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Virginia DD Waiver Compliance Checklist

A comprehensive self-audit checklist covering every major DBHDS compliance area under 12VAC35-105. Know exactly where your documentation stands before the next licensing review.

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8 compliance areas, 58+ audit items. Here is what you will be reviewing.

Individual Support Plan (ISP) Documentation

Current ISP on file for every individual served, signed by all team members
ISP goals are measurable with clearly defined outcomes and timelines
ISP reviews conducted quarterly with documented progress on each goal
Annual ISP updates completed within 30 days of the anniversary date
ISP addenda documented and signed when support needs change mid-cycle
Individual preferences, strengths, and desired outcomes documented in person-centered language
Backup plans documented for each critical support need

Staff Training Records & Certifications

All DSPs completed DBHDS-required orientation before working independently
Medication Administration Training (MAT) certification current for all staff administering medications
CPR and First Aid certifications current and on file for all direct care staff
Annual refresher training on rights, abuse/neglect reporting, and emergency procedures documented
Individual-specific training completed and documented for each person the DSP supports
Behavior support plan training documented for staff working with individuals who have BSPs
Supervisor competency assessments documented annually

Incident Reporting Procedures

Serious incidents reported to DBHDS within 24 hours through CHRIS
Internal incident reports completed within 24 hours of the event
Root cause analysis completed for Level II and Level III incidents
Corrective action plans developed and implemented with documented follow-up
Incident trending reviewed quarterly in Quality Improvement meetings
Staff trained on what constitutes a reportable incident per DBHDS definitions
Deaths reported to DBHDS within 24 hours and Mortality Review completed within 10 days

Medication Administration Records (MAR)

MARs completed for every scheduled medication pass with staff initials
Physician orders on file and current for every medication listed on the MAR
PRN medications documented with indication, time, dose, outcome, and staff signature

Rights Restrictions Documentation

Human Rights Committee review and approval documented for each restriction
Restrictions are the least restrictive alternative and tied to a specific assessed risk
Written consent obtained from the individual or authorized representative

Get the Full Checklist

Download all 8 compliance areas with 58+ audit items. Includes a printable PDF version for your team.

Why Self-Audit Before DBHDS Does

DBHDS licensing reviews under 12VAC35-105 cover documentation requirements that most providers find difficult to track manually. A single missing ISP signature, an expired MAT certification, or an unreported incident can trigger corrective action plans, provisional licenses, or worse. Providers who self-audit regularly find and fix gaps before they become citations.

58+

Specific audit items across all major compliance areas

DBHDS compliance categories covered

12VAC35

Aligned to Virginia licensing regulations

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