:  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.

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Part IV Safety and Security

6VAC35-41-480. Fire prevention plan.

6VAC35-41-480. Fire prevention plan.

Each facility shall develop a fire prevention plan that provides for an adequate fire protection service.

Interpretation: Goal: To ensure a safe environment.

Additional information: Plan should be developed with local fire authority.

Compliance Determination: Examine fire prevention plan and protection service.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-490 (A), (B), (C), (D), (E), (F), (G), (H), (I), (J), (K), & (L). Emergency and evacuation procedures.

6VAC35-41-490 (A). Emergency and evacuation procedures.

A. The provider shall develop a written emergency preparedness and response plan for each facility. The plan shall address:

1. Documentation of contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency;
2. Analysis of the provider's capabilities and potential hazards, including natural disasters, severe weather, fire, flooding, work place violence or terrorism, missing persons, severe injuries, or other emergencies that would disrupt the normal course of service delivery;
3. Written emergency management procedures outlining specific responsibilities for provision of administrative direction and management of response activities; coordination of logistics during the emergency; communications; life safety of employees, contractors, interns, volunteers, visitors and residents; property protection; community outreach; and recovery and restoration;
4. Written emergency response procedures for assessing the situation; protecting residents, employees, contractors, interns, volunteers, visitors, equipment and vital records; and restoring services. Emergency procedures shall address: a. Communicating with employees, contractors, and community responders; b. Warning and notification of residents; c. Providing emergency access to secure areas and opening locked doors; d. Conducting evacuations to emergency shelters or alternative sites and accounting for all residents; e. Relocating residents, if necessary; f. Notifying parents and legal guardians, as applicable and appropriate; g. Alerting emergency personnel and sounding alarms; h. Locating and shutting off utilities when necessary; and i. Providing for a planned, personalized means of effective egress for residents who use wheelchairs, crutches, canes, or other mechanical devices for assistance in walking.
5. Supporting documents that would be needed in an emergency, including emergency call lists, building and site maps necessary to shut off utilities, designated escape routes, and list of major resources such as local emergency shelters; and
6. Schedule for testing the implementation of the plan and conducting emergency preparedness drills.

Interpretation: Goal: To ensure that there are effective plans to respond to emergency situations and protect the life, health and safety of residents, staff, and visitors at the facility.

Additional information: Local Emergency Services Coordinator does not have to approve the plan but should be consulted regarding the plans of the facility and how the community might need to assist in the event of a major emergency.

Compliance Determination:  Examine the plan for required components to determine compliance with this section.  Review documentation of contact with the local emergency coordinator.

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Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-490 (B). Emergency and evacuation procedures.

B. The provider shall develop emergency preparedness and response training for all employees to ensure they are prepared to implement the emergency preparedness plan in the event of an emergency. Such training shall include the employees' responsibilities for:

1. Alerting emergency personnel and sounding alarms;
2. Implementing evacuation procedures, including evacuation of residents with special needs (i.e., deaf, blind, nonambulatory);
3. Using, maintaining, and operating emergency equipment;
4. Accessing emergency information for residents including medical information; and
5. Utilizing community support services.

Interpretation: Goal: To ensure that all employees are prepared to respond to emergency situations.

Additional information: Compliance with this provision will be measured under this subsection, and not under subsections 180 and 200.

Compliance Determination:

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 Review training records to ensure completion of required training components.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (C). Emergency and evacuation procedures.

C. Contractors and volunteers and interns shall be oriented in their responsibilities in implementing the emergency preparedness plan in the event of an emergency.

Interpretation: Goal: To ensure that all contactors and volunteers are prepared to respond to emergency situations.

Additional information: Compliance with this section will be measured under this section and not the three cited in this regulatory requirement.

Compliance Determination:  Examine documentation of required orientation of contractors and volunteers to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.

6VAC35-41-490 (D). Emergency and evacuation procedures.

D. The provider shall review and document the review of the emergency preparedness plan annually and make necessary revisions. Such revisions shall be communicated to employees, contractors, interns, and volunteers and incorporated into training for employees, contractors, interns, and volunteers and orientation of residents to services.

Interpretation: Goal: To ensure that the emergency plan is constantly reviewed and changed as needed.

Additional information: If deemed necessary during the review, the necessary revisions were made. If revisions were made to the emergency and evacuation procedures, examine documentation that (1) the changes were communicated to staff (i.e.: memorandum or training logs) and (2) the changes were incorporated into the applicable trainings and orientations.

Compliance Determination:

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 Interview staff to determine if changes were communicated to them, if applicable.  Review documentation of the annual review and, if deemed necessary  Review documentation of any changes.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (E). Emergency and evacuation procedures.

E. In the event of a disaster, fire, emergency, or any other condition that may jeopardize the health, safety, and welfare of residents, the provider shall take appropriate action to protect the health, safety, and welfare of the residents and to remedy the conditions as soon as possible.

Interpretation: Goal: To protect the life, health, safety and welfare of residents.

Additional information: None

Compliance Determination:  Ask the facility administrator if there were any applicable emergency situations. If there was an emergency situation, ask what actions were taken thereafter.  Assess to determine whether post-emergency actions were in compliance with this section. .

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (F). Emergency and evacuation procedures.

F. In the event of a disaster, fire, emergency, or any other condition that may jeopardize the health, safety, and welfare of residents, the provider should first respond and stabilize the disaster or emergency. After the disaster or emergency is stabilized, the provider shall report the disaster or emergency in accordance with 6VAC35-41-90 (serious incident reports).

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Interpretation: Goal: To protect the life, health, safety and welfare of residents.

Additional information: Incidents of this nature should be documented in BADGE via an SIR.

Compliance Determination:  Ask the facility administrator if there were any applicable emergency situations. If there was an emergency situation, ask what actions were taken thereafter.  Assess to determine whether post-emergency actions were in compliance with this section.  Examine the applicable serious incident report for compliance with this section and documentation that required reports were made.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (G). Emergency and evacuation procedures.

G. Floor plans showing primary and secondary means of emergency exiting shall be posted on each floor in locations where they can be seen easily by staff and residents.

Interpretation: Goal: To protect the life, health, safety and welfare of residents.

Additional information: The location of these plans may be recommended and specified by the local fire authority.

Compliance Determination:  Observe the floor plans for compliance.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (H). Emergency and evacuation procedures.

H. The responsibilities of the residents in implementing the emergency procedures shall be communicated to all residents within seven days following admission or a substantive change in the procedures.

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Interpretation: Goal: To ensure that residents have knowledge of how to respond to emergency situations.

Additional information: Communication to residents may be done through a resident orientation or through written materials.

Compliance Determination:  Review documentation of required communication to residents within the seven day timeframe.  Interview the facility administrator to determine if the responsibilities of the residents in the implementing the emergency procedures were communicated to all residents within seven days of admission or following any substantive change in the procedures to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (I). Emergency and evacuation procedures.

I. At least one evacuation drill (the simulation of the facility's emergency procedures) shall be conducted each month in each building occupied by residents. During any three consecutive calendar months, at least one evacuation drill shall be conducted during each shift.

Interpretation: Goal: To ensure that all residents and staff have practice in implementing evacuation drills.

Additional information: It is not required that staff awaken and evacuate sleeping children at night. Rather, the standard requires at a minimum that the staff quietly simulate the various duties they would carry out should there be an emergency. This would include simulating the activation of the alarm; simulating alerting emergency authorities; dispersing to evacuation duty stations; simulating the opening and closing of appropriate doors, e.g. having appropriate keys available, testing locks, etc.; and simulating other appropriate staff activities as required by the emergency plan.

Compliance Determination:  Examine documentation of required evacuation drills.  Interview staff to determine if evacuation drills was conducted during the audit period to determine compliance with this section.  If applicable, review any documentation of the evacuation drills.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster,

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taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (J). Emergency and evacuation procedures.

J. Evacuation drills shall include, at a minimum:

1. Sounding of emergency alarms;
2. Practice in evacuating buildings;
3. Practice in alerting emergency authorities;
4. Simulated use of emergency equipment; and
5. Practice in accessing resident emergency information.

Interpretation: Goal: To ensure the proper documentation of evacuation drills.

Additional information: None

Compliance Determination:  Interview staff to determine if each component of the evacuation drills was conducted.  Examine documentation of drills for required components.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-490 (K). Emergency and evacuation procedures.

K. A record shall be maintained for each evacuation drill and shall include the following:

1. Buildings in which the drill was conducted;
2. Date and time of drill;
3. Amount of time to evacuate the buildings;
4. Specific problems encountered;
5. Staff tasks completed including: a. Head count, and b. Practice in notifying emergency authorities; and
6. The name of the staff members responsible for conducting and documenting the drill and preparing the record.

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Interpretation: Goal: To ensure the proper documentation of evacuation drills.

Additional information: Specific problems encountered should be documented if there were any.

Leaving the items blank on the form would indicate that there no problems encountered.

Compliance Determination:  Examine documentation of drills for required components.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.

6VAC35-41-490 (L). Emergency and evacuation procedures.

L. The facility shall assign one staff member who shall ensure that all requirements regarding the emergency preparedness and response plan and the evacuation drill program are met.

Interpretation: Goal: To ensure that evacuation procedure are consistently implemented and reviewed.

Additional information: This standard requires the designation of a single individual to be responsible for the evacuation drill program. In large facilities with multiple units it may be appropriate to appoint one or more staff to conduct, supervise, and document individual evacuation drills. A single person must monitor those activities and take corrective action when appropriate.

Compliance Determination:  Interview the facility administrator to determine which staff member is assigned the responsibilities of this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-500. Contraband.

6VAC35-41-500. Contraband.

Written procedure shall provide for the control, detection, and disposition of contraband.

Interpretation: Goal: To ensure that there are established procedures for control, detection, and disposition of contraband.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section.

Applicable definitions:  "Contraband" means any item possessed by or accessible to a resident or found within a facility or on its premises (i) that is prohibited by statute, regulation, or facility procedure, (ii) that is not acquired through approved channels or in prescribed amounts, or (iii) that may jeopardize the safety and security of the facility or individual residents.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-510 (A), (B), (C), (D), & (E). Searches of residents.

6VAC35-41-510 (A). Searches of residents.

A. Each facility that conducts searches shall have procedures that provide that all searches shall be subject to the following:

1. Searches of residents' persons shall be conducted only for the purposes of maintaining facility security and controlling contraband while protecting the dignity of the resident.
2. Searches are conducted only by personnel who are authorized to conduct such searches.
3. The resident shall not be touched any more than is necessary to conduct the search.

Interpretation: Goal: To ensure that there are established procedures for staff action searches of residents.

Additional information: None

Compliance Determination:  Examine procedures for required components.

Applicable definitions:  "Contraband" means any item possessed by or accessible to a resident or found within a facility or on its premises (i) that is prohibited by statute, regulation, or facility procedure, (ii) that is not acquired through approved channels or in prescribed amounts, or (iii) that may jeopardize the safety and security of the facility or individual residents.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-510 (B). Searches of residents.

B. Facilities that do not conduct searches of residents shall have a procedure prohibiting them.

Interpretation: Goal: To ensure that there are established procedures for staff action searches of residents.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section, if applicable.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-510 (C). Searches of residents.

C. Patdown and frisk searches shall be conducted by personnel of the same sex as the resident being

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searched, except in emergencies.

Interpretation: Goal: To ensure that searches of residents shall be conducted only for the purposes of maintaining facility security and controlling contraband while protecting the dignity of the resident.

Additional information: None

Compliance Determination:  Examine procedure.  Interview staff to determine if searches are conducted only by staff of the same sex, except in emergencies.  Interview residents to determine if searches are conducted only by staff of the same sex, except in emergencies.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-510 (D). Searches of residents.

D. Strip searches and visual inspections of the vagina and anal cavity areas shall only be permitted (i) if ordered by a court; (ii) if conducted by law-enforcement personnel acting in his official capacity; or (iii) if the facility obtains the approval of the regulatory authority to conduct such searches. A facility that conducts such searches shall have a procedure that provides that the searches shall be subject to the following:

1. The search shall be performed by personnel of the same sex as the resident being searched;
2. The search shall be conducted in an area that ensures privacy; and
3. Any witness to the search shall be of the same sex as the resident.

Interpretation: Goal: To avoid any unnecessary force, embarrassment, or indignity to the resident.

Additional information: Visual inspection means the examination of the vagina and anal cavity without touching the examined area.

Compliance Determination:  Interview facility administrator to determine if strip searches or visual cavity inspections are conducted at the facility.  If such searches have been conducted ask for required approvals.  Examine procedure for required components.  If applicable, interview staff to determine if strip searches and visual cavity inspections comply with the requirements of this section.  If applicable, interview residents to determine if strip searches and visual cavity inspections comply with the requirements of this section.

Applicable definitions:

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 "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Regulatory authority" means the board or the department as designated by the board.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-510 (E). Searches of residents.

E. Manual and instrumental searches of the anal cavity or vagina shall be prohibited unless court ordered.

Interpretation: Interpretation: Goal: To avoid any unnecessary force, embarrassment, or indignity to the resident.

Additional information: None

Compliance Determination: Interview facility administrator to determine if any manual or instrumental searches of the anal cavity or vagina were conducted during the audit period.

If so, examine documentation of valid court order.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-520 (A), (B), & (C). Telephone access and emergency numbers.

6VAC35-41-520 (A). Telephone access and emergency numbers.

A. There shall be at least one continuously operable, nonpay telephone accessible to staff in each building in which residents sleep or participate in programs.

Interpretation: Goal: To ensure that residents have a safe and secure environment.

Additional information: The intent of this standard is for all staff to have access to a telephone as a means to communicate in each living unit and separate areas for programs or activities.

Compliance Determination:  Observe and test operation of telephone.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-520 (B). Telephone access and emergency numbers.

B. There shall be an emergency telephone number where a staff person may be immediately contacted 24 hours a day.

Interpretation: Goal: To ensure a means of constant communication.

Additional information: None

Compliance Determination:  Interview facility administrator to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.

6VAC35-41-520 (C). Telephone access and emergency numbers.

C. An emergency telephone number shall be provided to residents and the adults responsible for their care when a resident is away from the facility and not under the supervision of direct care staff or law-enforcement officials.

Interpretation:

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Goal: To ensure that when residents are away from the facility there is an effective means of communication to report significant events.

Additional information: None

Compliance Determination:  Interview the facility administrator to determine compliance with this section.  Interview residents to determine compliance with this section.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-530. Internet access.

6VAC35-41-530. Internet access.

Facilities that allow resident access to the Internet shall have procedures governing such usage.

Interpretation: Goal: To ensure the appropriate and supervised use of internet resources.

Additional information: None

Compliance Determination:  Examine procedure governing usage of the internet.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-540 (A) & (B). Weapons.

6VAC35-41-540 (A). Weapons.

A. The possession, use, and storage of weapons in facilities or on the premises where residents are reasonably expected to have access are prohibited except when specifically authorized by statutes or regulations or provided in subsection B of this section. For the purpose of this section, weapons shall include, but will not be limited to, (i) any pistol, revolver, or other weapon intended to propel a missile of any kind by action of an explosion; (ii) any dirk, bowie knife, except a pocket knife having a folding metal blade of less than three inches, switchblade knife, ballistic knife, machete, straight razor, slingshot, spring stick, metal knucks, or blackjack; (iii) nunchucks or other flailing instrument with two or more rigid parts that swing freely; and (iv) throwing star or oriental dart.

Interpretation: Goal: To ensure that residents have a safe and secure environment.

Additional information: None

Compliance Determination:  Examine the procedure to determine compliance with this section.  Interview facility administrator to determine compliance with this section.

Applicable definitions:  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-540 (B). Weapons.

B. Weapons shall be permitted if they are in the possession of a licensed security personnel or law-enforcement officer while in the course of his duties.

Interpretation: Goal: To ensure that residents have a safe and secure environment.

Additional information: None

Compliance Determination:  Examine the procedure.  Interview facility administrator if there were any instances of weapons on the premises.  Determine if any instances of weapons on the premises were in compliance with this section.

Applicable definitions: None.

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6VAC35-41-550 (A), (B), & (C). Transportation.

6VAC35-41-550 (A). Transportation.

A. It shall be the responsibility of the facility to have transportation available or to make the necessary arrangements for routine and emergency transportation.

Interpretation: Goal: To ensure a timely and proper response to emergencies.

Additional information: The does not require the facility to own or operate vehicles, provided it has made arrangements for routine and emergency transportation.

Compliance Determination:  Interview staff about how transportation is provided in routine and emergency situations.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-550 (B). Transportation.

B. There shall be written safety rules for transportation of residents and, if applicable, for the use and maintenance of vehicles.

Interpretation: Goal: To ensure residents are transported in a safe manner and properly maintained vehicles.

Additional information: “Use and maintenance of vehicles” includes, but is not limited to, a preventative maintenance and inspection plan (i.e.: oil changes and scheduling required inspections).

Compliance Determination:  Review the rules for (1) transportation of residents and (2) vehicle use and maintenance.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-550 (C). Transportation.

C. The facility shall have a procedure for the verification of appropriate licensure for staff whose duties

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involve transporting residents.

Interpretation: Goal: To ensure the safety of residents.

Additional information: None

Compliance Determination:  Examine the procedure to see if it provides for the verification of licensure for staff that transports residents.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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Part V Residents' Rights

6VAC35-41-560. Prohibited actions.

6VAC35-41-560. Prohibited actions.

The following actions are prohibited:

1. Discrimination in violation of the Constitution of the United States, the Constitution of the Commonwealth of Virginia, and state and federal statutes and regulations.

1. Deprivation of drinking water or food necessary to meet a resident's daily nutritional needs, except as ordered by a licensed physician for a legitimate medical purpose and documented in the resident's record;

1. Denial of contacts and visits with the resident's attorney, a probation officer, the department, regulatory authority, a supervising agency representative, or representatives of other agencies or groups as required by applicable statutes or regulations;

1. Bans on contacts and visits with family or legal guardians, except as permitted by other applicable state regulations or by order of a court of competent jurisdiction;

1. Any action that is humiliating, degrading, or abusive, including but not limited to physical abuse, sexual abuse, and sexual harassment;

1. Corporal punishment, which is administered through the intentional inflicting of pain or discomfort to the body through actions such as, but not limited to (i) striking or hitting with any part of the body or with an implement; (ii) pinching, pulling, or shaking; or (iii) any similar action that normally inflicts pain or discomfort;

1. Subjection to unsanitary living conditions;

1. Denial of opportunities for bathing or access to toilet facilities, except as ordered by a licensed physician for a legitimate medical purpose and documented in the resident's record;

1. Denial of health care;

10. Deprivation of appropriate services and treatment;

11. Application of aversive stimuli, except as permitted pursuant to other applicable state regulations. Aversive stimuli means any physical forces (e.g., sound, electricity, heat, cold, light, water, or noise) or substances (e.g., hot pepper, pepper sauce, or pepper spray) measurable in duration and intensity that when applied to a resident are noxious or painful to the individual;

12. Administration of laxatives, enemas, or emetics, except as ordered by a licensed physician or poison control center for a legitimate medical purpose and documented in the resident's record;

13. Deprivation of opportunities for sleep or rest, except as ordered by a licensed physician for a legitimate medical purpose and documented in the resident's record;

14. Placement of a resident alone in a locked room or a secured area where the resident is prevented from leaving;

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15. Use of mechanical restraints (e.g., handcuffs, waist chains, leg irons, disposable plastic cuffs, leather restraints, or a restraint chair);

16. Use of pharmacological restraints; and

17. Other constitutionally prohibited actions.

Interpretation: Goal: To ensure the proper care, protection, and treatment of residents.

Additional information: Each subdivision constitutes a separate regulatory requirement.

Compliance Determination:  Interview facility administrator or designee to determine if any resident was subject to a prohibited action.  Ask whether any charges or lawsuits were filed against staff for any prohibited action.  Interview a sample of residents to determine if any prohibited actions have occurred.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Department" or "DJJ" means the Department of Juvenile Justice.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Regulatory authority" means the board or the department as designated by the board.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-71-565 (A), (B), & (C). Vulnerable populations.

6VAC35-71-565 (A). Vulnerable populations A. The facility shall implement a procedure for assessing whether a resident is a member of a vulnerable population.

Interpretation:

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Goal: To ensure the proper care, protection, and treatment of residents.

Additional information: Refer to definition in 565 (C).

Compliance Determination: Review procedure Review documentation of assessments Interview superintendent or designee to determine how the procedure is implemented.

6VAC35-71-565 (B). Vulnerable populations B. If the assessment determines a resident is a vulnerable population, the facility shall implement any identified additional precautions such as heightened need for supervision, additional safety precautions, or separation from certain other residents. The facility shall consider on a case-by-case basis whether a placement would ensure the resident’s health and safety and whether the placement would present management or security problems.

Interpretation: Goal: To ensure the proper care, protection, and treatment of residents.

Additional information: Refer to definition in 565 (C).

Compliance Determination: Review assessments Review additional plan of care (e.g. Heightened need for supervision, additional safety precautions, or separation from certain other residents).

Review documentation of any founded grievances where plans for members of a vulnerable population were not implemented.

6VAC35-71-565 (C). Vulnerable populations C. For the purposes of this section, vulnerable populations means a resident or group of residents who have been assessed to be reasonably likely to be exposed to the possibility of being attacked or harmed, either physically or emotionally (e.g., very young residents; residents who are small in stature; residents who have limited English proficiency; residents who are gay, lesbian, bi-sexual, transgender, or intersex; residents with a history of being bullied or of self-injurious behavior).

Interpretation: Goal: To define vulnerable populations.

Additional information: None

6VAC35-41-570 (A), (B), (C), (D), (E), (F), (G), (H), (I) & (J). Residents' mail.

6VAC35-41-570 (A). Residents' mail.

A. A resident's incoming or outgoing mail may be delayed or withheld only in accordance with this section or as permitted by other applicable regulations or by order of a court.

Interpretation: Goal: To ensure the proper handling of resident’s mail.

Additional information: None

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Compliance Determination:  Interview staff responsible for processing mail to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-570 (B). Residents' mail.

B. In accordance with written procedures, staff may open and inspect residents' incoming and outgoing nonlegal mail for contraband. When based on legitimate facility interests of order and security, nonlegal mail may be read, censored, or rejected. In accordance with written procedures, the resident shall be notified when incoming or outgoing letters are withheld in part or in full.

Interpretation: Goal: To ensure the proper processing of resident’s mail.

Additional information: None

Compliance Determination:  Review procedure for required components.  Interview staff responsible for processing mail and ask about compliance with this section.  Interview the facility administrator to determine which, if any, residents had their non-legal mail withheld during the audit period.  If applicable, interview a sample of these residents to determine if they were notified of withheld mail.

Applicable definitions:  "Contraband" means any item possessed by or accessible to a resident or found within a facility or on its premises (i) that is prohibited by statute, regulation, or facility procedure, (ii) that is not acquired through approved channels or in prescribed amounts, or (iii) that may jeopardize the safety and security of the facility or individual residents.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-570 (C). Residents' mail.

C. In the presence of the recipient and in accordance with written procedures, staff may open to inspect for contraband, but shall not read, legal mail. Legal mail shall mean any written material that is sent to or received from a designated class of correspondents, as defined in procedures, which shall include any court, legal counsel, administrators of the grievance system, or administrators of the department, facility, provider, or governing authority.

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Interpretation: Goal: To ensure the proper processing of resident’s mail.

Additional information: Department administrators refer to Central Office personnel.

Compliance Determination:  Examine procedure for required components.  Interview staff responsible for processing mail to determine compliance with this section.  Interview the facility administrator to determine which, if any, residents had their legal mail opened and inspected for contraband during the audit period.  If applicable, interview a sample of these residents to determine if they were present when their legal mail was inspected.

Applicable definitions:  "Contraband" means any item possessed by or accessible to a resident or found within a facility or on its premises (i) that is prohibited by statute, regulation, or facility procedure, (ii) that is not acquired through approved channels or in prescribed amounts, or (iii) that may jeopardize the safety and security of the facility or individual residents.  "Department" or "DJJ" means the Department of Juvenile Justice.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-570 (D). Residents' mail.

D. Staff shall not read mail addressed to parents, immediate family members, legal guardian, guardian ad litem, counsel, courts, officials of the committing authority, public official, or grievance administrators unless permission has been obtained from a court or the facility administrator has determined that there is a reasonable belief that the security of a facility is threatened. When so authorized, staff may read such mail only in the presence of a witness and in accordance with written procedures.

Interpretation: Goal: To ensure the proper processing of resident’s mail.

Additional information: None

Compliance Determination:  Review procedures.  Interview staff responsible for processing mail to determine compliance with this section.  Interview the facility administrator to determine if mail described in this section was read by staff in accordance with this section.

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Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-570 (E). Residents' mail.

E. Except as otherwise provided in this section, incoming and outgoing letters shall be held for no more than 24 hours and packages for no more than 48 hours, excluding weekends and holidays.

Interpretation: Goal: To ensure the proper processing of resident’s mail.

Additional information: None

Compliance Determination:  Interview staff responsible for processing mail to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-570 (F). Residents' mail.

F. Cash, stamps, and other specified items may be held for the resident.

Interpretation:

Goal: To ensure the residents have the means by with to have written communications.

Additional information: None

Compliance Determination:  Interview the facility’s accounting or business department staff to determine compliance with this section.

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Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-570 (G). Residents' mail.

G. Upon request, each resident shall be given postage and writing materials for all legal correspondence and at least two other letters per week.

Interpretation:

Goal: To ensure the residents have the means by with to have written communications.

Additional information: None

Compliance Determination:  Interview staff and residents

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-570 (H). Residents' mail.

H. Residents shall be permitted to correspond at their own expense with any person or organization provided such correspondence does not pose a threat to facility order and security and is not being used to violate or to conspire to violate the law.

Interpretation:

Goal: To ensure residents have the means by which to have written communications.

Additional information: None

Compliance Determination:  Interview the facility administrator to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-570 (I). Residents' mail.

I. First class letters and packages received for residents who have been transferred or released shall be forwarded.

Interpretation: Goal: To ensure the proper processing of resident’s mail.

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Additional information: None

Compliance Determination:  Interview staff responsible for processing to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-570 (J). Residents' mail.

J. Written procedure governing correspondence of residents shall be made available to all staff and residents and shall be reviewed annually and updated as needed.

Interpretation:

Goal: To ensure the residents and staff have working knowledge of proper processing of mail.

Additional information: None

Compliance Determination:  Review the procedures in accordance with this section.  Ask a sample of staff about availability of the procedure  Ask a sample of residents about availability of the procedure

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-580. Telephone calls.

6VAC35-41-580. Telephone calls.

Residents shall be permitted reasonable access to a telephone in accordance with procedures that take into account the need for facility security and order, resident behavior, and program objectives.

Interpretation: Goal: To ensure the right of residents to have telephonic communications with approved persons.

Additional information: None

Compliance Determination:  Review procedures to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-590 (A) & (B). Visitation.

6VAC35-41-590 (A). Visitation.

A. Residents shall be permitted to reasonable visiting privileges, consistent with written procedures, that take into account (i) the need for security and order, (ii) the behavior of individual residents and visitors, (iii) the importance of helping the resident maintain strong family and community ties, (iv) the welfare of the resident; and (v) whenever possible, flexible visiting hours.

Interpretation: Goal: To ensure that residents maintain contact with family.

Additional information: None

Compliance Determination:  Review procedures, applicable regulations and court orders to determine compliance with this section.  Ask a sample of residents regarding visitation practices. Review any instances for compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-590 (B). Visitation.

B. Copies of the written visitation procedures shall be made available to the parents, when appropriate, legal guardians, the resident, and other interested persons important to the resident no later than the time of admission except that when parents or legal guardians do not participate in the admission process, visitation procedures shall be mailed, either electronically or via first class mail, to them by the close of the next business day after admission, unless a copy has already been provided to the individual.

Interpretation: Goal: To ensure that residents maintain contact with family.

Additional information: None

Compliance Determination:  Interview facility administrator to determine how and when visitation procedures are made available to family members and residents.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and

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responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-600 (A), (B), & (C). Contact with attorneys, courts, and law enforcement.

6VAC35-41-600 (A). Contact with attorneys, courts, and law enforcement.

A. Residents shall have uncensored, confidential contact with their legal representative in writing, as provided for in 6VAC35-41-570 (residents' mail), by telephone, or in person.

Interpretation: Goal: To ensure that residents have unimpeded access to their legal representative.

Additional information: Legal representative refers to the resident’s personal representative with legal standing. This generally will be an attorney who has agreed to represent a resident in legal proceedings or a guardian ad litem who has been appointed to represent the resident’s best interest in legal proceedings.

Compliance Determination:  Interview facility administrator to determine compliance with this section.  Interview residents to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-600 (B). Contact with attorneys, courts, and law enforcement.

B. Residents shall not be denied access to the courts.

Interpretation: Goal: To ensure that residents have unimpeded access to the legal system.

Additional information: None

Compliance Determination:  Interview facility administrator to determine compliance with this section.  Interview residents to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-600 (C). Contact with attorneys, courts, and law enforcement.

C. Residents shall not be required to submit to questioning by law enforcement, though they may do so voluntarily.

1. Residents' consent shall be obtained prior to any contact with law enforcement.
2. No employee may coerce a resident's decision to consent to have contact with law enforcement.
3. Each facility shall have procedures for establishing a resident's consent to any such contact and for documenting the resident's decision. The procedures may provide for (i) notification of the

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parent or legal guardian, as appropriate and applicable, prior to the commencement of questioning; and (ii) opportunity, at the resident's request, to confer with an attorney, parent or guardian, or other person in making the decision whether to consent to questioning.

Interpretation: Goal: To protect the residents from coercion by staff or law enforcement.

Additional information: None

Compliance Determination:  Review written procedures to determine compliance with this section.  Interview residents to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-610 (A), (B), (C), (D), & (E). Personal necessities and hygiene.

6VAC35-41-610 (A). Personal necessities and hygiene.

A. At admission, each resident shall be provided the following:

1. An adequate supply of personal necessities for hygiene and grooming;
2. A separate bed equipped with a mattress, a pillow, blankets, bed linens, and, if needed, a waterproof mattress cover; and
3. Individual washcloths and towels.

Interpretation: Goal: To ensure that resident’s basic needs are met upon their arrival at the JDC.

Additional information: At admission means within a reasonable period of time after arrival at the facility and assignment to a living unit.

Compliance Determination:  Interview staff to determine compliance with this section.  Interview residents and ask whether listed items were provided at admission.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-610 (B). Personal necessities and hygiene.

B. At the time of issuance, all items shall be clean and in good repair.

Interpretation: Goal: To ensure that resident’s basic needs are met upon their arrival at the JDC.

Additional information: Nome

Compliance Determination:  Interview residents and ask if all items were clean and in good repair.

Applicable definitions: None.

6VAC35-41-610 (C). Personal necessities and hygiene.

C. Personal necessities shall be replenished as needed.

Interpretation: Goal: To ensure that resident’s basic needs are met upon their arrival at the JDC.

Additional information: Personnel necessities would be those furnished by the facility and may not be the personal preference of the resident.

Compliance Determination:  Ask residents about the replenishment of items.

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Applicable definitions: None.

6VAC35-41-610 (D). Personal necessities and hygiene.

D. The washcloths, towels, and bed linens shall be cleaned or changed, at a minimum, once every seven days and more often, if needed. Bleach or another sanitizing agent approved by the federal Environmental Protection Agency to destroy bacteria shall be used in the laundering of such linens and table linens.

Interpretation: Goal: To ensure that bedding and bathing items are sanitized after being used by one resident prior to being used by another resident so as to prevent the transmission of bacteria or parasites from one resident to another.

Additional information: According to health department officials, any product containing chlorine bleach (laundry bleach with an active ingredient of 5.25% sodium hypochlorite) is a sanitizing agent. If a commercial or state operated laundry is used, the facility shall be deemed to be in compliance with this standard. There are also appropriate non-bleach sanitizers.

Compliance Determination:  Interview staff and ask about the cleaning/changing routine.  Interview residents and ask about the cleaning/changing routine.  Identify the Environmental Protection Agency-approved sanitizing agent.

Applicable definitions: None.

6VAC35-41-610 (E). Personal necessities and hygiene.

E. Staff shall promote good personal hygiene of residents by monitoring and supervising hygiene practices each day and by providing instruction when needed.

Interpretation: Goal: To ensure residents are educated in proper hygiene.

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-620. Showers.

6VAC35-41-620. Showers.

Residents shall have the opportunity to shower daily, except when a declaration of a state of emergency due to drought conditions has been issued by the Governor or water restrictions have been issued by the locality. Under these exceptional circumstances showers shall be restricted as determined by the facility administrator after consultation with local health officials. The alternate schedule implemented under these exceptional circumstances shall account for cases of medical necessity related to health concerns and shall be in effect only until such time as the water restrictions are lifted.

Interpretation: Goal: To ensure acceptable level of personal hygiene.

Additional information: None

Compliance Determination:  Interview residents and facility administrator to determine compliance with this section.

Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-630 (A), (B), (C), & (D). Clothing.

6VAC35-41-630 (A). Clothing.

A. Provision shall be made for each resident to have an adequate supply of clean and size-appropriate clothing and shoes for indoor and outdoor wear.

Interpretation: Goal: To ensure the provision of adequate clothing.

Additional information: None

Compliance Determination:  Interview residents to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-630 (B). Clothing.

B. Clothes and shoes shall be similar in style to those generally worn by individuals of the same age in the community who are engaged in similar activities.

Interpretation: Goal: To ensure that residents blend in with the community standards.

Additional information: None

Compliance Determination:  Observe clothing to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-630 (C). Clothing.

C. Residents shall have the opportunity to participate in the selection of their clothing.

Interpretation: Goal: To ensure that residents blend in with the community standards.

Additional information: Where residents have personal funds they may select suitable clothing by purchases. Where the facility furnishes clothing residents may select from the variety offered by the facility.

Compliance Determination:  Interview residents and staff to determine compliance with this section.

Applicable definitions:

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 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-630 (D). Clothing.

D. Residents shall be allowed to take personal clothing when leaving the facility.

Interpretation: Goal: To ensure that residents have access to personal property.

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-640. Residents' privacy.

6VAC35-41-640. Residents' privacy.

Residents shall be provided privacy while bathing, dressing, or conducting toileting activities. This section does not apply to medical personnel performing medical procedures or to staff providing assistance to residents whose physical or mental disabilities dictate the need for assistance with these activities as justified in the resident's record.

Interpretation: Goal: To ensure that residents’ privacy is protected from routine sight supervision by staff in accordance with this section.

Additional information: Privacy means the residents’ genitalia and the breasts of female residents are not observed through routine staff supervision.

Compliance Determination: Interview staff and residents to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-650 (A), (B), (C), (D), (E), & (F). Nutrition.

6VAC35-41-650 (A). Nutrition.

A. Each resident, except as provided in subsection B of this section, shall be provided a daily diet that (i) consists of at least three nutritionally balanced meals and an evening snack, (ii) includes an adequate variety and quantity of food for the age of the resident, and (iii) meets any applicable federal nutritional requirements.

Interpretation: Goal: To ensure resident daily diets include nutritionally balanced meals served in accordance with this section.

Additional information: DJJ Food Operations Manager conducts USDA audits for compliance with this section and his findings will be used as the basis for compliance determination.

Compliance Determination:  Interview residents to determine compliance with the provision of three meals and an evening snack each day.  Review menus for compliance with this section.  Review the results of USDA audits of the facility.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-650 (B). Nutrition.

B. Special diets or alternative dietary schedules, as applicable, shall be provided in the following circumstances: (i) when prescribed by a physician or (ii) when necessary to observe the established religious dietary practices of the resident. In such circumstances, the meals shall meet the minimum nutritional requirements of the U.S. Dietary Guidelines.

Interpretation: Goal: To ensure that special meals meet the minimum nutritional requirements of all applicable federal dietary requirements, such as U.S.D.A.

Additional information: None

Compliance Determination:  Ask facility administrator if any special diets or alternate dietary schedules were required during the audit period.  Interview Food Operations Manager for USDA compliance with special or alternative dietary requirements.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-650 (C). Nutrition.

C. Menus of actual meals served shall be kept on file for at least six months.

Interpretation: Goal: To ensure proper retention of records of meals served.

Additional information: None

Compliance Determination:  Review menu files to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-650 (D). Nutrition.

D. Staff who eat in the presence of the residents shall be served the same meals as the residents unless a special diet has been prescribed by a physician for the staff or residents or the staff or residents are observing established religious dietary practices.

Interpretation: Goal: To ensure residents are subjected to a consistent environment.

Additional information: None

Compliance Determination:  Interview staff and residents to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-650 (E). Nutrition.

E. There shall not be more than 15 hours between the evening meal and breakfast the following day, except when the facility administrator approves an extension of time between meals on weekends and holidays. When an extension is granted on a weekend or holiday, there shall never be more than 17 hours between the evening meal and breakfast.

Interpretation: Goal: To ensure that meals are served in an acceptable time frame.

Additional information: None

Compliance Determination:  Interview the facility administrator to determine compliance with this section.

Applicable definitions:

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 "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.

6VAC35-41-650 (F). Nutrition.

F. Providers shall assure that food is available to residents who for documented medical or religious reasons need to eat breakfast before the 15 hours have expired.

Interpretation: Goal: To ensure that nutritional needs of residents are met.

Additional information: It is not the intent of this standard that a full breakfast be served before the regularly scheduled breakfast. However, food such as fruit or cereal should be available. It is not the intent of this standard that a full breakfast be served before the regularly scheduled breakfast. However, food such as fruit or cereal should be available.

Compliance Determination:  Interview staff to determine if a resident required breakfast before the expiration of the 15 hours.

If applicable, interview residents to determine compliance with this section.

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-660 (A) & (B). School enrollment and study time.

6VAC35-41-660 (A). School enrollment and study time.

A. The facility shall make all reasonable efforts to enroll each resident of compulsory school attendance age in an appropriate educational program within five school business days after admission and in accordance with § 22.1-254 of the Code of Virginia and Regulations Governing the Reenrollment of Students Committed to the Department of Juvenile Justice (8VAC20-660), if applicable. Documentation of the enrollment and any attempt to enroll the resident shall be maintained in the resident's record.

Interpretation: Goal: To ensure that residents receive a proper education.

Additional information: § 22.1-254 of the Code of Virginia and Regulations Governing the Reenrollment of Students Committed to the Department of Juvenile Justice (8VAC20-660)

Compliance Determination:  Examine documentation of enrollment

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-660 (B). School enrollment and study time.

B. Each provider shall develop and implement written procedures to ensure that each resident has adequate study time.

Interpretation: Goal: To ensure that residents receive a proper education.

Additional information: None

Compliance Determination:  Examine procedure  Interview residents

Applicable definitions:

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 "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-670 (A) & (B). Religion.

6VAC35-41-670 (A). Religion.

A. Residents shall not be required or coerced to participate in or be unreasonably denied participation in religious activities.

Interpretation: Goal: To protect the rights of residents.

Additional information: An individual, as guaranteed by the United States Constitution, has a right to follow his own conscience in matters of religion. Participation in religious practices must be a personal decision left to the discretion of the resident and the resident’s family or legal guardian. Resident’s come from a variety of religious backgrounds. Facilities should respect the religious beliefs of a resident who may have a different faith background than the sponsors of the facility and are encouraged to provide opportunities for that resident to practice his faith.

Residents being locked in their rooms when they elect not to attend a religious activity would be deemed as punishment and coercive. Residents not attending the activity are to be engaged in other meaningful activities.

Compliance Determination:  Interview a sample of residents to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-670 (B). Religion.

B. The provider's procedures on religious participation shall be available to residents and any individual or agency considering placement of an individual in the facility.

Interpretation: Goal: To protect the rights of residents.

Additional information: An individual, as guaranteed by the United States Constitution, has a right to follow his own conscience in matters of religion. Participation in religious practices must be a personal decision left to the discretion of the resident and the resident’s family or legal guardian. Resident’s come from a variety of religious backgrounds. Facilities should respect the religious beliefs of a resident who may have a different faith background than the sponsors of the facility and are encouraged to provide opportunities for that resident to practice his faith.

Compliance Determination:  Review orientation checklist in a sample of case files.  Review procedures related to this section.  Interview residents to determine compliance with this section.

Applicable definitions:

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 "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-680 (A), (B), (C), & (D). Recreation.

6VAC35-41-680 (A). Recreation.

A. The provider shall have a written description of its recreation program that describes activities that are consistent with the facility's total program and with the ages, developmental levels, interests, and needs of the residents that includes:

1. Opportunities for individual and group activities, both structured and unstructured;
2. Use of available community recreational resources and facilities;
3. Scheduling of activities so that they do not conflict with meals, religious services, educational programs, or other regular events; and
4. Regularly scheduled indoor and outdoor recreational activities that are structured to develop skills and attitudes.

Interpretation: Goal: To ensure that residents have opportunities for age appropriate recreation.

Additional information: The provision of outdoor activities should be included in the recreation plan. The recreation plan should be developed and supervised by a person trained in recreation or a related field. Assess how large muscle activities are provided daily.

Compliance Determination:  Review the written description of the facility’s recreation program.  Ask staff about compliance with this section  Review recreation plan for required elements.  Review recreation schedule for compliance with the plan.  If outdoor recreation is not provided in accordance with the plan, examine documentation of conditions preventing its occurrence.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-680 (B). Recreation.

B. The provider shall develop and implement written procedures to ensure the safety of residents participating in recreational activities that include:

1. How activities will be directed and supervised by individuals knowledgeable in the safeguards required for the activities;

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1. How residents are assessed for suitability for an activity and the supervision provided; and
2. How safeguards for water related activities will be provided, including ensuring that a certified life guard supervises all swimming activities.

Interpretation: Goal: To ensure that residents are medically approved and that there are safeguards for water safety.

Additional information: The life guard does not have to be a facility staff member. Life guards are certified for different swimming activities. Some lifeguards are certified to provide services at swimming pools while other life guards are certified to provide services for open water activities, such as swimming at the beach, in a lake or in a river. Providers will need to ensure that facility provided life guards are certified for the type of activity being conducted. The American Red Cross can provide additional information regarding life guards.

Compliance Determination:  Review procedure for components and compliance with this section.

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-680 (C). Recreation.

C. For all overnight recreational trips away from the facility, the provider shall document trip planning to include:

1. A supervision plan for the entire duration of the activity including awake and sleeping hours;
2. A plan for safekeeping and distribution of medication;
3. An overall emergency, safety, and communication plan for the activity including emergency numbers of facility administration;
4. Staff training and experience requirements for each activity;
5. Resident preparation for each activity;
6. A plan to ensure that all necessary equipment for the activity is in good repair and appropriate for the activity;
7. A trip schedule giving addresses and phone numbers of locations to be visited and how the location was chosen and evaluated;
8. A plan to evaluate residents' physical health throughout the activity and to ensure that the activity is conducted within the boundaries of the resident's capabilities, dignity, and respect for self-determination;
9. A plan to ensure that a certified life guard supervises all swimming activities in which residents participate; and 10. Documentation of any variations from trip plans and reason for the variation.

Interpretation: Goal: To ensure that trips are well planned meeting the safety needs of residents.

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Additional information: When determining the level and nature of supervision to be provided, the decision must be based on a consideration of the ages, developmental levels, interests, and needs of the residents as well as the type of activities involved. As residents involved in recreational activities are exposed to potential injuries, altercations and other dangers that put them at risk, it is the intent of this standard that competent adult supervision is provided during facility sponsored recreational activities in order to minimize problems.

Compliance Determination:  Examine the recreation plan  Review documentation of trip plan to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-680 (D). Recreation.

D. All overnight out-of-state or out-of-country recreational trips require written permission from each resident's legal guardian. Documentation of the written permission shall be kept in the resident's record.

Interpretation: Goal: To ensure that trips are well planned meeting the safety needs of residents.

Additional information: None

Compliance Determination:  If applicable, review written documentation to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a

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biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-690 (A) & (B). Residents' funds.

6VAC35-41-690 (A). Residents' funds.

A. The provider shall implement written procedures for safekeeping and for recordkeeping of any money that belongs or is provided to residents, including allowances, if applicable.

Interpretation: Goal: To provide for the safe keeping of residents’ funds.

Additional information: "Residents' funds" means the personal funds of individual residents, not facility programming funds.

Compliance Determination:  Examine procedure.  Review written procedures to determine compliance with this section.  Interview facility administrator regarding implementation of this procedure to determine compliance with this section.

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-690 (B). Residents' funds.

B. A resident's funds, including any allowance or earnings, shall be used for the resident's benefit, for payments ordered by a court, or to pay restitution for damaged property or personal injury as determined by disciplinary procedures.

Interpretation: Goal: To provide for the safe keeping of residents’ funds.

Additional information: "Residents' funds" means the personal funds of individual residents, not facility programming funds.

Compliance Determination: Interview the facility administrator to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-700. Fundraising.

6VAC35-41-700. Fundraising.

The provider shall not use residents in its fundraising activities without the written permission of the legal guardian and the consent of residents.

Interpretation: Goal: To ensure the confidentiality of residents.

Additional information: Fundraising event often result in disclosure of the place of confinement and identity of residents.

Compliance Determination:  Interview facility administrator to determine if there have been any fundraising events during the audit period.  Review written permission if applicable.

Applicable definitions:

 "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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Part VI Program Operation Article 1 Admission, Transfer, and Discharge

6VAC35-41-710. Placement pursuant to a court order.

6VAC35-41-710. Placement pursuant to a court order.

When a resident is placed in a facility pursuant to a court order, the following requirements shall be met by maintaining a copy of a court order in the resident's case record:

1. 6VAC35-41-730 (application for admission).
2. 6VAC35-41-740 (admission procedures).
3. 6VAC35-41-750 (written placement agreement).
4. 6VAC35-41-780 (emergency admissions).
5. 6VAC35-41-810 (discharge procedures).

Interpretation: Goal: Defines ways residents are admitted to the facility by legal means.

Additional information: Compliance will be assessed in the five above areas.

Compliance Determination:  Review sample of residents’ case records for valid court order.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-720 (A) & (B). Readmission to a shelter care program.

6VAC35-41-720 (A). Readmission to a shelter care program.

A. When a resident is readmitted to a shelter care facility within 30 days from discharge, the following requirements shall not apply:

1. 6VAC35-41-730 (application for admission).
2. 6VAC35-41-740 (admission procedures).

Interpretation: Goal: Defines readmission requirements.

Additional information: Compliance assessed in those areas.

Compliance Determination:  None

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Shelter care facility" means a facility or an emergency shelter specifically approved to provide a range of services, as needed, on an individual basis not to exceed 90 days.

6VAC35-41-720 B). Readmission to a shelter care program.

B. When a resident is readmitted to a shelter care facility within 30 days from discharge, the facility shall:

1. Review and update all information on the face sheet as provided in 6VAC35-41-340 (face sheet);
2. Complete a health screening in accordance with 6VAC35-41-1200 (health screening at admission);
3. Complete required admission and orientation process as provided in 6VAC35-41-760 (admission); and
4. Update in the case record any other information regarding the resident that has changed since discharge.

Interpretation: Goal: To ensure that readmissions are properly documented.

Additional information: None

Compliance Determination:  Examine documentation in each area.  Review sample of documentation to determine compliance with this section.

Applicable definitions:

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 "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Shelter care facility" means a facility or an emergency shelter specifically approved to provide a range of services, as needed, on an individual basis not to exceed 90 days.

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6VAC35-41-730 (A), (B), & (C). Application for admission.

6VAC35-41-730 (A). Application for admission.

A. Except for placements pursuant to a court order or resulting from a transfer between residential facilities located in Virginia and operated by the same governing authority, all admissions shall be based on evaluation of an application for admission.

Interpretation: Goal: To ensure there is an application for admission that contains information necessary to determine placement.

Additional information: None

Compliance Determination:  Examine documentation to determine compliance with this section.

Applicable definitions:  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.

6VAC35-41-730 (B). Application for admission.

B. Providers shall develop and fully complete, prior to acceptance for care, an application for admission that is designed to compile information necessary to determine:

1. The educational needs of the prospective resident;
2. The mental health, emotional, and psychological needs of the prospective resident;
3. The physical health needs, including the immunization needs, of the prospective resident;
4. The protection needs of the prospective resident;
5. The suitability of the prospective resident's admission;
6. The behavior support needs of the prospective resident; and
7. Information necessary to develop a service plan and a behavior support plan.

Interpretation: Goal: To ensure there is an application for admission that contains information necessary to determine placement.

Additional information: None

Compliance Determination:  Examine documentation in a sample of case files to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.

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 "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-730 (C). Application for admission.

C. Each facility shall develop and implement written procedures to assess each prospective resident as part of the application process to ensure that:

1. The needs of the prospective resident can be addressed by the facility's services;
2. The facility's staff are trained to meet the prospective resident's needs; and
3. The admission of the prospective resident would not pose any significant risk to (i) the prospective resident or (ii) the facility's residents or staff.

Interpretation: Goal: To ensure there is an application for admission that contains information necessary to determine placement.

Additional information: None

Compliance Determination:  Review procedure to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-740 (A) & (B). Admission procedures.

6VAC35-41-740 (A). Admission procedures.

A. Except for placements pursuant to a court order, the facility shall admit only those residents who are determined to be compatible with the services provided through the facility.

Interpretation: Goal: To ensure that only residents compatible with the services provided through the facility are admitted to the program.

Additional information: None

Compliance Determination:  Examine documentation in sample of case files to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-740 (B). Admission procedures.

B. The facility's written criteria for admission shall include the following:

1. A description of the population to be served;
2. A description of the types of services offered;
3. Intake and admission procedures;
4. Exclusion criteria to define those behaviors or problems that the facility does not have the staff with experience or training to manage; and
5. Description of how educational services will be provided to the population being served.

Interpretation: Goal: To ensure clearly defined admission criteria.

Additional information: None

Compliance Determination:  Review written admission criteria to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is

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not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-750 (A) & (B). Written placement agreement.

6VAC35-41-750 (A). Written placement agreement.

A. Except for placements pursuant to a court order or when a resident admits himself to a shelter care facility, each resident's record shall contain, prior to a routine admission, a completed placement agreement signed by a facility representative and the legal guardian or placing agency. Routine admission means the admittance of a resident following evaluation of an application for admission and execution of a written placement agreement.

Interpretation: Goal: To ensure there is an agreement setting forth the right and responsibilities of all parties.

Additional information: None

Compliance Determination:  Examine documentation in a sample of case files to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Shelter care facility" means a facility or an emergency shelter specifically approved to provide a range of services, as needed, on an individual basis not to exceed 90 days.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-750 (B). Written placement agreement.

B. The written placement agreements shall:

1. Authorize the resident's placement;
2. Address acquisition of and consent for any medical treatment needed by the resident;
3. Address the rights and responsibilities of each party involved;
4. Address financial responsibility for the placement;
5. Address visitation with the resident; and
6. Address the education plan for the resident and the responsibilities of all parties.

Interpretation: Goal: To define the contents of a placement agreement.

Additional information: Formats may differ but at a minimum must contain the above.

Compliance Determination;  Examine documentation of placement agreements in a sample of case files to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-760 (A) & (B). Admission.

6VAC35-41-760 (A). Admission.

A. Written procedure governing the admission and orientation of residents to the facility shall provide for:

1. Verification of legal authority for placement;
2. Search of the resident and the resident's possessions, including inventory and storage or disposition of property, as appropriate;
3. Health screening;
4. Notification of parents and legal guardians, as applicable and appropriate, including of (i) admission, (ii) visitation, and (iii) general information, including how the resident's parent or legal guardian may request information and register concerns and complaints with the facility.

The facility shall ask the parent or legal guardian regarding whether the resident has any immediate medical concerns or conditions;

1. Interview with resident to answer questions and obtain information;
2. Explanation to resident of program services and schedules;
3. An orientation on the residents' rights including, but not limited to, the prohibited actions provided for in 6VAC35-41-560 (prohibited actions); and
4. Assignment of resident to a housing unit or room.

Interpretation: Goal: To ensure that residents are properly admitted to the facility.

Additional information: None

Compliance Determination:  Review procedure to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-760 (B). Admission.

B. When a resident is readmitted to a shelter care facility within 30 days from discharge, the facility shall update the information required in subsection A of this section.

Interpretation: Goal: To ensure that resident information is accurate.

Additional information: None

Compliance Determination:  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Shelter care facility" means a facility or an emergency shelter specifically approved to provide a range of services, as needed, on an individual basis not to exceed 90 days.

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6VAC35-41-770 (A) & (B). Orientation to facility rules and disciplinary procedures.

6VAC35-41-770 (A). Orientation to facility rules and disciplinary procedures.

A. During the orientation to the facility, residents shall be given written information describing facility rules, the sanctions for rule violations, and the facility's disciplinary process. These shall be explained to the resident and documented by the dated signature of resident and staff.

Interpretation: Goal: To ensure that residents understand rules.

Additional information: None

Compliance Determination:  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-770 (B). Orientation to facility rules and disciplinary procedures.

B. Where a language or literacy problem exists that can lead to a resident misunderstanding the facility rules and regulations, staff or a qualified person under the supervision of staff shall assist the resident.

Interpretation: Goal: To ensure that residents understand rules.

Additional information: None

Compliance Determination:  Interview residents and staff to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-780. Emergency admissions.

6VAC35-41-780. Emergency admissions.

Providers accepting emergency admissions, which are the unplanned or unexpected admission of a resident in need of immediate care excluding self-admittance to a shelter care facility or a court ordered placement, shall:

1. Develop and implement written procedures governing such admissions that shall include procedures to make and document prompt efforts to obtain (i) a written placement agreement signed by the legal guardian or (ii) the order of a court;
2. Place in each resident's record the order of a court, a written request for care or documentation of an oral request for care, and justification of why the resident is to be admitted on an emergency basis; and
3. Except placements pursuant to court orders, clearly document in written assessment information gathered for the emergency admission that the individual meets the facility's criteria for admission.

Interpretation: Goal: To ensure that emergency admissions are properly assessed.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.

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 "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Shelter care facility" means a facility or an emergency shelter specifically approved to provide a range of services, as needed, on an individual basis not to exceed 90 days.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-790 (A) & (B). Resident transfer between residential facilities located in Virginia and operated by the same governing authority.

6VAC35-41-790 (A). Resident transfer between residential facilities located in Virginia and operated by the same governing authority.

A. Except for transfers pursuant to a court order, when a resident is transferred from one to another facility operated by the same provider or governing authority the sending facility shall provide the receiving facility, at the time of transfer, a written summary of (i) the resident's progress while at the facility; (ii) the justification for the transfer; (iii) the resident's current strengths and needs; and (iv) any medical needs, medications, and restrictions and, if necessary, instructions for meeting these needs.

Interpretation: Goal: To ensure the proper transfer between facilities the documentation needed to address needs of residents.

Additional information: A city, county, or commission may operate a variety of programs.

Compliance Determination:  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-790 (B). Resident transfer between residential facilities located in Virginia and operated by the same governing authority.

B. Except for transfers pursuant to a court order, when a resident is transferred from one to another facility operated by the same provider or governing authority the receiving facility shall document at the time of transfer:

1. Preparation through sharing information with the resident, the family and the placing agency about the facility, the staff, the population served, activities, and criteria for admission;
2. Notification to the family, if appropriate; the resident, the placement agency, and the legal guardian; and
3. Receipt of the written summary from the sending facility required by subsection A of this section.

Interpretation:

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Goal: To ensure the proper transfer between facilities the documentation needed to address needs of residents.

Additional information: A city, county, or commission may operate a variety of programs.

Compliance Determination:  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-800. Placement of residents outside the facility.

6VAC35-41-800. Placement of residents outside the facility.

A resident shall not be placed outside the facility prior to the facility obtaining a placing agency license from the Department of Social Services, except as permitted by statute or by order of a court of competent jurisdiction.

Interpretation: Goal: To ensure that a facility placing resident outside the facility is legally authorized to do so.

Additional information: Virginia DSS can be contacted for an explanation of the process.

Compliance Determination:  Examine documentation for any such cases to determine compliance with this section.  Determine if facility has a placing agency license to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-810 (A), (B), (C), & (D). Discharge procedures.

6VAC35-41-810 (A). Discharge procedures.

A. The provider shall have written criteria for discharge that shall include:

1. Criteria for a resident's completing the program that are consistent with the facility's programs and services;
2. Conditions under which a resident may be discharged before completing the program; and
3. Procedures for assisting placing agencies in placing the residents should the facility cease operation.

Interpretation: Goal: To ensure there is a discharge criteria consistent for all residents.

Additional information: None

Compliance Determination:  Review written criteria to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-810 (B). Discharge procedures.

B. The provider's criteria for discharge shall be accessible to prospective residents, legal guardians, and placing agencies.

Interpretation: Goal: To ensure there is a discharge criteria consistent for all residents.

Additional information: None

Compliance Determination:  Interview residents to determine compliance with this section.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person

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judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-810 (C). Discharge procedures.

C. Residents shall be discharged only to the legal guardian, legally authorized representative, or foster parent with the written authorization of a representative of the legal guardian. Residents over the age of 17 or who have been emancipated may assume responsibility for their own discharge.

Interpretation: Goal: To ensure there is a legal discharge for all residents.

Additional information: None

Compliance Determination:  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-810 (D). Discharge procedures.

D. As appropriate and applicable, information concerning current medications, need for continuing therapeutic interventions, educational status, and other items important to the resident's continuing care shall be provided to the legal guardian or legally authorized representative, as appropriate.

Interpretation: Goal: To ensure that the continuing needs of the resident are identified and transmitted to appropriate persons.

Additional information: None

Compliance Determination:  Examine documentation in case files.  Interview the facility administrator to determine compliance with this section.

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Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-820 (A) & (B). Discharge documentation.

6VAC35-41-820 (A). Discharge documentation.

A. Except for residents discharged pursuant to a court order, the case record shall contain the following:

1. Documentation that discharge planning occurred prior to the planned discharge date;
2. Documentation that discussions with the parent or legal guardian, placing agency, and resident regarding discharge planning occurred prior to the planned discharge date;
3. A written discharge plan developed prior to the planned discharge date; and
4. As soon as possible, but no later than 30 days after discharge, a comprehensive discharge summary placed in the resident's record and sent to the placing agency. The discharge summary shall review the following: a. Services provided to the resident; b. The resident's progress toward meeting service plan objectives; c. The resident's continuing needs and recommendations, if any, for further services and care; d. Reasons for discharge and names of persons to whom resident was discharged; e. Dates of admission and discharge; and f. Date the discharge summary was prepared and the signature of the person preparing it.

Interpretation: Goal: To ensure that the services provided to the resident are properly documented.

Additional information: None

Compliance Determination:  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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 "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-820 (B). Discharge documentation.

B. When a resident is discharged pursuant to a court order, the case record shall contain a copy of the court order.

Interpretation: Goal: To document the legal discharge of the resident.

Additional information: None

Compliance Determination:  Examine documentation in case files for valid court order to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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Article 2 Programs and Services

6VAC35-41-840 (A), (B), & (C). Structured programming.

6VAC35-41-840 (A). Structured programming.

A. Each facility shall implement a comprehensive, planned, and structured daily routine, including appropriate supervision designed to:

1. Meet the residents' physical and emotional needs;
2. Provide protection, guidance, and supervision;
3. Ensure the delivery of program services; and
4. Meet the objectives of any individual service plan.

Interpretation: Goal: To ensure there is a program designed to meet the needs of the residents.

Additional information: None

Compliance Determination:  Examine program description  Examine the daily routine  Observe how program is implemented  Observe services delivered pursuant to plan  Compare service plan objectives and determine if program is providing those services  Observe if the programs provides a safe and secure environment  Interview facility administrator to determine implementation of a daily routine.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-840 (B). Structured programming.

B. Each facility shall have goals, objectives, and strategies consistent with the facility's mission and program objectives utilized when working with all residents until the residents' individualized service plans are developed. These goals, objectives, and strategies shall be provided to the residents in writing during orientation to the facility.

Interpretation: Goal: To ensure that residents immediately enter a program with structured objectives.

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Additional information: None

Compliance Determination:  Examine documentation of initial goals and objectives given to the resident at orientation in a sample of case files.  Interview residents to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-840 (C). Structured programming.

C. Residents shall be allowed to participate in the facility's programs, as applicable, upon admission.

Interpretation: Goal: To ensure that residents immediately enter the structured program.

Additional information: Residents need to immediately be involved in program to ensure a smooth adjustment to the program and routine.

Compliance Determination:  Interview staff and residents to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-850 (A), (B), & (C). Daily log.

6VAC35-41-850 (A). Daily log.

A. A daily communication log shall be, in accordance with facility procedures, maintained to inform staff of significant happenings or problems experienced by residents.

Interpretation: Goal: To ensure a process where staff can document the activities of residents.

Additional information: A daily communication log is a necessary tool to past information from shift to shift.

Compliance Determination:  Examine procedure to determine compliance with this section.  Examine documentation in daily logs to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-850 (B). Daily log.

B. The date and time of the entry and the identity of the individual making each entry shall be recorded.

Interpretation: Goal: To ensure a process where staff can document the activities of residents.

Additional information: A daily communication log is a necessary tool to past information from shift to shift.

Compliance Determination:  Review a sample of documentation in daily logs to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-850 (C). Daily log.

C. If the facility records log book-type information on a computer, all entries shall post the date, time, and identity of the person making an entry. The computer shall prevent previous entries from being overwritten.

Interpretation: Goal: To ensure a secure electronic documentation process.

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Additional information: None

Compliance Determination:  Interview staff and ask for demonstration to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-860 (A), (B), (C), (D), (E), (F), & (G). Individual service plan.

6VAC35-41-860 (A). Individual service plan.

A. An individual service plan shall be developed and placed in the resident's record within 30 days following admission and implemented immediately thereafter. The initial individual service plan shall be distributed to the resident; the resident's family, legal guardian, or legally authorized representative; the placing agency; and appropriate facility staff.

Interpretation: Goal: To ensure that a plan is developed to address the needs of the resident.

Additional information: It is important to distribute the plan to all involved parties that may play an important role in the delivery of services to the resident.

Compliance Determination:  Examine documentation in case files.  Review sample of case files for development and timing of the individual service plan.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-860 (B). Individual service plan.

B. Individual service plans shall describe in measurable terms the:

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1. Strengths and needs of the resident;
2. Resident's current level of functioning;
3. Goals, objectives, and strategies established for the resident including a behavior support plan, if appropriate;
4. Projected family involvement;
5. Projected date for accomplishing each objective; and
6. Status of the projected discharge plan and estimated length of stay except that this requirement shall not apply to a facility that discharges only upon receipt of the order of a court of competent jurisdiction.

Interpretation: Goal: To ensure the development of a service plan that meets the need of the resident.

Additional information: None

Compliance Determination:  Examine documentation is a sample of case files

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-860 (C). Individual service plan.

C. Each service plan shall include the date it was developed and the signature of the person who developed it.

Interpretation: Goal: To ensure the development of a service plan that meets the need of the resident.

Additional information: None

Compliance Determination:  Examine documentation is a sample of case files.  Review sample of individual service plans for the required date and signature to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan

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specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.

6VAC35-41-860 (D). Individual service plan.

D. The service plan shall be reviewed within 60 days of the development of the plan and within each 90-day period thereafter. The individual service plan shall be revised as necessary. Any changes to the plan shall be made in writing. All participants shall receive copies of the revised plan.

Interpretation: Goal: To ensure the review of the service plan to determine if revisions are needs to assess progress of the resident.

Additional information: None

Compliance Determination:  Examine documentation is a sample of case files.  Review sample of individual service plans to determine compliance with this section.  Interview participants to determine if they received copies of any revised plan.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.

6VAC35-41-860 (E). Individual service plan.

E. The resident and facility staff shall participate in the development of the individual service plan.

Interpretation: Goal: To ensure that appropriate parties participate in the development of the plan.

Additional information: None

Compliance Determination:  Examine documentation in a sample of case files.  Interview residents and staff to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-860 (F). Individual service plan.

F. The (i) supervising agency and (ii) resident's parents, legal guardian, or legally authorized representative, if appropriate and applicable, shall be given the opportunity to participate in the development of the resident's individual service plan.

Interpretation: Goal: To ensure that appropriate parties participate in the development of the plan.

Additional information: None

Compliance Determination:  Examine documentation in a sample of case files  Interview the facility administrator to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-860 (G). Individual service plan.

G. Copies of the individual service plan shall be provided to the (i) resident; (ii) parents or legal guardians, as appropriate and applicable, and (iii) the placing agency.

Interpretation: Goal: To ensure that appropriate parties notified of the plan.

Additional information: None

Compliance Determination:  Examine documentation in a sample of case files.  Interview sample of residents and facility administrator to determine compliance with this section.

Applicable definitions:

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 "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-870 (A), (B), & (C). Quarterly reports.

6VAC35-41-870 (A). Quarterly reports.

A. Except when a resident is placed in a shelter care program, the resident's progress toward meeting his individual service plan goals shall be reviewed and a progress report shall be prepared within 60 days of the development of the plan and within each 90-day period thereafter and shall review the status of the following:

1. Resident's progress toward meeting the plan's objectives;
2. Family's involvement;
3. Continuing needs of the resident;
4. Resident's progress towards discharge; and
5. Status of discharge planning.

Interpretation: Goal: To ensure there is a timely review of the plan to assess progress and identify needed changes.

Additional information: None

Compliance Determination:  Review a sample of case files to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-870 (B). Quarterly reports.

B. Each quarterly progress report shall include the date it was developed and the signature of the person who developed it.

Interpretation: Goal: To ensure there is a timely review of the plan to assess progress and identify needed changes.

Additional information: None

Compliance Determination:  Examine documentation and review a sample of quarterly reports to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-870 (C). Quarterly reports.

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C. All quarterly progress reports shall be distributed to the resident; the resident's family, legal guardian, or legally authorized representative; the placing agency; and appropriate facility staff.

Interpretation: Goal: To ensure there is a distribution of progress report to the parties involved in the plan.

Additional information: None

Compliance Determination:  Examine documentation is a sample of case files.  Interview a sample of residents to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-880. Therapy

6VAC35-41-880. Therapy.

Therapy, if provided, shall be provided by an individual (i) licensed as a therapist by the Department of Health Professions or (ii) who is licensure eligible and working under the supervision of a licensed therapist unless exempted from these requirements under the Code of Virginia.

Interpretation: Goal: To ensure that qualified professional provide therapy.

Additional information: See § 54.1-3501 of the Code of Virginia

Compliance Determination:  Examine documentation of licensure or documentation that individual is under the supervision of licensed therapist to determine compliance with this section.

Applicable definitions: None.

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6VAC35-41-890 (A), (B), (C), & (D). Community relationships.

6VAC35-41-890 (A). Community relationships.

A. Opportunities shall be provided for the residents to participate in activities and to utilize resources in the community.

Interpretation: Goal: To ensure that the individual in integrated into the normal activities of other youth in the community.

Additional information: None

Compliance Determination:  Interview staff and residents to determine compliance with this section. 

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-890 (B). Community relationships.

B. In addition to the requirements of 6VAC35-41-290 (background checks for volunteers or interns), written procedures shall govern how the facility will determine if participation in such community activities or programs would be in the residents' best interest.

Interpretation: Goal: To ensure that community activities are appropriate.

Additional information: None

Compliance Determination:  Review written procedure to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-890 (C). Community relationships.

C. Each facility shall have a staff community liaison who shall be responsible for facilitating cooperative relationships with neighbors, the school system, local law enforcement, local government officials, and the community at large.

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Interpretation: Goal: To ensure an integration of community resources into the program’s services.

Additional information: Facility administrator can perform this function or delegate to a staff member.

Compliance Determination:  Interview community liaison to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-890 (D). Community relationships.

D. Each provider shall develop and implement written procedures for promoting positive relationships with the neighbors that shall be approved by the department.

Interpretation: Goal: To ensure an integration of community resources into the program’s services.

Additional information: None

Compliance Determination:  Review written procedure to determine compliance with this section.

Applicable definitions:  "Department" or "DJJ" means the Department of Juvenile Justice.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-900. Resident visitation at the homes of staff.

6VAC35-41-900. Resident visitation at the homes of staff.

Resident visitation at the homes of staff is prohibited unless written permission from the (i) resident's parent or legal guardian, as applicable and appropriate, (ii) the facility administrator, and (iii) the placing agency is obtained before the visitation occurs. The written permission shall be kept in the resident's record.

Interpretation: Goal: To ensure that staff interaction with residents is appropriate and approved.

Additional information: None

Compliance Determination:  Interview facility administrator to determine if there were any instances of a resident visiting the home of any staff member during the audit period.  If applicable, review required documentation to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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Article 3 Supervision

6VAC35-41-910. Additional assignments of direct care staff.

6VAC35-41-910. Additional assignments of direct care staff.

If direct care staff assume nondirect care responsibilities, such responsibilities shall not interfere with the staff's direct care duties.

Interpretation: Goal: To ensure that the facility has adequate support functions.

Additional information: Residents “assist” in support functions as long as it is part of the established structure program.

Compliance Determination:  Interview residents and direct care staff.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.

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6VAC35-41-920 (A), (B), (C), (D), (E), & (F). Staff supervision of residents.

6VAC35-41-920 (A). Staff supervision of residents.

A. No member of the direct care staff shall be on duty and responsible for the direct care of residents more than six consecutive days without a rest day, except in an emergency. For the purpose of this section, a rest day shall mean a period of not less than 24 consecutive hours during which a staff person has no responsibility to perform duties related to the operation of the facility.

Interpretation: Goal: To ensure that direct care staff receives adequate rest.

Additional information: Facility administrators need to be aware of FLSA requirements.

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-920 (B). Staff supervision of residents.

B. Direct care staff shall have an average of at least two rest days per week in any four-week period.

Interpretation: Goal: To ensure that direct care staff receives adequate rest.

Additional information: Facility administrators need to be aware of FLSA requirements.

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:

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 "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-920 (C). Staff supervision of residents.

C. Direct care staff shall not be on duty more than 16 consecutive hours, except in an emergency.

Interpretation: Goal: To ensure that direct care staff receives adequate rest.

Additional information: Facility administrators need to be aware of FLSA requirements.

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-920 (D). Staff supervision of residents.

D. There shall be at least one trained direct care staff on duty and actively supervising residents at all times that one or more residents are present.

Interpretation: Goal: To ensure adequate supervision of residents.

Additional information: Actively supervising means staff is not engaged in other activities that distract their attention when there is only one staff on duty.

Compliance Determination:  Interview facility administrator to determine compliance with this section.  Review a sample of training records, duty rosters and timesheets.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.

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 "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-920 (E). Staff supervision of residents.

E. Whenever residents are being supervised by staff there shall be at least one staff person present with a current basic certification in standard first aid and a current certificate in cardiopulmonary resuscitation issued by a recognized authority.

Interpretation: Goal: To ensure that staff are available to respond to emergencies.

Additional information: None

Compliance Determination:  Review documentation in training records to determine compliance with this section.  Review sample of duty rosters for those with current certifications

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-920 (F). Staff supervision of residents.

F. The provider shall develop and implement written procedures that address staff supervision of residents including contingency plans for resident illnesses, emergencies, off-campus activities, and resident preferences. These procedures shall be based on the:

1. Needs of the population served;
2. Types of services offered;
3. Qualifications of staff on duty; and
4. Number of residents served.

Interpretation: Goal: To ensure clearly defined procedures to address staff supervision requirements.

Additional information: None

Compliance Determination:  Review procedure to determine compliance with this section.  Interview staff to determine compliance with this section.  Examine procedure

Applicable definitions:  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.

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 "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-930 (A), (B), (C), & (D). Staffing pattern.

6VAC35-41-930 (A). Staffing pattern.

A. During the hours that residents are scheduled to be awake, there shall be at least one direct care staff member awake, on duty, and responsible for supervision of every 10 residents, or portion thereof, on the premises or participating in off-campus, facility sponsored activities, except that independent living programs shall have at least one direct care staff member awake, on duty, and responsible for supervision of every 15 residents on the premises or participating in off-campus, facility sponsored activities.

Interpretation: Goal: To ensure adequate supervision of residents.

Additional information: None

Compliance Determination:  Review a sample of duty rosters and compare with the number of residents at the facility to determine compliance with this section.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-930 (B). Staffing pattern.

B. During the hours that residents are scheduled to sleep there shall be no less than one direct care staff member on duty and responsible for supervision of every 16 residents, or portion thereof, on the premises.

Interpretation: Goal: To ensure adequate supervision of residents.

Additional information: None

Compliance Determination:  Review a sample of duty rosters and compare with the number of residents at the facility to determine compliance with this section.

Applicable definitions:

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 "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.  "Premises" means the tracts of land on which any part of a facility is located and any buildings on such tracts of land.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-930 (C). Staffing pattern.

C. There shall be at least one direct care staff member on duty and responsible for the supervision of residents in each building where residents are sleeping. This requirement does not apply to approved independent living programs.

Interpretation: Goal: To ensure adequate supervision of residents.

Additional information: Depending upon its design, a building may contain one living unit or several separate living units.

Compliance Determination: Review a sample of duty roster and shift status reports to determine compliance with this section.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-930 (D). Staffing pattern.

D. On each floor where residents are sleeping, there shall be at least one direct care staff member awake and on duty for every 30 residents or portion thereof.

Interpretation: Goal: To ensure that staff are available to respond to emergencies.

Additional information: None

Compliance Determination:  Review documentation in training records.  Review sample of duty rosters for those with current certifications.  Compare with number of residents at the facility.

Applicable definitions:

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 "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "On duty" means the period of time an employee is responsible for the direct supervision of one or more residents.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-940 (A) & (B). Outside personnel working in the facility.

6VAC35-41-940 (A). Outside personnel working in the facility.

A. Facility staff shall monitor all situations in which outside personnel perform any kind of work in the immediate presence of residents in the facility.

Interpretation: Goal: To ensure a safe and secure environment for residents.

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-940 (B). Outside personnel working in the facility.

B. Adult inmates shall not work in the immediate presence of any resident and shall be monitored in a way that there shall be no direct contact between or interaction among adult inmates and residents.

Interpretation: Goal: To ensure a safe and secure environment for residents.

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:

“Adult inmate” means an individual who is 18 years or older who is incarcerated with the Department of Corrections.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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Part VII Work Programs

6VAC35-41-950 (A), (B), (C), & (D). Work and employment.

6VAC35-41-950 (A). Work and employment.

A. Assignment of chores that are paid or unpaid work assignments shall be in accordance with the age, health, ability, and service plan of the resident.

Interpretation: Goal: To ensure a structured program of care that meets the needs of the residents.

Additional information: None

Compliance Determination:  Interview facility administrator to determine compliance with this section.  Review a sample of service plans for residents to determine if there are work assignments and if they are appropriate.  Interview residents about chores and work assignments to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-950 (B). Work and employment.

B. Chores shall not interfere with school programs, study periods, meals, or sleep.

Interpretation: Goal: To ensure a structured program of care that meets the needs of the residents.

Additional information: None

Compliance Determination:  Interview educational staff and residents to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-950 (C). Work and employment.

C. Work assignments or employment outside the facility, including reasonable rates of pay, shall be approved by the facility administrator with the knowledge and consent of the parent or legal guardian as appropriate and applicable.

Interpretation:

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Goal: To ensure that residents work in an appropriate environment and are paid properly.

Additional information: None

Compliance Determination:  Interview facility administrator to determine compliance with this section.  Examine documentation of notification to appropriate legal guardian.

Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.

6VAC35-41-950 (D). Work and employment.

D. In both work assignments and employment the facility administrator shall evaluate the appropriateness of the work and the fairness of the pay.

Interpretation: Goal: To ensure that residents work in an appropriate environment and are paid properly.

Additional information: None

Compliance Determination:  Interview facility administrator to determine compliance with this section.

Applicable definitions:  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.

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Part VIII Independent Living Programs

6VAC35-41-960 (A) & (B). Independent living programs.

6VAC35-41-960 (A). Independent living programs.

A. Independent living programs shall be a competency based program, specifically approved by the board to provide the opportunity for the residents to develop the skills necessary to become independent decision makers, to become self-sufficient adults, and to live successfully on their own following completion of the program.

Interpretation: Goal: To ensure the appropriate design of an Independent Living Program.

Additional information: The design should be based on an acceptable competency based design.

Compliance Determination:  Examine program to determine compliance with this section.  Examine documentation of approval to determine compliance with this section.

Applicable definitions:  "Board" means Board of Juvenile Justice.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-960 (B). Independent living programs.

B. Independent living programs shall have a written description of the curriculum and methods used to teach living skills, which shall include finding and keeping a job, managing personal finances, household budgeting, hygiene, nutrition, and other life skills.

Interpretation: Goal: Establishes the basic element of an Independent Living Program

Additional information: None

Compliance Determination:  Examine program for the required elements to determine compliance with this section.  Review curriculum.

Applicable definitions:  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-970 (A), (B), & (C). Independent living programs curriculum and assessment.

6VAC35-41-970 (A). Independent living programs curriculum and assessment.

A. Each independent living program must demonstrate that a structured program using materials and curriculum approved by the board is being used to teach independent living skills. The curriculum must include information regarding each of the areas listed in subsection B of this section.

Interpretation: Goal: To ensure that the Independent Living Program provides the structure and appropriate curriculum.

Additional information: None

Compliance Determination:  Examine documentation of curriculum approval

Applicable definitions:  "Board" means Board of Juvenile Justice.

6VAC35-41-970 (B). Independent living programs curriculum and assessment.

B. Within 14 days of placement the provider must complete an assessment, including strengths and needs, of the resident's life skills using an independent living assessment tool approved by the department. The assessment must cover the following areas:

1. Money management and consumer awareness;
2. Food management;
3. Personal appearance;
4. Social skills;
5. Health and sexuality;
6. Housekeeping;
7. Transportation;
8. Educational planning and career planning;
9. Job seeking skills; 10. Job maintenance skills; 11. Emergency and safety skills; 12. Knowledge of community resources; 13. Interpersonal skills and social relationships; 14. Legal skills; 15. Leisure activities; and 16. Housing.

Interpretation: Goal: To ensure there is an assessment is completed, including strengths and needs, of the resident's life skills using an independent living assessment tool approved by the department.

Additional information: Assessment tool must be approved by the department.

Compliance Determination:  Examine assessment tool to determine compliance with this section.  Examine documentation in a sample of case files to determine compliance with this section.

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Applicable definitions:  "Department" or "DJJ" means the Department of Juvenile Justice.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-970 (C). Independent living programs curriculum and assessment.

C. The resident's individualized service plan shall include, in addition to the requirements found in 6VAC35-41-860 (individual service plan), goals, objectives, and strategies addressing each of the areas listed in subsection B of this section, as applicable.

Interpretation: Goal: To ensure the development of a service plan that meets the need of the resident.

Additional information: 860 includes

1. Strengths and needs of the resident;
2. Resident's current level of functioning;
3. Goals, objectives, and strategies established for the resident including a behavior support plan, if appropriate;
4. Projected family involvement;
5. Projected date for accomplishing each objective; and
6. Status of the projected discharge plan and estimated length of stay except that this requirement shall not apply to a facility that discharges only upon receipt of the order of a court of competent jurisdiction

Compliance Determination:  Examine a sample of case files to determine compliance with this section.

Applicable definitions:  "Individual service plan" or "service plan" means a written plan of action developed, revised as necessary, and reviewed at intervals to meet the needs of a resident. The individual service plan specifies (i) measurable short-term and long-term goals and (ii) the objectives, strategies, and time frames for reaching the goals.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-980. Employee training in independent living programs.

6VAC35-41-980. Employee training in independent living programs.

Each independent living program shall develop and implement procedures to train all direct care staff within 14 days of employment on the content of the independent living curriculum, the use of the independent living materials, the application of the assessment tool, and the documentation methods used.

Documentation of the training shall be kept in the employee's staff record.

Interpretation: Goal: To ensure the proper training of staff.

Additional information: None

Compliance Determination:  Examine documentation of procedures and that staff was trained within 14 days on the independent living curriculum.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.

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6VAC35-41-990. Medication management in independent living programs.

6VAC35-41-990. Medication management in independent living programs.

If residents age 18 years or older are to share in the responsibility for their own medication with the provider, the independent living program shall develop and implement written procedures that include:

1. Training for the resident in self administration and recognition of side effects;
2. Method for storage and safekeeping of medication;
3. Method for obtaining approval for the resident to self administer medication from a person authorized by law to prescribe medication; and
4. Method for documenting the administration of medication.

Interpretation: Goal: To establish guidance for the medication management.

Additional information: Elements of this procedure should be approved by the program’s health authority.

Compliance Determination:  Examine procedure

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-1000. Nutrition procedure in independent living programs.

6VAC35-41-1000. Nutrition procedure in independent living programs.

Each independent living program shall develop and implement written procedures that ensure that each resident is receiving adequate nutrition as required in 6VAC35-41-650 A, B, and C (nutrition).

Interpretation: Goal: To ensure proper nutrition guidance.

Additional information: 6VAC35-41-650 A, B, and C are to be assessed for compliance.

Compliance Determination:  Examine procedures  Establish compliance with 6VAC35-41-650 A, B, and C

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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Part IX Wilderness Programs and Adventure Activities

6VAC35-41-1010 (A), (B), & (C). Wilderness program.

6VAC35-41-1010 (A). Wilderness program.

A. The provider must obtain approval by the board prior to operating a primitive camping program.

Interpretation: Goal: To establish guidance for the operation.

Additional information: None

Compliance Determination:  Examine documentation of approval to determine compliance with this section.

Applicable definitions:  "Board" means Board of Juvenile Justice.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

6VAC35-41-1010 (B). Wilderness program.

B. Any wilderness program must meet the following conditions: (i) maintain a nonpunitive environment; (ii) have an experience curricula; (iii) accept residents only nine years of age or older who cannot presently function at home, in school, or in the community.

Interpretation: Goal: To establish guidance for the operation.

Additional information: None

Compliance Determination:  Examine program description to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1010 (C). Wilderness program.

C. Any wilderness work program or wilderness work camp program shall have a written program description covering:

1. Its intended resident population;
2. How work assignments, education, vocational training, and treatment will be interrelated;
3. The length of the program;
4. The type and duration of treatment and supervision to be provided upon release or discharge; and
5. The program's behavioral expectations, incentives, and sanctions.

Interpretation:

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Goal: To establish guidance for the operation.

Additional information: None

Compliance Determination:  Examine program description to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-1020 (A) & (B). Wilderness programs or adventure activities.

6VAC35-41-1020 (A). Wilderness programs or adventure activities.

A. All wilderness programs and providers that take residents on wilderness or adventure activities shall develop and implement procedures that include:

1. Staff training and experience requirements for each activity;
2. Resident training and experience requirements for each activity;
3. Specific staff to resident ratio and supervision plan appropriate for each activity, including sleeping arrangements and supervision during night time hours;
4. Plans to evaluate and document each participant's physical health throughout the activity;
5. Preparation and planning needed for each activity and time frames;
6. Arrangement, maintenance, and inspection of activity areas;
7. A plan to ensure that any equipment and gear that is to be used in connection with a specified wilderness or adventure activity is appropriate to the activity, certified if required, in good repair, in operable condition, and age and body size appropriate;
8. Plans to ensure that all ropes and paraphernalia used in connection with rope rock climbing, rappelling, high and low ropes courses, or other adventure activities in which ropes are used are approved annually by an appropriate certifying organization and have been inspected by staff responsible for supervising the adventure activity before engaging residents in the activity;
9. Plans to ensure that all participants are appropriately equipped, clothed, and wearing safety gear, such as a helmet, goggles, safety belt, life jacket, or a flotation device, that is appropriate to the adventure activity in which the resident is engaged; 10. Plans for food and water supplies and management of these resources; 11. Plans for the safekeeping and distribution of medication; 12. Guidelines to ensure that participation is conducted within the boundaries of the resident's capabilities, dignity, and respect for self-determination; 13. Overall emergency, safety, and communication plans for each activity including rescue procedures, frequency of drills, resident accountability, prompt evacuation, and notification of outside emergency services; and 14. Review of trip plans by the trip coordinator.

Interpretation: Goal: To ensure that programs provide the elements to establish safe and secure guidelines.

Additional information: None

Compliance Determination:  Examine procedure for each element to determine compliance with this section.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

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 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1020 (B). Wilderness programs or adventure activities.

B. Direct care workers hired by wilderness campsite programs and providers that take residents on wilderness or adventure activities shall be trained in a wilderness first aid course.

Interpretation: Goal: To ensure that programs provide the elements to establish safe and secure guidelines.

Additional information: Wilderness First Aid in an extended course of Standard First Aid

Compliance Determination:  Examine documentation of wilderness first aid to determine compliance with this section.

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1030. Initial physical for wilderness programs or adventure activities.

6VAC35-41-1030. Initial physical for wilderness programs or adventure activities.

Initial physical forms used by wilderness campsite programs and providers that take residents on wilderness or adventure activities shall include:

1. A statement notifying the doctor of the types of activities the resident will be participating in; and
2. A statement signed by the doctor stating the individual's health does not prevent him from participating in the described activities.

Interpretation: Goal: To ensure that residents obtain medical approval to participate in such program.

Additional information: None

Compliance Determination:  Examine documentation in a sample of case files to determine compliance with this section.

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1040 (A), (B), (C), (D), (E), & (F). Physical environment of wilderness programs or adventure activities.

6VAC35-41-1040 (A). Physical environment of wilderness programs or adventure activities.

A. Each resident shall have adequate personal storage area.

Interpretation: Goal: To establish basic criteria for wilderness programs.

Additional information: None

Compliance Determination:  Observe space and ensure that each resident has adequate personal storage areas.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1040 (B). Physical environment of wilderness programs or adventure activities.

B. Fire extinguishers of a 2A 10BC rating shall be maintained so that it is never necessary to travel more than 75 feet to a fire extinguisher from combustion-type heating devices, campfires, or other source of combustion.

Interpretation: Goal: To provide for fire safety in wilderness programs.

Additional information: http://www.scouting.org/scoutsource/HealthandSafety/Guidelines_Policies.aspx

Compliance Determination:  Examine fire extinguishers to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1040 (C). Physical environment of wilderness programs or adventure activities.

C. Artificial lighting shall be provided in a safe manner.

Interpretation: Goal: To provide safe lighting.

Additional information: Guidance can be found at http://www.scouting.org/scoutsource/HealthandSafety/Guidelines_Policies.aspx

Compliance Determination:  Observe lighting

Applicable definitions:

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None.

6VAC35-41-1040 (D). Physical environment of wilderness programs or adventure activities.

D. All areas of the campsite shall be lighted for safety when occupied by residents.

Interpretation: Goal: To provide safe lighting.

Additional information: None

Compliance Determination:  Observe lighting to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1040 (E). Physical environment of wilderness programs or adventure activities.

E. A telephone or other means of communication is required at each area where residents sleep or participate in programs.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Observe means of communication to ensure a telephone is at each area where residents sleep or participate in programs.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1040 (F). Physical environment of wilderness programs or adventure activities.

F. First aid kits used by wilderness campsite programs and providers that take residents on adventure activities shall be activity appropriate and shall be accessible at all times.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine first aid kits to determine compliance with this section.

Applicable definitions:

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 "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1050 (A), (B), (C), (D), (E), (F), (G), (H), & (I). Sleeping areas of wilderness programs or adventure activities.

6VAC35-41-1050 (A). Sleeping areas of wilderness programs or adventure activities.

A. In lieu of or in addition to dormitories, cabins, or barracks for housing residents, primitive campsites may be used.

Interpretation: Goal: To establish sleeping areas for residents.

Additional information: None

Compliance Determination:  Observe areas to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1050 (B). Sleeping areas of wilderness programs or adventure activities.

B. Sleeping areas shall be protected by screening or other means to prevent admittance of flies and mosquitoes.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination: Observe areas to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1050 (C). Sleeping areas of wilderness programs or adventure activities.

C. A separate bed, bunk, or cot shall be made available for each person.

Interpretation: Goal: To establish comfortable sleeping areas.

Additional information: A raised platform of some kind is required.

Compliance Determination:  Observe beds to determine compliance with this section.

Applicable definitions: None.

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6VAC35-41-1050 (D). Sleeping areas of wilderness programs or adventure activities.

D. A mattress cover shall be provided for each mattress.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine mattress cover to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1050 (E). Sleeping areas of wilderness programs or adventure activities.

E. Bedding shall be clean, dry, sanitary, and in good repair.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Observe bedding to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1050 (F). Sleeping areas of wilderness programs or adventure activities.

F. Bedding shall be adequate to ensure protection and comfort in cold weather.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine bedding to determine compliance with this section.  Interview residents to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1050 (G). Sleeping areas of wilderness programs or adventure activities.

G. Sleeping bags, if used, shall be fiberfill and rated for 0°F.

Interpretation: Goal: To provide for the safety of residents.

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Additional information: None

Compliance Determination:  Examine sleeping bag to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1050 (H). Sleeping areas of wilderness programs or adventure activities.

H. Linens shall be changed as often as required for cleanliness and sanitation but not less frequently than once a week.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Interview residents to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1050 (I). Sleeping areas of wilderness programs or adventure activities.

I. Staff of the same sex may share a sleeping area with the residents.

Interpretation: Goal: Provide for the safe supervision of residents

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1060 (A) & (B). Personal necessities in wilderness programs or adventure activities.

6VAC35-41-1060 (A). Personal necessities in wilderness programs or adventure activities.

A. Each resident shall be provided with an adequate supply of clean clothing that is suitable for outdoor living and is appropriate to the geographic location and season.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine clothing to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1060 (B). Personal necessities in wilderness programs or adventure activities.

B. Sturdy, water resistant, outdoor footwear shall be provided for each resident.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Observe footwear to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1070 (A), (B), (C), (D), (E), & (F). Trip or activity coordination for wilderness programs or adventure activities.

6VAC35-41-1070 (A). Trip or activity coordination for wilderness programs or adventure activities.

A. All wilderness programs and facilities that take residents on wilderness or adventure activities must designate one staff person to be the trip coordinator who will be responsible for all facility wilderness or adventure trips.

1. This person must have experience in and knowledge regarding wilderness activities and be trained in wilderness first aid. The individual must also have at least one year experience at the facility and be familiar with the facility procedures, staff, and residents.
2. Documentation regarding this knowledge and experience shall be found in the individual's staff record.
3. The trip coordinator will review all trip plans and procedures and will ensure that staff and residents meet the requirements as outlined in the facility's procedure regarding each wilderness or adventure activity to take place during the trip.
4. The trip coordinator will review all trip plans and procedures and will ensure that staff and residents meet the requirements as outlined in the facility's procedure regarding each wilderness or adventure activity to take place during the trip.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1070 (B). Trip or activity coordination for wilderness programs or adventure activities.

B. The trip coordinator shall conduct a post trip debriefing within 72 hours of the group's return to base to evaluate individual and group goals as well as the trip as a whole.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Interview trip coordinator to ensure the post trip debriefing is being conducted.

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Applicable definitions: None.

6VAC35-41-1070 (C). Trip or activity coordination for wilderness programs or adventure activities.

C. The trip coordinator will be responsible for writing a summary of the debriefing session and shall be responsible for ensuring that procedures are updated to reflect improvements needed.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine documentation summary to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1070 (D). Trip or activity coordination for wilderness programs or adventure activities.

D. A trip folder will be developed for each wilderness or adventure activity conducted away from the facility and shall include:

1. Medical release forms including pertinent medical information on the trip participants;
2. Phone numbers for administrative staff and emergency personnel;
3. Daily trip logs;
4. Incident reports;
5. Swimming proficiency list if trip is near water;
6. Daily logs;
7. Maps of area covered by the trip; and
8. Daily plans.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine documentation of trip folders to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-1070 (E). Trip or activity coordination for wilderness programs or adventure activities.

E. The provider shall ensure that before engaging in any aquatic activity, each resident shall be classified by the trip coordinator or his designee according to swimming ability in one of two classifications: swimmer and nonswimmer. This shall be documented in the resident's record and in the trip folder.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine documentation in residents records and trip folder

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1070 (F). Trip or activity coordination for wilderness programs or adventure activities.

F. The provider shall ensure that lifesaving equipment is provided for all aquatic activities and is placed so that it is immediately available in case of an emergency. At a minimum, the equipment shall include:

1. A whistle or other audible signal device; and
2. A lifesaving throwing device.

Interpretation: Goal: To provide for the safety of residents.

Additional information: None

Compliance Determination:  Examine equipment to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

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Part X Family Oriented Group Homes

6VAC35-41-1080. Requirements of family oriented group home systems.

6VAC35-41-1080. Requirements of family oriented group home systems.

Family oriented group home systems shall have written procedures for:

1. Setting the number of residents to be housed in each home and room of the home and prohibiting individuals less than 18 years of age and individuals older than 17 years of age from sharing sleeping rooms without specific approval from the facility administrator;
2. Providing supervision of and guidance for the family oriented group home parents and relief staff;
3. Admitting and orienting residents;
4. Preparing a treatment plan for each resident within 30 days of admission or 72 hours in the case of a shelter care facility, and reviewing the plan quarterly;
5. Providing appropriate programs and services from intake through release;
6. Providing residents with spending money;
7. Managing resident records and releasing information;
8. Providing medical and dental care to residents;
9. Notifying parents and guardians, as appropriate and applicable, the placing agency, and the department of any serious incident as specified in written procedures; 10. Making a program supervisor or designated staff person available to residents and house parents 24 hours a day; and 11. Ensuring the secure control of any firearms and ammunition in the home.

Interpretation: Goal: To establish the criteria for a Family Operated Group Home Program

Additional information: None

Compliance Determination:  Examine procedure

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Department" or "DJJ" means the Department of Juvenile Justice.  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.  "Family oriented group home" means a private home in which residents may reside upon placement by a lawful placing agency.  "Group home" means a juvenile residential facility that is a community based, home-like single dwelling, or its acceptable equivalent, other than the private home of the operator, and does not exceed the capacity approved by the regulatory authority. For the purpose of this chapter, a group home includes a halfway house that houses residents in transition from a commitment to the department.

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 "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Shelter care facility" means a facility or an emergency shelter specifically approved to provide a range of services, as needed, on an individual basis not to exceed 90 days.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-1090. Examination by physician.

6VAC35-41-1090. Examination by physician.

Each resident admitted to a family oriented group home shall have a physical examination including tuberculosis screening within 30 days of admission unless the resident was examined within six months prior to admission to the program.

Interpretation: Goal: To ensure a health assessment of each resident.

Additional information: None

Compliance Determination:  Examine documentation in case files

Applicable definitions:  "Family oriented group home" means a private home in which residents may reside upon placement by a lawful placing agency.  "Group home" means a juvenile residential facility that is a community based, home-like single dwelling, or its acceptable equivalent, other than the private home of the operator, and does not exceed the capacity approved by the regulatory authority. For the purpose of this chapter, a group home includes a halfway house that houses residents in transition from a commitment to the department.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1100. Requirements of family group homes.

6VAC35-41-1100. Requirements of family group homes.

Each family oriented group home shall have:

1. A fire extinguisher, inspected annually;
2. Smoke alarm devices in working condition;
3. Alternative methods of escape from second story;
4. Modern sanitation facilities;
5. Freedom from physical hazards;
6. A written emergency plan that is communicated to all new residents at orientation;
7. An up-to-date listing of medical and other emergency resources in the community;
8. A separate bed for each resident, with clean sheets and linens weekly;
9. A bedroom that is well illuminated and ventilated; is in reasonably good repair; is not a hallway, unfinished basement or attic; and provides conditions for privacy; 10. A place to store residents' clothing and personal items; 11. Sanitary toilet and bath facilities that are adequate for the number of residents; 12. A safe and clean place for indoor and outdoor recreation; 13. Adequate furniture; 14. Adequate laundry facilities or laundry services; 15. A clean and pleasant dining area; 16. Adequate and nutritionally balanced meals; and 17. Daily provision of clean clothing and articles necessary for maintaining proper personal hygiene.

Interpretation: Goal: To establish a safe environment.

Additional information: None

Compliance Determination:  Inspect the home for each item

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Family oriented group home" means a private home in which residents may reside upon placement by a lawful placing agency.  "Group home" means a juvenile residential facility that is a community based, home-like single dwelling, or its acceptable equivalent, other than the private home of the operator, and does not exceed the capacity approved by the regulatory authority. For the purpose of this chapter, a group home includes a halfway house that houses residents in transition from a commitment to the department.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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 "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1110. Other applicable regulations.

6VAC35-41-1110. Other applicable regulations.

Each family oriented group home shall also be subject to and comply with the requirements of the following provisions of this chapter:

1. 6VAC35-41-180 (employee and volunteer background checks);
2. 6VAC35-41-190 (required initial orientation);
3. 6VAC35-41-200 (required initial training); and
4. 6VAC35-41-210 (required retraining).

Interpretation: Goal: To establish other applicable regulations for Family Operated Group Homes

Additional information: Refer to each listed regulatory requirement.

Compliance Determination: Assess compliance for each listed regulatory requirement

Applicable definitions:  "Family oriented group home" means a private home in which residents may reside upon placement by a lawful placing agency.  "Group home" means a juvenile residential facility that is a community based, home-like single dwelling, or its acceptable equivalent, other than the private home of the operator, and does not exceed the capacity approved by the regulatory authority. For the purpose of this chapter, a group home includes a halfway house that houses residents in transition from a commitment to the department.

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Part XI Respite Care

6VAC35-41-1120. Definition of respite care.

6VAC35-41-1120. Definition of respite care.

Respite care facility shall mean a facility that is specifically approved to provide short-term, periodic residential care to residents accepted into its program in order to give the parents or legal guardians temporary relief from responsibility for their direct care.

Interpretation: Goal: Defines Respite Care.

Additional information: None

Compliance Determination: None

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1130 (A) & (B). Admission and discharge from respite care.

6VAC35-41-1130 (A). Admission and discharge from respite care.

A. Acceptance of an individual as eligible for respite care by a respite care facility is considered admission to the facility. Each individual period of respite care is not considered a separate admission.

Interpretation: Goal: Defines admission to respite care.

Additional information: None

Compliance Determination: None

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-1130 (B). Admission and discharge from respite care.

B. A respite care facility shall discharge a resident when the legal guardian no longer intends to use the facility's services.

Interpretation: Goal: Establishes requirement for discharge.

Additional information: None

Compliance Determination:  Examine discharge documentation

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1140. Updating health records in respite care.

6VAC35-41-1140. Updating health records in respite care.

Respite care facilities shall update the information required by 6VAC35-41-1170 B (health care procedures) at the time of each stay at the facility.

Interpretation: Goal: To ensure up-to-date health records

Additional information: None

Compliance Determination:  Examine documentation in health records

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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Part XII Health Care Services

6VAC35-41-1150. Definitions applicable to health care services.

6VAC35-41-1150. Definitions applicable to health care services. "Health authority" means the individual, government authority, or health care contractor responsible for organizing, planning, and monitoring the timely provision of appropriate health care services, including arrangements for all levels of health care and the ensuring of quality and accessibility of all health services, consistent with applicable statutes and regulations, prevailing community standards, and medical ethics. "Health care record" means the complete record of medical screening and examination information and ongoing records of medical and ancillary service delivery including, but not limited to, all findings, diagnoses, treatments, dispositions, prescriptions, and their administration. "Health care services" means those actions, preventative and therapeutic, taken for the physical and mental well-being of a resident. Health care services include medical, dental, orthodontic, mental health, family planning, obstetrical, gynecological, health education, and other ancillary services. "Health trained personnel" means an individual who is trained by a licensed health care provider to perform specific duties such as administering heath care screenings, reviewing screening forms for necessary follow-up care, preparing residents and records for sick call, and assisting in the implementation of certain medical orders.

Interpretation: Goal: To establish definitions.

Additional information: None

Compliance Determination: None

Applicable definitions:  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1160. Provision of health care services.

6VAC35-41-1160. Provision of health care services.

Treatment by nursing personnel shall be performed pursuant to the laws and regulations governing the practice of nursing within the Commonwealth. Other health-trained personnel shall provide care within their level of training and certification.

Interpretation: Goal: To ensure the proper administration of a healthcare program that meets the needs of the residents.

Additional information: None

Compliance Determination: Interview the facility administrator to determine compliance with this section Review training records, licensure, and certification.

Applicable definitions: None.

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6VAC35-41-1170 (A), (B), & (C). Health care procedures.

6VAC35-41-1170 (A). Health care procedures.

A. The provider shall have and implement written procedures for promptly:

1. Arranging for the provision of medical and dental services for health problems identified at admission;
2. Arranging for the provision of routine ongoing and follow-up medical and dental services after admission;
3. Arranging for emergency medical and mental health care services, as appropriate and applicable, for each resident as provided by statute or by the agreement with the resident's legal guardian;
4. Arranging for emergency medical and mental health care services, as appropriate and applicable, for any resident experiencing or showing signs of suicidal or homicidal thoughts, symptoms of mood or thought disorders, or other mental health problems; and
5. Ensuring that the required information in subsection B of this section is accessible and up to date.

Interpretation: Goal: To ensure proper provision of residents’ medical needs.

Additional information: None

Compliance Determination:  Review procedures to determine compliance with this section.  Interview health services administrator to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1170 (B). Health care procedures.

B. The following written information concerning each resident shall be readily accessible to staff who may have to respond to a medical or dental emergency:

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1. Name, address, and telephone number of the physician and dentist to be notified;
2. Name, address, and telephone number of a relative or other person to be notified;
3. Medical insurance company name and policy number or Medicaid number;
4. Information concerning: a. Use of medication; b. All allergies, including medication allergies; c. Substance abuse and use; d. Significant past and present medical problems; and
5. Written permission for emergency medical care, dental care, and obtaining immunizations or a procedure and contacts for obtaining consent.

Interpretation: Goal: To ensure proper provision of residents’ medical needs.

Additional information: When medical staff are not at the facility the above information has to be available to staff.

Compliance Determination:  Interview medical staff as to location of emergency information.  Interview direct care staff as to it being accessible.  Review a sample of medical records to determine compliance.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1170 (C). Health care procedures.

C. Facilities approved to provide respite care shall update the information required by subsection B of this section at the time of each stay at the facility.

Interpretation: Goal: To ensure up-to-date health records.

Additional information: None

Compliance Determination:  Examine documentation in case files to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is

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not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-1180 (A) & (B). Health-trained personnel.

6VAC35-41-1180 (A). Health-trained personnel.

A. Health-trained personnel shall provide care as appropriate to their level of training and certification and shall not administer health care services for which they are not qualified or specifically trained.

Interpretation: Goal: To ensure proper provision of residents’ medical needs.

Additional information: None

Compliance Determination:  Interview medical staff for functions as health trained staff to determine the level of training and certification  Review a sample of case file to determine the level of service provided is appropriate.  Review sample training records for health trained personnel as applicable.

Applicable definitions: None.

6VAC35-41-1180 (B). Health-trained personnel.

B. The facility shall retain documentation of the training received by health-trained personnel necessary to perform any designated health care services. Documentation of applicable, current licensure or certification shall constitute compliance with this section.

Interpretation: Goal: To ensure proper provision of residents’ medical needs.

Additional information: It is important that staff conducting health screenings at admission be properly trained. None medical staff who administer medications need certification of medication management training.

Compliance Determination: Interview the designated local health authority to determine compliance with this section.

Review a sample of training records of applicable.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-1190 (A), (B), (C), & (D). Consent to and refusal of health care services.

6VAC35-41-1190 (A). Consent to and refusal of health care services.

A. The knowing and voluntary agreement, without undue inducement or any element of force, fraud, deceit, duress, or other form of constraint or coercion, of a person who is capable of exercising free choice (informed consent) to health care shall be obtained from the resident, parent, guardian, or legal custodian as required by law.

Interpretation: Goal: To ensure that resident and parents are aware of proposed medical treatment.

Additional information: "Informed consent" means the agreement by a patient to a treatment, examination or procedure after the patient receives the material facts regarding the nature, consequences and risks of the proposed treatment, examination, or procedure and the alternatives to it. For an invasive procedure where there is some risk to the patient, informed consent is documented on a written form containing the juvenile’s signature or that of the legal guardian if required. This is not the same as the signed permission for medical treatment obtained from a parent or guardian.

Compliance Determination:  Interview designated local health authority and residents to determine compliance with this section.  Review of a sample of medical records to determine compliance with this section.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1190 (B). Consent to and refusal of health care services.

B. The resident, parent, guardian, or legal custodian, as applicable, shall be advised by an appropriately trained medical professional of (i) the material facts regarding the nature, consequences, and risks of the proposed treatment, examination, or procedure and (ii) the alternatives to it.

Interpretation: Goal: To ensure that resident and parents are aware of proposed medical treatment.

Additional information: "Informed consent" means the agreement by a patient to a treatment, examination or procedure after the patient receives the material facts regarding the nature, consequences and risks of the proposed treatment, examination, or procedure and the alternatives to it. For an invasive procedure where there is some risk to the patient, informed consent is documented on a written form containing the juvenile’s signature or that of the legal guardian if

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required. This is not the same as the signed permission for medical treatment obtained from a parent or guardian.

Compliance Determination:  Interview designated local health authority and residents to determine compliance with this section.  Review of a sample of medical records to determine compliance with this section.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1190 (C). Consent to and refusal of health care services.

C. Residents may refuse in writing medical treatment and care. This subsection does not apply to medication refusals that are governed by 6VAC35-41-1280 (medication).

Interpretation: Goal: To ensure the residents right to refuse medical treatment.

Additional information: None

Compliance Determination:  Review medical files to determine compliance with this section.  Interview designated local health authority to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1190 (D). Consent to and refusal of health care services.

D. When health care is rendered against the resident's will, it shall be in accordance with applicable laws and regulations.

Interpretation: Goal: To ensure the proper provision of health care services.

Additional information: When questions in this area arise, the auditor may contact the DJJ Health Services Administrator.

Compliance Determination:

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 Interview the designated local health authority to determine compliance with this section.  Review a sample of medical records as applicable to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1200. Health screening at admission.

6VAC35-41-1200. Health screening at admission.

The facility shall require that:

1. To prevent newly arrived residents who pose a health or safety threat to themselves or others from being admitted to the general population, all residents shall immediately upon admission undergo a preliminary health screening consisting of a structured interview and observation by health care personnel or health-trained staff. As necessary to maintain confidentiality, all or a portion of the interview shall be conducted with the resident without the presence of the parent or guardian.
2. Residents admitted to the facility who pose a health or safety threat to themselves or others shall not be admitted to the facility's general population but provision shall be made for them to receive comparable services.
3. Immediate health care is provided to residents who need it.

Interpretation: Goal: To ensure that newly admitted residents do not pose a risk to others.

Additional information: A health-trained staff person must be trained in the specific health-related task he or she performs, but does not need to be trained in any other health-related tasks. Thus, a health-trained staff person who conducts preliminary health screenings at admission must be trained to conduct the required structured interview and observation, using the facility's approved health screening form, but need not be trained in any other health-related tasks unless those are part of his or her job duties. Training must be provided by health care staff or trainers who follow training have been trained by health care staff.

Compliance Determination:  Review sample of files for the appropriate health screening at admission  Determine if screening was by health care personnel or health trained staff  Review medical files to determine the immediacy of health care.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1210 (A), (B), & (C). Tuberculosis screening.

6VAC35-41-1210 (A). Tuberculosis screening.

A. Within seven days of placement each resident shall have had a screening assessment for tuberculosis.

The screening assessment can be no older than 30 days.

Interpretation: Goal: To ensure the prompt identification of any individual who may have tuberculosis.

Additional information: None

Compliance Determination:  Review sample of medical records to determine compliance with this section.

Applicable definitions:  "Placement" means an activity by any person that provides assistance to a placing agency, parent, or legal guardian in locating and effecting the movement of a resident to a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1210 (B). Tuberculosis screening.

B. A screening assessment for tuberculosis shall be completed annually on each resident.

Interpretation: Goal: To ensure the identification of any individual who may have tuberculosis.

Additional information: None

Compliance Determination:  Review sample of medical records to determine compliance with this section.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1210 (C). Tuberculosis screening.

C. The facility's screening practices shall be performed consistent with any current recommendations of the Virginia Department of Health, Division of Tuberculosis Prevention and Control and the Department of Health and Human Services Centers for Disease Control and Prevention for the detection, diagnosis, prophylaxis, and treatment of pulmonary tuberculosis.

Interpretation: Goal: To ensure the identification of any individual who may have tuberculosis.

Additional information: The DJJ Health Services Administrator can be interviewed for the current requirements of CDC if needed.

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Compliance Determination:  Interview medical staff to determine compliance with this section.  Review a sample of medical records to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-1220 (A) & (B). Medical examinations and treatment.

6VAC35-41-1220 (A). Medical examinations and treatment.

A. Except for residents placed in a shelter care facility, each resident accepted for care shall have a physical examination by or under the direction of a licensed physician no earlier than 90 days prior to admission to the facility or no later than seven days following admission, except (i) the report of an examination within the preceding 12 months shall be acceptable if a resident transfers from one facility licensed or certified by a state agency to another and (ii) a physical examination shall be conducted within 30 days following an emergency admission if a report of physical examination is not available.

Interpretation: Goal: To ensure the proper identification of healthcare needs.

Additional information: None

Compliance Determination:  Review a sample of medical files to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Shelter care facility" means a facility or an emergency shelter specifically approved to provide a range of services, as needed, on an individual basis not to exceed 90 days.

6VAC35-41-1220 (B). Medical examinations and treatment.

B. Each resident shall have an annual physical examination by or under the direction of a licensed physician and an annual dental examination by a licensed dentist.

Interpretation: Goal: To ensure proper documentation of residents’ health records.

Additional information: None

Compliance Determination:  Review a sample of medical and dental records to determine compliance with this section.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.

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 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1230 (A) & (B). Infectious or communicable diseases.

6VAC35-41-1230 (A). Infectious or communicable diseases.

A. A resident with a communicable disease shall not be admitted unless a licensed physician certifies that:

1. The facility is capable of providing care to the resident without jeopardizing residents and staff; and
2. The facility is aware of the required treatment for the resident and the procedures to protect residents and staff.

The requirements of this subsection shall not apply to shelter care facilities.

Interpretation: Goal: To ensure the health of residents by the control of infectious and communicable diseases.

Additional information: None

Compliance Determination:  Review documentation of compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1230 (B). Infectious or communicable diseases.

B. The facility shall implement written procedures approved by a medical professional that:

1. Address staff (i) interactions with residents with infectious, communicable, or contagious medical conditions; and (ii) use of standard precautions;
2. Require staff training in standard precautions, initially and annually thereafter; and
3. Require staff to follow procedures for dealing with residents who have infectious or communicable diseases.

Interpretation: Goal: To ensure the health of residents by the control of infectious and communicable diseases.

Additional information: None

Compliance Determination:  Review procedures to determine compliance with this section.  Review staff training records to determine compliance with this section.

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Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-1240. Suicide prevention.

6VAC35-41-1240. Suicide prevention.

Written procedure shall provide (i) for a suicide prevention and intervention program, developed in consultation with a qualified medical or mental health professional, and (ii) for all direct care staff to be trained in the implementation of the program.

Interpretation: Goal: To ensure the safety and protection of residents with mental health needs.

Additional information: None

Compliance Determination:  Review procedures to determine compliance with this section.  Examine procedure.  Examine the suicide and intervention program for documentation of consultation with a qualified medical or mental health professional.

Applicable definitions:  "Direct care staff" means the staff whose primary job responsibilities are (i) maintaining the safety, care, and well-being of residents and (ii) implementing the structured program of care and behavior management program.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

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6VAC35-41-1250 (A), (B), (C), (D), (E), & (F). Residents' health records.

6VAC35-41-1250 (A). Residents' health records.

A. Each resident's health record shall include written documentation of (i) the initial physical examination, (ii) an annual physical examination by or under the direction of a licensed physician including any recommendation for follow-up care, and (iii) documentation of the provision of follow-up medical care recommended by the physician or as indicated by the needs of the resident.

Interpretation: Goal: To ensure proper documentation of residents’ health records.

Additional information: None

Compliance Determination:  Review a sample of medical records to determine compliance with this section.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1250 (B). Residents' health records.

B. The resident's active health records (i) shall be kept confidential and inaccessible from unauthorized persons, (ii) shall be readily accessible in case of emergency, and (iii) shall be made available to authorized staff consistent with applicable state and federal statutes and regulations.

Interpretation: Goal: To ensure confidentiality of health records that are readily accessible to authorized staff.

Additional information: None

Compliance Determination:  Observe location of accessibility of medical records.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.

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 "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1250 (C). Residents' health records.

C. Each physical examination report shall include:

1. Information necessary to determine the health and immunization needs of the resident, including: a. Immunizations administered at the time of the exam; b. Vision exam; c. Hearing exam; d. General physical condition including documentation of apparent freedom from communicable disease, including tuberculosis; e. Allergies, chronic conditions, and handicaps, if any; f. Nutritional requirements including special diets, if any; g. Restrictions on physical activities, if any; and h. Recommendations for further treatment, immunizations, and other examinations indicated;
2. Date of the physical examination; and
3. Signature of a licensed physician, the physician's designee, or an official of a local health department.

Interpretation:

Goal: To ensure there is information necessary to determine the health of the resident.

Additional information: If the Physical Examination Form has s statement that information is located on another document (such as vision screen) and that document is in the health record compliance will be demonstrated.

Compliance Determination:  Review sample of physical examination reports for each element.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1250 (D). Residents' health records.

D. Each resident's health record shall include written documentation of (i) an annual examination by a licensed dentist and (ii) documentation of follow-up dental care recommended by the dentist or as indicated by the needs of the resident. This requirement does not apply to shelter care facilities and respite care facilities.

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Interpretation: Goal: To ensure proper documentation of residents’ medical needs.

Additional information: None

Compliance Determination:  Examine documentation in a sample of healthcare files.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1250 (E). Residents' health records.

E. Each resident's health record shall include notations of health and dental complaints and injuries and shall summarize symptoms and treatment given.

Goal: To ensure proper documentation of residents’ medical needs.

Additional information: None

Compliance Determination: Review a sample of healthcare records to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1250 (F). Residents' health records.

F. Each resident's health record shall include or document the facility's efforts to obtain treatment summaries of ongoing psychiatric or other mental health treatment and reports, if applicable.

Goal: To ensure proper documentation of residents’ medical needs.

Additional information: None

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Compliance Determination:  Review a sample of healthcare records to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1260 (A) & (B). First aid kits.

6VAC35-41-1260 (A). First aid kits.

A. A well stocked first aid kit shall be maintained, with an inventory of its contents, and readily accessible for dealing with minor injuries and medical emergencies.

Interpretation: Goal: To ensure that first kits are properly maintained and available for emergencies.

Additional information: None

Compliance Determination:  Interview staff about accessibility of first aid kids.  Review inventory of first aid kit.

Applicable definitions: None.

6VAC35-41-1260 (B). First aid kits.

B. First aid kits should be monitored in accordance with established facility procedures to ensure kits are maintained, stocked, and ready for use.

Interpretation: Goal: To ensure that first kits are properly maintained and available for emergencies.

Additional information: None

Compliance Determination: Examine procedures to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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6VAC35-41-1270 (A) & (B). Hospitalization and other outside medical treatment of residents.

6VAC35-41-1270 (A). Hospitalization and other outside medical treatment of residents.

A. When a resident needs hospital care or other medical treatment outside the facility:

1. The resident shall be transported safely; and
2. A parent or legal guardian, a staff member, or a law-enforcement officer, as appropriate, shall accompany the resident and stay at least during admission.

Interpretation: Goal: To ensure the safety of the resident transported outside the facility for medical purposes.

Additional information: None

Compliance Determination:  Interview facility administrator to determine compliance with this section.  Examine documentation to determine if resident want accompanied, and if so, by whom.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1270 (B). Hospitalization and other outside medical treatment of residents.

B. If a parent or legal guardian does not accompany the resident to the hospital or other medical treatment outside the facility, the parent or legal guardian shall be informed that the resident was taken outside the facility for medical attention as soon as is practicable.

Interpretation: Goal: To ensure that parents are aware of the resident’s medical needs.

Additional information: None

Compliance Determination: Review documentation to verify parent of legal guardian was properly informed.

Applicable definitions:

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 "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.

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6VAC35-41-1280 (A), (B), (C), (D), (E), (F), (G), (H), (I), (J), (K), (L), & (M). Medication.

6VAC35-41-1280 (A). Medication.

A. All medication shall be properly labeled consistent with the requirements of the Virginia Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia). Medication prescribed for individual use shall be so labeled.

Interpretation: Goal: To ensure that receive to proper medications.

Additional information: None

Compliance Determination:  Observe labels to determine compliance with this section,

Applicable definitions: None.

6VAC35-41-1280 (B). Medication.

B. All medication shall be securely locked, unless otherwise ordered by a physician on an individual basis for keep-on-person or equivalent use.

Interpretation: Goal: To ensure the safety and security of medications.

Additional information: None

Compliance Determination:  Review a sample of Medication Administration Records for those medications that are “keep-on-person.”  Observe the storage location of medication to determine secure storage.

Applicable definitions: None.

6VAC35-41-1280 (C). Medication.

C. All staff responsible for medication administration who do not hold a license issued by the Virginia Department of Health Professions authorizing the administration of medications shall have successfully completed a medication training program approved by the Board of Nursing or be licensed by the Commonwealth of Virginia to administer medications before they can administer medication. All staff who administer medication shall complete annual refresher medication training.

Interpretation:

Goal: To ensure that only trained staff administers medications.

Additional information: None

Compliance Determination:

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 Interview medical staff and ask if staff other than medical staff administer medication.  Examine licensure of medical staff. If other non-medical staff administers medications, review training records for those staff.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.

6VAC35-41-1280 (D). Medication.

D. Staff authorized to administer medication shall be informed of any known side effects of the medication and the symptoms of the effects.

Interpretation: Goal: To ensure the safe delivery of medications.

Additional information: Healthcare file should contain description of medication and identify side effects.

Compliance Determination:  Interview staff and ask how they are made aware of symptoms and side effects.  Review a sample of healthcare records to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1280 (E). Medication.

E. A program of medication, including procedures regarding the use of over-the-counter medication pursuant to written or verbal orders signed by personnel authorized by law to give such orders, shall be initiated for a resident only when prescribed in writing by a person authorized by law to prescribe medication.

Interpretation: Goal: To ensure the safe delivery of medications.

Additional information: Written standing orders for over-the-counter medication should be signed by the health authority and maintain on file. Verbal orders should be noted in the healthcare record when written orders are not available.

Compliance Determination:  Review a sample of healthcare records to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1280 (F). Medication.

F. All medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the requirements of § 54.2-2408 of the Code of Virginia and the Virginia

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Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia).

Interpretation: Goal: To ensure the safe delivery of medications.

Additional information: For further information regarding the requirements of § 54.2-2408 of the Code of Virginia and the Virginia Drug Control Act (§ 54.1-3400, the DJJ Health Service Administrator can be consulted when there are questions.

Compliance Determination:  Review a sample of MARs in healthcare records  Interview the local health authority to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1280 (G). Medication.

G. A medication administration record shall be maintained of all medicines received by each resident and shall include:

1. Date the medication was prescribed or most recently refilled;
2. Drug name;
3. Schedule for administration;
4. Strength;
5. Route;
6. Identity of the individual who administered the medication; and
7. Dates the medication was discontinued or changed.

Interpretation:

Goal: To ensure that delivery of medication is properly documented.

Additional information: The medication administration record must record both prescribed and over-the-counter medicines received by each resident.

Compliance Determination:  Review a sample of MARs in healthcare records to determine compliance with this section.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1280 (H). Medication.

H. In the event of a medication incident or an adverse drug reaction, first aid shall be administered if indicated. Staff shall promptly contact a poison control center, pharmacist, nurse, or physician and shall take actions as directed. If the situation is not addressed in standing orders, the attending physician shall

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be notified as soon as possible and the actions taken by staff shall be documented. A medical incident shall mean an error made in administering a medication to a resident including the following: (i) a resident is given incorrect medication; (ii) medication is administered to an incorrect resident; (iii) an incorrect dosage is administered; (iv) medication is administered at a wrong time or not at all; and (v) the medication is administered through an improper method. A medication error does not include a resident's refusal of appropriately offered medication.

Interpretation:

Goal: To ensure that delivery of medication is properly administered.

Additional information: The attending physician is the physician who has prescribed the medication or the physician that is responsible for providing medical care to the resident.

Standing orders refer to the documented order of the physician prescribing the medication that indicates how the medication is to be administered and the actions to take if there is a medication error or an adverse reaction to the medication. If there is no standing order from the physician pertaining to the specific medication, the attending physician shall be notified as soon as possible.

It is recommended that standing orders be filed in the resident’s record when the medication is no longer in use.

Compliance Determination:  Review a sample of health care records for proper documentation including actions taken by staff.

Applicable definitions: "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1280 (I). Medication.

I. Written procedures shall provide for (i) the documentation of medication incidents, (ii) the review of medication incidents and reactions and making any necessary improvements, (iii) the storage of controlled substances, and (iv) the distribution of medication off campus. The procedures must be approved by a health care professional. Documentation of this approval shall be retained.

Interpretation: Goal: To ensure the proper retention of documentation, storage of controlled substances, and off campus distribution of medication.

Additional information: The health care professional should be the health authority for the facility.

Compliance Determination:  Examine procedures to determine compliance with this section.  Review documentation of approval

Applicable definitions:  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1280 (J). Medication.

J. Medication refusals shall be documented including action taken by staff. The facility shall follow

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procedures for managing such refusals that shall address:

1. Manner by which medication refusals are documented, and
2. Physician follow-up, as appropriate.

Interpretation: Goal: To ensure proper documentation of medication refusals.

Additional information: If is extremely necessary to document actions taken by staff.

Compliance Determination: Examine procedure to determine compliance with this section.

Review a sample of medical records for documentation of refusals and physician follow up as appropriate.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

6VAC35-41-1280 (K). Medication.

K. Disposal and storage of unused, expired, and discontinued medications shall be in accordance with applicable laws and regulations.

Interpretation: Goal: To ensure that no unused, expired, and discontinued medications are kept at the facility.

Additional information: None

Compliance Determination: Interview health staff to determine disposal and storage practices.

Examine dates on stored medications.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.

6VAC35-41-1280 (L). Medication.

L. The telephone number of a regional poison control center and other emergency numbers shall be posted on or next to each nonpay telephone that has access to an outside line in each building in which residents sleep or participate in programs.

Interpretation: Goal: To ensure proper access by staff to emergency services.

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Additional information: None

Compliance Determination: Examine posting of phone numbers to determine compliance with this section.

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1280 (M). Medication.

M. Syringes and other medical implements used for injecting or cutting skin shall be locked and inventoried in accordance with facility procedures.

Interpretation: Goal: To provide for the safe storage of sharps.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section.  Examine inventory and compare to actual supply.  Observe location of syringes and medical implements to determine secure storage.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.

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Part XIII Behavior Support and Management

6VAC35-41-1290 (A), (B), (C), (D), (E), & (F). Behavior management.

6VAC35-41-1290 (A). Behavior management.

A. Each facility shall implement a behavior management program. Behavior management shall mean those principles and methods employed to help a resident achieve positive behavior and to address and correct a resident's inappropriate behavior in a constructive and safe manner in accordance with written procedures governing program expectations, treatment goals, and residents' and employees' safety and security.

Interpretation: Goal: To establish principles and methods employed to help a resident achieve positive behavior and to address and correct a resident's inappropriate behavior.

Additional information: None

Compliance Determination: Examine procedure to determine compliance with this section.

Review documentation of behavior program implementation, Interview staff and residents to verify program implementation.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1290 (B). Behavior management.

B. Written procedures governing this program shall provide the following:

1. A description of the rules of conduct and behavioral expectations for the resident;
2. Orientation of residents as provided in 6VAC35-41-770 (orientation to facility rules and disciplinary procedures);
3. A description of a system of privileges and sanctions that is used and available for use.
4. Specification of the staff members who may authorize the use of privileges and sanctions;
5. Documentation requirements when sanctions are imposed.

Interpretation: Goal: To establish principles and methods employed to help a resident achieve positive behavior and to address and correct a resident's inappropriate behavior.

Additional information: None

Compliance Determination:

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 Examine procedure to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Rules of conduct" means a listing of a facility's rules or regulations that is maintained to inform residents and others of the behavioral expectations of the behavior management program, about behaviors that are not permitted, and about the sanctions that may be applied when impermissible behaviors occur.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1290 (C). Behavior management.

C. Written information concerning the procedures of the provider's behavior management program shall be provided prior to admission to prospective residents, legal guardians, and placing agencies. For court-ordered and emergency admissions, this information shall be provided to:

1. Residents within 12 hours following admission;
2. Placing agencies within 72 hours following the resident's admission; and
3. Legal guardians within 72 hours following the resident's admission.

Interpretation: Goal: To ensure that resident, parents and placing agencies are aware of the facility’s behavior management program.

Additional information: None

Compliance Determination:  Interview staff

Applicable definitions:  "Emergency" means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action such as a fire, chemical release, loss of utilities, natural disaster, taking of hostages, major disturbances, escape, and bomb threats. Emergency does not include regularly scheduled employee time off or other situations that could be reasonably anticipated.  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.

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 "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1290 (D). Behavior management.

D. When substantive revisions are made to procedures governing management of resident behavior, written information concerning the revisions shall be provided to:

1. Residents prior to implementation; and
2. Legal guardians and placing agencies prior to implementation.

Interpretation: Goal: To ensure that resident, parents and placing agencies are aware of the facility’s behavior management program.

Additional information: None

Compliance Determination:  Interview staff regarding how changes are communicated to staff and residents.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1290 (E). Behavior management.

E. The facility administrator or designee shall review the behavior management program and procedures at least annually to determine appropriateness for the population served.

Interpretation: Goal: To ensure that the program is effective.

Additional information: None

Compliance Determination:  Interview administrator to determine compliance with this section.  Examine documentation of annual review.

Applicable definitions:  "Annual" means within 13 months of the previous event or occurrence.  "Facility administrator" means the individual who has the responsibility for the on-site management and operation of the facility on a regular basis.

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6VAC35-41-1290 (F). Behavior management.

F. Any time residents are present, staff must be present who have completed all trainings in behavior management.

Interpretation: Goal: To ensure that only trained staff manages resident’s behavior.

Additional information: If staff have not completed the required annual refresher they are not allowed to supervise residents.

Compliance Determination:  Examine documentation to determine that staff has been trained in behavior management.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1300 (A), (B), & (C). Behavior support.

6VAC35-41-1300 (A). Behavior support.

A. Each facility shall have a procedure regarding behavior support plans for use with residents who need supports in addition to those provided in the facility's behavior management program that addresses the circumstances under which such plans shall be utilized. Such plans shall support the resident's self-management of his own behavior and shall include:

1. Identification of positive and problem behavior;
2. Identification of triggers for behaviors;
3. Identification of successful intervention strategies for problem behavior;
4. Techniques for managing anger and anxiety; and
5. Identification of interventions that may escalate inappropriate behaviors.

Interpretation: Goal: To ensure that residents with special behavioral support needs have support plan to address those needs.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section.  Examine documentation in case files

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1300 (B). Behavior support.

B. Individualized behavior support plans shall be developed in consultation with the:

1. Resident;
2. Legal guardian, if applicable;
3. Resident's parents, if applicable;
4. Program director;
5. Placing agency staff; and
6. Other applicable individuals.

Interpretation: Goal: To ensure that residents with special behavioral support needs have support plan to address those needs and there is consultation with appropriate person in the development of the plans.

Additional information: None

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Compliance Determination:  Examine documentation of plans in case files.

Applicable definitions:  "Parent" or "legal guardian" means (i) a biological or adoptive parent who has legal custody of an individual, including either parent if custody is shared under a joint decree or agreement; (ii) a biological or adoptive parent with whom the individual regularly resides; (iii) a person judicially appointed as a legal guardian; or (iv) a person who exercises the rights and responsibilities of legal custody by delegation from a biological or adoptive parent, upon provisional adoption, or otherwise by operation of law.  "Placing agency" means (i) any person, group, court, court service unit, or agency licensed or authorized by law to place residents in a juvenile residential facility or (ii) a local board of social services authorized to place residents in a juvenile residential facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1300 (C). Behavior support.

C. Prior to working alone with an assigned resident, each staff member shall review and be prepared to implement the resident's behavior support plan.

Interpretation: Goal: To ensure that residents with special behavioral support needs have support plan to address those needs and staff review the plan.

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1310 (A) & (B). Timeout.

6VAC35-41-1310 (A). Timeout.

A. A facility may use a systematic behavior management technique program component designed to reduce or eliminate inappropriate or problematic behavior by having a staff require a resident to move to a specific location that is away from a source of reinforcement for a specific period of time or until the problem behavior has subsided (time-out) under the following conditions:

1. The provider shall develop and implement written procedures governing the conditions under which a resident may be placed in timeout and the maximum period of timeout.
2. The conditions and maximum period of timeout shall be based on the resident's chronological and developmental level.
3. The area in which a resident is placed shall not be locked nor the door secured in a manner that prevents the resident from opening it.
4. A resident in timeout shall be able to communicate with staff.
5. Staff shall check on the resident in the timeout area at least every 15 minutes and more often depending on the nature of the resident's disability, condition, and behavior.

Interpretation: Goal: To establish guidelines for the use of timeout to manage behavior.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section.

Applicable definitions:  "Juvenile residential facility" or "facility" means a publicly or privately operated facility or placement where 24-hour per day care is provided to residents who are separated from their legal guardians and that is required to be certified. As used in this regulation, the term includes, but is not necessarily limited to, group homes, family-oriented group homes, and halfway houses and excludes juvenile correctional centers and juvenile detention centers.  "Provider" means the person, corporation, partnership, association, locality, commission, or public agency to whom a license or certificate is issued and who is legally responsible for compliance with the regulatory and statutory requirements relating to the facility.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.  "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1310 (B). Timeout.

B. Use of timeout and staff checks on the residents shall be documented.

Interpretation: Goal: To ensure the proper documentation of the use of timeout and staff checks.

Additional information: None

Compliance Determination:

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 Examine documentation of timeout to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1320 (A), (B), (C), & (D). Physical restraint.

6VAC35-41-1320 (A). Physical restraint.

A. Physical restraint shall be used as a last resort only after less restrictive interventions have failed or to control residents whose behavior poses a risk to the safety of the resident, others, or the public.

1. Staff shall use the least force deemed reasonable to be necessary to eliminate the risk or to maintain security and order and shall never use physical restraint as punishment or with the intent to inflict injury.
2. Staff may physically restrain a resident only after less restrictive behavior interventions have failed or when failure to restrain would result in harm to the resident or others.
3. Physical restraint shall be implemented, monitored, and discontinued only by staff that have been trained in the proper and safe use of restraint.
4. Physical restraint shall mean the application of behavior intervention techniques involving a physical intervention to prevent an individual from moving all or part of that individual's body.

Interpretation: Goal: To ensure that residents are properly restrained and only as a last resort.

Additional information: The facility program should specify each element. If Handle with Care is used the elements are part of that program.

Compliance Determination:

Interview staff to determine compliance with this section.

Review sample staff training records.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

6VAC35-41-1320 (B). Physical restraint.

B. Written procedures governing use of physical restraint shall include:

1. The staff position who will write the report and timeframe;
2. The staff position who will review the report and timeframe; and
3. Methods to be followed should physical restraint, less intrusive interventions, or measures permitted by other applicable state regulations prove unsuccessful in calming and moderating the resident's behavior.

Interpretation: Goal: To ensure that residents are properly restrained and only as a last resort.

Additional information: None

Compliance Determination:  Examine procedure to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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 "Written" means the required information is communicated in writing. Such writing may be available in either hard copy or in electronic form.

6VAC35-41-1320 (C). Physical restraint.

C. All physical restraints shall be reviewed and evaluated to plan for continued staff development for performance improvement.

Interpretation: Goal: To ensure the appropriate use of physical restraints.

Additional information: None

Compliance Determination:  Examine documentation of review to determine compliance with this section.

Applicable definitions: None.

6VAC35-41-1320 (D). Physical restraint.

D. Each application of physical restraint shall be fully documented in the resident's record including:

1. Date and time of the incident;
2. Staff involved;
3. Justification for the restraint;
4. Less restrictive behavior interventions that were unsuccessfully attempted prior to using physical restraint;
5. Duration;
6. Description of method or methods of physical restraint techniques used;
7. Signature of the person completing the report and date; and
8. Reviewer's signature and date.

Interpretation: Goal: To ensure proper documentation of each restraint.

Additional information: None

Compliance Determination:  Review a sample of case files for to determine compliance with requirement to document physical restraint.

Applicable definitions:  "Case record" or "record" means written or electronic information relating to one resident and the resident's family, if applicable. This information includes, but is not limited to, social, medical, psychiatric, and psychological records; reports; demographic information; agreements; all correspondence relating to care of the resident; service plans with periodic revisions; aftercare plans and discharge summary; and any other information related to the resident.  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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6VAC35-41-1330. Chemical agents.

6VAC35-41-1330. Chemical agents.

Staff are prohibited from using pepper spray and other chemical agents to manage resident behavior.

Interpretation: Goal: Establish the prohibition of chemical agents

Additional information: None

Compliance Determination:  Interview staff to determine compliance with this section.

Applicable definitions:  "Resident" means an individual who is legally placed in, formally placed in, or admitted to a juvenile residential facility for supervision, care, training, or treatment on a 24-hour per day basis.

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