N.J. Admin. Code § 8:111-1.4

Current through Register Vol. 56, No. 12, June 17, 2024

Section 8:111-1.4 - Qualifications and responsibilities of the medical director and physicians

(a) Facilities required under N.J.A.C. 10:161A-7 to hire a medical director shall ensure that the physician is currently licensed in accordance with the laws of this State to perform the scope of services set forth in this chapter. This physician must be certified by ASAM/ABAM, by July 15, 2016. This physician shall be a member in good standing in the medical community.

1. A physician currently licensed to practice in the State of New Jersey, who has not completed ASAM/ABAM certification by July 15, 2016, must have worked in a substance use disorders treatment facility a minimum of five years for at least 20 hours per week and have completed the ASAM/ABAM/American Association for the Treatment of Opioid Dependence (AATOD) clinicians training course, http://www.aatod.org/clinician.html.

(b) For those facilities in which the medical director is not required to be on-site on a full-time basis, the medical director is required to be on-site as often as necessary in order to perform the responsibilities of the position. The facility shall establish minimal timeframes in which the medical director is required to be on-site, as well as time limits in which the medical director shall arrive at the facility should his or her services be needed if the medical director is not on-site. The facility shall establish the parameters in which the medical director is available by cell phone/telephone, pager or other means.

(c) The medical director shall be responsible for the direction, provision and quality of medical services provided to clients including, but not limited to, the following:

1. Providing administrative oversight of the facility's medical services;

2. Assisting the administrator of the facility in the development and maintenance of written objectives, policies, a procedure manual, an organization plan and a quality assurance program for medical services, and review of all medical policies and procedures at least annually.

i. Such documentation shall be shared with the facility's physician, the director of nursing services and other appropriate medical staff on an ongoing basis or as revisions are made;

3. In conjunction with the administrator and the governing authority of the substance use disorders treatment facility, planning and budgeting for medical services;

4. Ensuring that medical services are coordinated and integrated with other client care services to ensure continuity of care for each client;

5. Ensuring that the facility complies with required medical staffing patterns set forth in this chapter;

6. Assisting in the development of written job descriptions for the medical staff, reviewing of credentials, participating in hiring medical staff, delineating privileges of medical staff and assigning duties of the medical staff;

7. Participating in staff orientation and staff education activities when applicable;

8. Approving the content and location of emergency kits or carts; medications, including controlled substances; use of over-the-counter floor stock medications maintained on a list at the facility; and the amounts that may be and are stored throughout the facility, equipment and supplies, the expiration dates of medically related time-sensitive items, the frequency with which these items are reviewed for appropriateness and completeness and assigning qualified staff to perform these reviews;

9. Reviewing any physical examination reports and medical screening results conducted off-site of a client for the preadmissions process or for other medical concerns, in order to ensure that the client's medical needs are considered and addressed in the development of the treatment plan and throughout treatment; and

10. Providing supervision of the facility's physician(s).

(d) Facility physicians who are not the medical director shall meet the following qualifications:

1. Be currently licensed as a physician in New Jersey;

2. Have at least two full years of experience as being employed as a physician; and

3. Be a member in good standing in the medical community.

(e) Facility physician(s) shall not serve as the facility's medical director unless meeting the qualifications set forth in (a) above.

(f) Physicians providing medical care to clients in a residential substance use disorders treatment facility shall be responsible for:

1. Ensuring the provision or documentation of a complete medical examination as required by N.J.A.C. 8:111-9.1;

2. Ordering, interpreting and documenting medical and drug screening tests as appropriate;

3. Documenting all orders for medical services to be provided to the client, including frequency and type of treatment, therapies to be administered or coordinated and medications prescribed;

4. Ensuring that all medical interventions are documented in the clinical record; and

5. Ensuring that medical follow-up of all acute or chronic illness and conditions are entered in the client's treatment plan, that referrals for medical services are accomplished during the client's treatment or as part of the client's continuum of care plan, as appropriate.

(g) In facilities that provide medical services on-site, the physician shall ensure that the appropriate medical staff participate as part of the multidisciplinary treatment team, with such participation documented in client progress notes.

(h) A facility is not required to hire psychiatrists, but if a facility does elect to hire a psychiatrist, the facility shall engage psychiatrists who are certified or eligible for certification by the American Board of Psychiatry and Neurology, Inc., or the American Osteopathic Board of Neurology and Psychiatry.

N.J. Admin. Code § 8:111-1.4

Amended and recodified from 10:161A-1.4 53 N.J.R. 2208(a), effective 12/20/2021