12VAC35-105: DBHDS Provider Licensing, Inspections, and Appeals

To operate legally under 12VAC35-105, the DBHDS licensing requirements obligate any organization delivering mental health, developmental disability, substance use disorder, or brain injury residential services in Virginia to hold a valid license from the Department of Behavioral Health and Developmental Services before serving a single individual. The regulation, issued under Title 37.2 of the Code of Virginia, sets standards for governance, staffing, facilities, documentation, and incident reporting, and it gives the commissioner enforcement tools that run from written sanctions to summary suspension.

Who Has to Be Licensed

The license requirement attaches to the organization, not the individual clinician. Any person, entity, or organization providing one of the 33 service categories listed in the regulation must be licensed, including outpatient mental health and substance use treatment, group homes and other residential services, assertive community treatment, case management, crisis stabilization, day support, therapeutic day treatment, respite, and medication for opioid use disorder.¹

Federal agencies are excluded. Individual practitioners licensed by a Virginia health regulatory board under the Department of Health Professions are also exempt, as are practitioners exempt from health professions licensing under specific Code of Virginia provisions covering medicine, nursing, professional counseling, psychology, and social work.² A licensed clinical psychologist in solo private practice does not need a separate DBHDS license. The moment that psychologist forms an organization employing other clinicians to deliver listed services, the organization itself needs one.

The Three License Types

DBHDS issues conditional, provisional, and full licenses, and the type you hold determines how long you can operate before the next review.

A conditional license goes to new providers that have met the administrative and policy requirements but have not yet demonstrated compliance with every operational regulation. It lasts up to six months and can be renewed, but total time on conditional status cannot exceed 12 consecutive months.³

A provisional license is issued when a provider cannot maintain compliance, has violations threatening health or safety, has multiple violations, or has failed to follow through on a corrective action plan. It also caps at six months per term and 12 consecutive months total.³

A full license is granted once a provider demonstrates compliance with all applicable regulations. It can run for up to three years (triennial) or one year (annual), at the commissioner’s discretion. After a conditional or provisional term, the first full renewal cannot exceed one year. The commissioner can shorten a license term or downgrade the license type at any point if compliance slips.³

What You Need Before You Apply

The initial provider application requires disclosure of your business structure and an organizational chart showing the chain of command from the governing body to direct care staff. Alongside that, you have to assemble:

A complete policy and procedure manual, cross-referenced to specific regulatory sections, including a written human rights policy that complies with 12VAC35-115⁴
A narrative description of services explaining what will be delivered and how
A mission statement and a philosophy of care consistent with state-approved treatment approaches
A quality assurance plan covering error tracking, complaints, clinical outcomes, and serious incidents
Financial documentation, including a projected budget, proof of startup funds, and a business plan projecting at least one year of operational solvency
Evidence of required insurance coverage, including professional liability and general liability
A record management system that protects patient privacy while allowing state inspectors immediate access

Inspectors cross-check policies against the service narrative, staffing plans against service descriptions, and budgets against projected operations. Inconsistencies between documents are a common reason applications stall.

Applying Through the CONNECT Portal

All applications run through the DBHDS CONNECT Provider Portal, a paperless platform for submissions, document uploads, status tracking, and communication with licensing staff.⁵ New applicants register by entering identification, provider organization details, and contact information, then complete a training module and attest to viewing required videos. Account validation typically takes 24 to 48 hours after a security review.⁶

Once validated, you begin the Initial Provider Application from your dashboard. DBHDS reviews the packet for completeness; missing items generate a portal notification with revision instructions. After the document review clears, an inspector schedules a pre-licensing site visit to verify the physical facility and interview leadership. Passing the visit produces a conditional license, and you can begin operating while demonstrating full compliance during the months that follow.

Staffing, Training, and Background Checks

Providers must hire Qualified Mental Health Professionals (QMHPs) registered with the Virginia Board of Counseling under 18VAC115-80. QMHPs cannot practice independently; they work as employees or contractors of DBHDS or a DBHDS-licensed provider. The regulation distinguishes among QMHP-Adult, QMHP-Child, and QMHP-Trainee designations, each with its own education and experience thresholds in human services. Every personnel file must contain verified credentials and a clear job description.

Criminal history background checks are mandatory, including the Central Criminal Records Exchange and the Child Protective Registry.⁷ Your written policy must require applicants to disclose prior convictions or pending charges for barrier crimes listed in Virginia Code §§ 37.2-416, 37.2-416.1, 37.2-506, 37.2-506.1, and 37.2-607, as well as any founded case of child abuse or neglect. A nolo contendere plea counts as a conviction. Each employee’s file must include the disclosure statement and evidence that all required screenings were submitted.

Training is ongoing, not one-time. DBHDS guidance requires most core topics to be completed within 15 business days of hire, with annual retraining:⁸

Serious incident reporting, within 15 business days of hire and annually
Emergency preparedness, on the same schedule
Infection control, within 15 business days and annually
Behavior intervention policies within 15 business days, enrollment in an approved behavior supports program within 30 days, and annual retraining
Medication administration through a Board of Nursing-approved program within 30 days of hire, an annual refresher, and mandatory retraining within 10 business days of any documented medication error
CPR and first aid registration within 30 days of hire, with retraining before certification expires

Staff-to-individual ratios are set by service intensity, and proof of every training completion must be available during inspections.

Facility and Safety Standards

Every service location needs a valid occupancy permit from local building officials, annual fire inspections, working smoke detectors, and fire extinguishers. Residential settings face detailed rules on living space: single-occupancy bedrooms must have at least 80 square feet of floor space, multi-occupancy bedrooms at least 60 square feet per person, and no more than four residents may share a bedroom (two in group homes). Each person needs private storage accessible from the bedroom, and no required path to a bathroom may pass through another person’s bedroom.⁹

Infection control policies must address handwashing, sanitation of common areas, and medical waste handling. An emergency preparedness plan covering natural disasters, power outages, and medical emergencies must be documented and practiced through regular drills involving both staff and individuals receiving services.

Inspections and Corrective Action Plans

The Office of Licensing conducts annual unannounced inspections, with developmental services provider inspections typically starting at the beginning of the calendar year.¹⁰ Licensing specialists sample individual records and employee files, check policy compliance, and verify that previously cited deficiencies have been corrected.

When violations are identified, the provider receives a licensing report and must submit a written corrective action plan within 15 business days. The plan must include the corrective steps, a completion date for each action, and a designated person responsible for implementation. One extension of up to 10 additional business days may be granted if requested before the deadline. If violations pose a danger to individuals receiving services, an immediate corrective action plan is required with no waiting period.¹¹

DBHDS either approves the plan or returns it for revision, in which case the provider has 10 additional business days to resubmit. Failure to submit or implement an adequate plan is itself grounds for revocation.

Sanctions, Suspension, and Revocation

Under Virginia Code § 37.2-419, the commissioner may impose sanctions when a licensed provider violates the licensing regulations, the human rights regulations, or the underlying statutes, and the violation either adversely affects the rights of individuals or poses an imminent and substantial threat to health, safety, or welfare. Before sanctions are imposed, the commissioner must notify the provider in writing of the specific violations and convene an informal conference where a presiding officer recommends whether to issue a special order. Sanctions in a special order stay in effect during any appeal.¹²

A license or renewal may be denied, and any existing license may be revoked or suspended, for:¹³

Violating the licensing statutes or regulations
Conduct or practices detrimental to the welfare of individuals or in violation of their human rights
Permitting or aiding illegal acts
Failing to submit reports or make records available on request
Refusing to admit a DBHDS representative who presents state-issued photo identification
Failing to submit or implement an adequate corrective action plan
Submitting misleading or false information to the department

That last ground stands on its own. Inaccurate information in an initial application, corrective action plan, or routine report can independently justify revocation even without any other deficiency.

For group homes and residential services for adults, the commissioner can issue a summary suspension order when conditions pose an immediate and substantial threat to residents. It takes effect immediately, before any hearing.¹⁴ The department must arrange an administrative hearing within three business days of issuing the order. The hearing officer submits written findings and a recommendation within five business days, and the commissioner issues a final order within seven business days of receiving that recommendation. A provider may appeal an upheld suspension to circuit court within 10 days of the final order.

Appealing an Adverse Licensing Decision

A provider that receives a notice of intent to deny or revoke has 10 days from the certified letter to submit a written request for an informal conference to the Director of the Office of Licensing. Miss the deadline and the license closes on the 10th day; there is no grace period.¹⁵

Once a request is received, the Director of Licensing notifies the commissioner within five working days. A presiding officer contacts the provider within five business days of appointment to schedule the conference, which must occur no later than 45 days after appointment unless all parties agree otherwise. The presiding officer submits a written report with recommendations within 14 business days of the conference, and the commissioner’s final decision is communicated within five business days after that.

If the commissioner’s decision goes against the provider, the next step is a formal administrative hearing on a compressed schedule: the hearing officer is assigned within two days, a pre-hearing phone conference is scheduled within four days, and documentary evidence exchange follows. A provider dissatisfied with the formal hearing outcome may appeal to the circuit court in the locality where the provider is located.

1
Virginia Code Commission. Virginia Administrative Code 12VAC35-105-30 – Licenses
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Virginia Code Commission. Virginia Administrative Code 12VAC35-105-20 – Definitions
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Virginia Code Commission. Virginia Administrative Code 12VAC35-105-50 – Issuance of Licenses
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Legal Information Institute. Virginia Administrative Code 12VAC35-115-175 – Human Rights Complaint Process
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Virginia Department of Behavioral Health and Developmental Services. Licensing Information for Providers and Applicants
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Department of Behavioral Health and Developmental Services (DBHDS). CONNECT Provider Portal – How Do I Register for the Initial Application Process
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Virginia Code Commission. Virginia Administrative Code 12VAC35-105-400 – Criminal Background Checks and Registry Searches
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Department of Behavioral Health and Developmental Services (DBHDS). Frequency of Training and Retraining Guidance for DBHDS Licensed Providers
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Virginia Code Commission. Virginia Administrative Code 12VAC35-105 – Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services
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Department of Behavioral Health and Developmental Services (DBHDS). 2026 Annual Inspections for Providers of Developmental Services
11
Virginia Code Commission. Virginia Administrative Code 12VAC35-105-170 – Corrective Action Plan
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Virginia Code Commission. Virginia Administrative Code 12VAC35-105-100 – Sanctions
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Virginia Code Commission. Virginia Administrative Code 12VAC35-105-110 – Denial, Revocation, or Suspension of a License
14
Virginia Code Commission. Virginia Administrative Code 12VAC35-105-115 – Summary Suspension
15
Virginia Department of Behavioral Health and Developmental Services (DBHDS). Office of Licensing Protocols