Substance abuse treatment services instructions



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Department of Public Health

Bureau of Substance Abuse Services

APPLICATION FOR APPROVAL OF A GENERAL HOSPITAL

LICENSED UNDER M.G.L. c. 111, § 51

TO PROVIDE

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:


Metrowest:
Judi Robbins

Licensing Inspector

DPH Metrowest Regional Office

5 Randolph Street

Canton, MA 02021

781-828-7909

TTY: 781-828-7277

FAX: 781-828-7703




Greater Boston:
Ben Sullivan

Licensing Inspector

DPH Greater Boston Public Health Office

10 Malcolm X Blvd.

Roxbury, MA 02119

617-541-8306

TTY: 617-541-8314

FAX: 617-541-2861




Central & Western:
Erica M. Piedade,

Licensing Inspector

DPH Western MA Regional Health Office

23 Service Center

Northampton, MA 01060

413-586-7525, x1182

TTY: 800-769-9991

FAX: 413-784-1037




Northeast:
Ann Canavan

Licensing Inspector

Northeast Regional Health Office

365 Tewksbury Hospital

East Street

Tewksbury, MA 01876

978-851-7261, x 4023

TTY: 978-851-0829

FAX: 978-640-1027


Southeast:
Ruth Karmelin-Bice

Licensing Inspector

DPH Southeast Regional Health Office

1736 Purchase Street

New Bedford, MA 02740

508-984-0624

TTY: 508-984-0636

FAX: 508-984-0605








Department of Public Health

Bureau of Substance Abuse Services

APPLICATION FOR APPROVAL OF A GENERAL HOSPITAL

LICENSED UNDER M.G.L. c. 111, § 51 TO PROVIDE

SUBSTANCE ABUSE TREATMENT SERVICES


Program Legal Name:      

Program Location Address:

Street:      

Tel:      

TTY/TDD:     

Fax:     


City:      

State: Massachusetts

Zip:      

Program Mailing Address: NOTE: This is the address BSAS will use to send license and all other notices.

Street:      

Tel:      

TTY/TDD:     

Fax:     


City:      

State: Massachusetts

Zip:      



Applicant (Corporate) Legal Name:          

Applicant (Corporate) Mailing Address:

Tel:      

TTY/TDD:     

Fax:     


Street:      

City:      

State:      

Zip:      

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:      



EIN/TIN:      

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

Licenses/Approvals


License/approval No.

Expiration Date

1


MA-DPH/BSAS License:

     

     

2

MA-DPH/DHCQ:

     

     

3

MA-DMH

     

     

4

MA-FD Controlled Substance Registration

     

     

5

MA-FD Controlled Substance Registration for Suboxone

     

     

6

US-DEA Controlled Substance Registration

     

     

Accreditations: Identify accrediting body:

Dates of Current Accreditation

Start End

7

Joint Commission (formerly JCAHO)

     

     

8

CARF

     

     

9

COA

     

     

10

Other:      

     

     



SERVICES PROVIDED


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

Counseling

Operating Under the Influence Offender Aftercare

Day Treatment


OPIOID TREATMENT: Check if prescribing: Methadone Suboxone Special Populations:

Detoxification Adolescent Pregnant Women

Maintenance


RESPONSIBLE OFFICIALS

Officer of Governing Body:      

(e.g. president, chairperson of board)

Title:     

Street Address:     

T el :     

City:      

State:      

Zip:     

Fax :     

Email address:     

Executive Director:      

Street Address:     

T el :     

City:     

State:     

Zip:     

Fax      

Email address:     

Program Director:      

Street Address:     

T el :     

City:     

State:     

Zip:     

Fax      

Email address:      

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.

_______________________________________________________ ________________________

Officer of Governing Body Date

_______________________________________________________ ________________________

Executive Director Date


Commonwealth of Massachusetts

County of ____________________


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.


___________________________________________

Notary Public



My Commission Expires on


Application Documentation:

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.

TAB No.

Application Documentation

Regulation


Section

PROGRAM DESIGN


1

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)

164.070(C)

2

Exclusion Criteria: Attach policies and procedures describing criteria for excluding individuals

164.070(G)(H)(I)

3

Client Record: Attach sample of client record forms and formats (new applications only).

164.083 (B)(5)

4

Qualified Service Organization Agreements: If serving pregnant women, and not directly providing emergency obstetrical and medical back-up, attach QSOAs for these services.

164.034

164.082
PERSONNEL

5

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

164,040(A)(20)

164.044 (B)(2)(b,d,e,f); (D), (F)
164.084

6

Supervision of Contract and Temporary Staff: Identify supervisors of contract and temporary staff; describe schedule and method of supervision and method of documenting supervision.

164.044

164.047

Staffing Pattern:

7

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.

164.048 (D)

8

Staff Schedule: Using the tables provided, list nursing and patient care staff schedule for each shift.

9

Multi-Disciplinary Review: Describe method of providing multidisciplinary review, including participants (specify if by QSOA), frequency, and how the review is documented.

164.048 (B)(1)


TAB No.

Application Documentation

Regulation


Section

SUBSTANCE ABUSE TREATMENT SERVICES


10

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)

11
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

164.133

164.302

12

Individual Treatment Plan: Describe process of developing Individual Treatment Plans

164.073 (A)

13

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:

i. Clients under 21 years of age

ii. Clients who do not speak English

iii. Accommodate clients’ employment or other obligation

iv. Accommodate clients suffering from mental health disorders which limit ability to participate

c. Operating Under the Influence Second and Multiple Offender Aftercare: Describe the following, in the order presented below, and identified by letter and topic:

(1) Alcohol and Drug Screening Protocols



(2) Procedures for Making Reports to Referring Court or Agency

164.074

164.133

164.212

164.223

164.232

14

Pregnant Women: Attach protocols followed in providing opioid treatment for pregnant women

164.304

15
Referrals: Describe process for making referrals for continued substance abuse treatment; include process of referring clients to opioid treatment (methadone and/or suboxone)

164.074 (J)

16

Preventing Discharge to a Shelter: Describe steps taken to prevent discharge to a homeless shelter.

164.075

17

Aftercare: Attach policy and procedure for aftercare, including referrals.

164.076


APPENDIX A:

Copies of Current Licenses, Approvals and Accreditations

STAFF LIST: Include at TAB 7. List below all current directors, senior clinical staff, nursing staff and patient care staff; staff credentials and experience. Attach additional sheets if necessary.

Position

Full Name

Highest Educ. (degree/year)


Years Experience in Substance Abuse Treatment
Program/Clinical Director

     

     

     

Medical Director


     

     

     

Master’s Level Clinical Staff(specify position)







     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Nursing Director

     

     

     

Nursing Staff:







     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Patient Care (or Ancillary) Staff: (e.g. OT, PT, rehabilitative staff; non-licensed direct care staff)







     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Attach Resumes of Incumbents:

Program/Clinical Director Medical Director Senior Clinician specializing in services to youth if serving youth(164.082(B))

Nursing Director/Supervisor Psychiatrist or Psychologist if providing outpatient services (or attach QSOA)





NURSING STAFF SCHEDULE: Include at Tab 8. Attach additional sheets if needed.

Shift



List Nursing Staff on Each Shift:

Full Name

Position

Indicate which days staff person is on duty

7 am – 3 pm


     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

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Mon Tues Wed Thurs Fri Sat Sun

     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

Mon Tues Wed Thurs Fri Sat Sun

3pm – 11 pm


     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

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11 pm – 7 am


     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

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Mon Tues Wed Thurs Fri Sat Sun



PATIENT CARE (ANCILLARY) STAFF: Include at Tab 8. Attach additional sheets if needed.
Shift



List Patient Care (Ancillary) Staff on each shift

Full Name

Position

Indicate which days staff person is on duty

7 am – 3 pm


     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

Mon Tues Wed Thurs Fri Sat Sun

     

     

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3pm – 11 pm


     

     

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11 pm – 7 am


     

     

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BSAS Application for Approval of General Hospital Substance Abuse Treatment Program



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