SUBSTANCE ABUSE TREATMENT SERVICES INSTRUCTIONS Completion of Application: Carefully review the entire application package before completing the application.
Applicants must be in compliance with requirements of Appendix A of 105 CMR 164 Licensure of Substance Abuse Treatment Programs. Submission of an application constitutes affirmation that applicant is fully compliant with these requirements. Applications must be completed as follows:
1. Complete information requested on pages 1, 2, 3 and 4.
2. Complete all items. If an item is not applicable to your program, note “N/A” in the space provided or in the listing of Tabs (application documentation).
3. The “Attestations and Certifications” section on page 4 must be signed in ink by the specified applicant authorities.
5. Signatures must be witnessed and confirmed by a notary public.
6. The listing of required application documentation begins on page 5. Information requested must be provided in the form and order specified -- that is, narrative descriptions when instructed to “describe” and forms, policies, certificates, etc. attached when required.
7. Tables included with this package must be used to record requested information; applicants may make copies of these tables as needed. All required tables are at the end of the application. Insert completed tables in the application under the appropriate Tab.
8. Enter applicant program name in the space provided at the top of each page.
9. Each documentation item must be numbered as specified in the “Tab No.” column. Note that the relevant regulatory section is listed in the right hand column to assist applicants in ensuring that the documentation provided complies with regulatory requirements. If a Tab is not applicable to your program, include a page listing the Tab Number and noting that it is “N/A.”
10. Application documentation must be assembled in the order listed, with tabbed dividers between each numbered item.
11. Do not staple or bind documentation.
Submission of Application: 1. Copy pages 1 and 2 and send them to:
Department of Public Health
Bureau of Substance Abuse Services
250 Washington Street, Third Floor
Boston, MA 02108
Attn: Gerry Romano
2. Send the original of pages 1 and 2 and all application documentation to the licensing inspector for your region as follows:
Program Mailing Address: NOTE: This is the address BSAS will use to send license and all other notices.
Applicant (Corporate) Legal Name:
Applicant (Corporate) Mailing Address:
Applicant Organization Type:
Commonwealth of Massachusetts Department, Agency or Institution
Corporation, specify whether: For Profit, or Not for Profit (attach 501 C(3) certificate) Incorporated in (state):
Partnership Sole Proprietor Other: specify:
Licensing Application For: New Program Existing Program (Renewal)
Is program funded by BSAS? Yes No
CURRENT LICENSES, APPROVALS and ACCREDITATIONS: Complete the table below. Enter “N/A” if license, approval or accreditation is not applicable. Include copies of licenses, approvals and accreditations in Appendix A of the application, using numbered tabs as listed below.
Appendix A Order
MA-FD Controlled Substance Registration
MA-FD Controlled Substance Registration for Suboxone
US-DEA Controlled Substance Registration
Accreditations: Identify accrediting body:
Dates of Current Accreditation
Joint Commission (formerly JCAHO)
MEDICALLY MANAGED INTENSIVE INPATIENT DETOXIFICATION Special Populations:
No. of beds: Adolescent Pregnant Women
Check if providing, directly or through QSOA: Methadone Suboxone
OUTPATIENT SERVICES: Check if prescribing suboxone: Special Populations:
Driver Alcohol Education Adolescent Pregnant Women
OPIOID TREATMENT: Check if prescribing: Methadone Suboxone Special Populations:
Detoxification Adolescent Pregnant Women
Officer of Governing Body:
(e.g. president, chairperson of board)
T el :
T el :
T el :
Attestations and Certifications:
I/We hereby certify under the penalties of perjury that to the best of my/our knowledge:
As required by M.G.L.c. 62C, §49A, the applicant has complied with all laws of the Commonwealth related to taxes, reporting of employees and contractors, and withholding and remitting of child support;
The applicant will comply with the laws of the Commonwealth of Massachusetts and all applicable rules and regulations promulgated by the Department of Public Health; and
The information included in this application and submitted to the Department related to this application is true.
On this _____ day of _____________, 20__, before me, the undersigned notary public, personally appeared the above named persons, proved to me through satisfactory evidence of identification, which were ___________________________________ __________________________________________________, and ______________________________________________,
to be the persons who signed the preceding document in my presence, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of their knowledge and belief.
My Commission Expires on
The following pages list documentation which must be submitted with the application.
All documentation must be included at the time of application submission. Applications with incomplete documentation will be returned.
Attach documentation in the order listed, with each item labeled with a separate tab.
Applications not conforming to this requirement will be returned.
Each item of documentation must comply with Appendix A of 105 CMR 164 Licensure of Substance Abuse Treatment Programs. Relevant sections of regulations are listed to the right of each item for reference.
Treatment Goals and approach: Describe applicant’s substance abuse treatment, including the following, listed in the order presented below, and identified by letter and topic (e.g. ‘a. Treatment Methods’).
a. Treatment Methods: describe treatment methods used specifying how treatment methods are expected to achieve program goals. Include standards used to determine appropriateness of methods, identifying which methods are evidence based.
b. Special Populations: Describe special populations served and design of programs for these populations.
164.074 (A)(B)(D)(I) (J)
164.082 (A) (B) (C)
Exclusion Criteria: Attach policies and procedures describing criteria for excluding individuals
Client Record: Attach sample of client record forms and formats (new applications only).
Qualified Service Organization Agreements: If serving pregnant women, and not directly providing emergency obstetrical and medical back-up, attach QSOAs for these services.
Training: Describe the following, in the order presented below and identified by letter and topic.
a. Orientation of Contract or Temporary Staff
b. Schedule of monthly in-service training for previous 12 months, related to substance use disorders, co-occurring disorders, sexually transmitted diseases and viral hepatitis. Include subject, presenter and duration of training session.
c. HIPAA and 42 CFR: describe method for training staff on requirements of HIPAA and 42 CFR; include frequency, duration and method of documenting participation in training.
d. HIV/AIDS Education: schedule, including subject, presenter and duration of training to develop staff skills regarding HIV/AIDS
164.044 (B)(2)(b,d,e,f); (D), (F) 164.084
Supervision of Contract and Temporary Staff: Identify supervisors of contract and temporary staff; describe schedule and method of supervision and method of documenting supervision.
Staff List: Using the table provided, list all clinical and patient care staff positions, incumbents, their qualifications, and experience in substance abuse treatment services. Attach resumes.
Staff Schedule: Using the tables provided, list nursing and patient care staff schedule for each shift.
Multi-Disciplinary Review: Describe method of providing multidisciplinary review, including participants (specify if by QSOA), frequency, and how the review is documented.
SUBSTANCE ABUSE TREATMENT SERVICES
Assessment: Describe assessment process, listed in the order presented below, and identified by letter and topic.
a. Appropriateness: Describe method for determining appropriateness of care in relation to client’s treatment need, including standards used to formulate diagnosis.
b. Assessing of Infections Disease Risk: Attach protocols used to assess clients’ risks related to HIV and TB.
c. Assessment of Prescription Medications: Attach protocols used to assess client’s current prescription medications in relation to opioid agonist medications
d. Women of Child Bearing Age: Describe process of completing pregnancy tests prior to administering opioid agonist or prior to detoxification.
e. Consent: Attach sample of consent form(s); include consent to opioid treatment.
f. Additional Evaluations: Describe method for obtaining additional evaluations when needed
164.072 (A) (B) (C) (D) (E) (F) (H)
164.302 (A) (2), (3 b & c), (4, a, e, h)
Detoxification and Maintenance: Attach the following:
a.Detoxification Protocols: All protocols for detoxification from all substances
b. Maintenance: Protocols followed to establish and adjust dosages for opioid maintenance
Individual Treatment Plan: Describe process of developing Individual Treatment Plans
Treatment Programming: Attach the following, listed in the order presented below and identified by letter and topic:
a. Schedule of substance abuse treatment programming.
b. Driver Alcohol Education: Provide the following, in the order presented below and identified by letter and topic:
(1) Describe process used to assess developmental status of clients under the age of 21.
(2) Attach curriculum used for group education, and weekly group schedule, specifying staff leading group sessions. Describe alternative programming provided to: