105 CMR 164.314
Staffing Pattern
(A) In accordance with federal regulations, the Licensed or Approved Provider shall designate
a Medical Director who shall be responsible for administering all medical services provided by
the program, and for ensuring the program complies with all applicable federal, state, and local
laws and regulations. The Medical Director shall be a physician with documented clinical
experience with opioid-dependent, alcohol, and other drug-dependent persons or 40 hours of
documented continuing education in treating addicted persons and medications for treatment of
addiction, including all FDA-approved medications for treatment of opioid use disorder. The
Medical Director shall ensure there are policies and procedures in place for:
(1) Ensuring that a medical evaluation, including a medical history is taken for each patient;
and
Ensuring that appropriate laboratory studies are completed and recorded in patient
records.
(B) In addition to the staffing requirements of 105 CMR 164.048, the Licensed or Approved
Provider shall establish a staffing pattern in sufficient numbers and positions necessary for the
service type provided. Such staffing pattern shall include the following positions:
Senior Clinician among direct service staff who shall be responsible for the clinical/
educational operation of the substance use disorder service;
(2) Licensed psychiatrist or licensed psychologist on staff or available through a QSOA;
Practitioner, registered nurse, or licensed practical nurse on staff and on-site during
hours when medication is dispensed;
(4) If serving pregnant women, an obstetrician/gynecologist available on staff or through
a QSOA;
(5) Sufficient staff, including counseling staff, for coverage on all shifts to ensure patient
needs are met.
(C) Supervision. In addition to supervision requirements set forth in 105 CMR 164.044, the
Licensed or Approved Provider shall ensure supervision of nursing staff is overseen by a
practitioner, a registered nurse, or a Licensed Practical Nurse (LPN) or other Qualified Health
Care Professional provider defined under 105 CMR 164.005 who possesses the skills and
supervision experience as determined by program and/or meets the requirements under
professional licensure; provided, however that the supervisor shall be educationally prepared at
or above the level of the nursing staff under his or her supervision.