Virginia Developmental Services Record-Keeping Policy Manual
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The Virginia ADM-1.0 Administration Policy establishes the framework for compliance with 12VAC35-105, which governs record-keeping requirements for developmental services under the Virginia Department of Behavioral Health and Developmental Services (DBHDS). This policy ensures that providers maintain accurate, secure, and comprehensive documentation to support person-centered care, regulatory compliance, and audit readiness. Aligned with federal Home and Community-Based Services (HCBS) Final Rule requirements and Virginia Code §37.2-404, this policy emphasizes the importance of maintaining records that reflect high-quality service delivery and uphold individual rights.
Providers are required to document individualized service plans (ISPs), progress notes, assessments, and discharge summaries in a timely manner to demonstrate compliance with service goals and Medicaid standards. Records must be securely stored in accordance with HIPAA regulations, with retention periods of at least five years post-discharge for adults or until age 28 for minors. Providers must also implement robust quality assurance processes, including regular audits and staff training, to ensure documentation accuracy and adherence to DBHDS standards.
This policy underscores the critical role of proper record management in ensuring accountability, supporting reimbursement claims, and facilitating audits. By adhering to 12VAC35-105, providers can deliver high-quality developmental services while maintaining full compliance with Virginia’s regulatory framework.