Staffing Pattern

(A) The Licensed or Approved Provider shall provide an adequate number of qualified personnel to fulfill the service objectives and needs of each patient or resident served based upon acuity, patient assessments, treatment plans, and other relevant factors as determined by the Licensed or Approved Provider. At a minimum, such staffing shall include: (1) A program director who shall administer the day-to-day operations of the facility and who shall be on the premises during regular business hours. In his or her absence a professional staff person shall be designated to act in his or her place. The Licensed or Approved Provider shall provide the designee with contact information for the administration in the event of an emergency. (2) A multidisciplinary team that includes professionals sufficient to meet the needs of each patient or resident served with recognized expertise in a variety of areas of substance use disorder treatment. The team may include the Licensed or Approved Provider's staff as well as other treatment professionals through QSOAs, as necessary to care for patients and residents served. The team may include, but is not limited to, physicians, psychiatrists, psychologists, acupuncturists, advanced practice registered nurses, physician assistants, registered nurses, licensed practical nurses, licensed social workers, psychiatric nurses, substance use disorder counselors with master's or bachelor's degrees in a related field and certified or licensed substance use disorder counselors, licensed mental health counselors, case managers, care coordinators, recovery coaches, and peers. (a) The multidisciplinary team shall review assessments, treatment plans and other patient- and resident-specific issues to ensure quality of services and to provide education and training to staff. (b) The Licensed or Approved Provider shall ensure that the multidisciplinary team is incorporated into the staffing plan. (B) In addition, the Licensed or Approved Provider shall ensure that on each shift specific staff members are designated to: (1) Initiate an emergency response as described in 105 CMR 164.062; and (2) Perform cardio-pulmonary resuscitation. (C) The Licensed or Approved Provider shall establish a staffing pattern sufficient to meet the program's patient or resident acuity, which includes paid staff in numbers, qualifications and shift coverage to ensure: (1) required services are provided; (2) safety of patients, residents and staff; and (3) the program operates in accordance with 105 CMR 164.000. (D) The Department may issue guidance specifying minimum numbers of staff, and may determine that a staffing pattern is insufficient to ensure 105 CMR 164.048(C)(1) through (3). Providers must make every reasonable effort to provide sufficient staff in order to guarantee admissions up to their licensed capacity.