New Jersey SUD Personnel File and Staff Qualification Requirements Under N.J.A.C. 8:111 and 8:43K

Answer this before you open a single personnel file.

Residential. The Department of Health readopted the chapter with technical changes and recodified it: "Effective Dates: November 10, 2021, Readoption; December 20, 2021, Technical Changes and Recodification. New Expiration Date: November 10, 2028." The section numbers map one for one, so 10:161A-3.5 is 8:111-3.5. If your policy manual or audit tool still says 10:161A, it cites a chapter that does not exist.

Outpatient. N.J.A.C. 8:43K was proposed April 21, 2025 at 57 N.J.R. 743(a) in the New Jersey Register, adopted January 15, 2026, filed January 16, 2026 as R.2026 d.045, and took effect April 6, 2026. It expires April 6, 2033. In the same rulemaking the Department repealed the old outpatient chapter outright: the cover block of the Notice of Adoption reads "Adopted Repeals: N.J.A.C. 10:161B", and 10:161B is not among the provisions the Filed line lists as not adopted.

On the license paper, be precise. No transitional or interim license is issued. Proposed N.J.A.C. 8:43K-2.11, Transitional licensure, which would have deemed a facility fully licensed under N.J.A.C. 8:43A and/or 8:121 to be licensed under the new chapter, is listed in the Filed line among the provisions not adopted. The Department explained why in its Summary of Agency-Initiated Changes: "The Department will not adopt proposed new N.J.A.C. 8:43K-2.11, Transitional license, because the Department will not issue an interim license." Adopted 8:43K-2.1(a) still contains a leftover reference to a transitional license, so the accurate statement is that none is issued, not that the chapter never mentions one.

8:43A did not go away. The Department proposed to repeal N.J.A.C. 8:43A-20, 21, 22, 23 and 26 (Subchapter 26 is Drug Abuse Treatment Services) and to amend 8:43A-1.1, 1.3, 2.2 and 33.3 to strip outpatient drug abuse treatment out of that chapter. The Filed line records all of it as "not adopted." The Department's stated reason: maintaining those rules "will allow facilities a choice between being licensed pursuant to N.J.A.C. 8:43A or 8:43K." So 8:43A still lists outpatient drug abuse treatment in its scope, still carries a drug abuse treatment fee, and still states drug abuse treatment standards at 8:43A-26. What is unambiguous is that 10:161B is gone. Which of 8:43A and 8:43K governs your program is a function of the license you hold and elect to renew, and it is the first thing to confirm with the Division of Certificate of Need and Licensing.

The adopted chapter contains one renewal pathway that expressly converts an existing license into an 8:43K license, at 8:43K-2.1(b)2: "Renewal of an existing license issued pursuant to N.J.A.C. 8:43A to provide outpatient services as a new license pursuant to this chapter, at least 90 days before the expiration of its existing license." (An accredited facility may instead renew by deemed status under 8:43K-2.6, which routes back through 2.1; what CARF accreditation asks of the personnel file is in our CARF behavioral health guide.) The Department separately said it "will issue new licenses to the providers with multiple existing licenses following the effective date of this rulemaking." The adopted text does not name 10:161B licensees in that pathway, and the withdrawn transitional section named only 8:43A and 8:121. If your license paper was issued under 10:161B, no adopted provision states how it converts. Confirm with the Division of Certificate of Need and Licensing before you calendar anything.

On standards, the conservative operating assumption is different from the license question and much simpler. Because 10:161B was repealed on April 6, 2026 with no phase-in for staffing, credentialing or personnel records anywhere in the adopted text, run your outpatient personnel file to 8:43K now. The only two dated carve-outs in the whole chapter were the October 3, 2026 measles screening date at 8:43K-4.12(c), which has now passed, and the April 6, 2026 physical-plant grandfather at 8:43K-7.2(a)2, and the second one is a building rule inside the health care services subchapter, not a personnel rule.

If you think you are still operating under 10:161B. A repealed chapter is not a live rule set, and nothing in the adopted text continues it in force for any facility. One concrete thing that vanished: the repealed 10:161B-1.9(b) provided that "Counseling staff employed in an outpatient treatment facility subsequent to June 1, 2009 shall have three years from the date of employment to obtain LCADC or CADC status or another health professional license that includes work of an alcohol or drug counseling nature within its scope of practice." That was outpatient, pre-conversion (10:161B, repealed). N.J.A.C. 8:43K carries no such clock. Do not run an outpatient program to 10:161B today. The open question is the license instrument, not the standards.

Every line below is stated in the licensure chapter that governs that setting; where a Consumer Affairs board rule also applies, it is named and applies in both settings. If you operate both, this is the table to work from.

Two acronyms and one term run through this table. LCADC is the licensed clinical alcohol and drug counselor, a master's-level license that may diagnose and supervise. CADC is the certified alcohol and drug counselor, which needs no graduate degree, works under supervision and may not diagnose. Seronegative means a blood test found no antibodies, so the person is not immune.

The two BCLS duties are close but not identical: residential (8:111-3.5(h)) names the American Heart Association and the American Red Cross as the certifying bodies, while outpatient (8:43K-4.11(a)5) names none. One shared expiration tracker covers both, but confirm with the Division which certifications satisfy the residential wording before assuming a single course serves both settings.

Widely circulated summaries of New Jersey SUD licensure still name the Division of Mental Health and Addiction Services as the licensing authority. That has not been right for years, and it matters, because it sends people to the wrong agency, the wrong rule set and the wrong complaint line.

These facilities are licensed by the New Jersey Department of Health, Division of Certificate of Need and Licensing. The authority line on the residential chapter reads: "Authority: N.J.S.A. 26:2B-14 and 26:2G-23; and Reorganization Plan Nos. 001-2017 and 001-2018." It was authorized by the Commissioner of Health. If you print a branch name on a notice, use the one the rule itself uses: 8:111-1.3 defines the Division as "the Division of Certificate of Need and Licensing within the Health Services Branch of the Department." The outpatient chapter uses different unit names again, so on the outpatient side name the office your license paperwork names.

The transfer happened in two steps. Reorganization Plan No. 001-2017 moved mental health and addiction functions from the Department of Human Services to Health. Reorganization Plan No. 001-2018 moved most functions back to Human Services but retained the licensure and inspection functions at N.J.S.A. 26:2B-14, 26:2G-23 and 26:2G-24 with the Department of Health. That exception is why the Department of Health licenses you today even though DMHAS still exists.

The recodification carried the correction into the rule text. The first of four technical changes was "Deleting references to the "Department of Human Services," "DHS," "Division of Mental Health and Addiction Services," and "DMHAS," and adding in place thereof, references to the "Department of Health" or the "Department"". A second replaced "Office of Licensing" and "OOL" with "Division of Certificate of Need and Licensing" or "Office." A few DMHAS references survive on purpose, where DMHAS is named as a service-system entity rather than as your licensor. At 8:111-1.7(c)11i the administrator still shares facility outcome data with "relevant staff, DMHAS, the Department and, when necessary, the governing authority."

DMHAS remains in the picture on the outpatient program side. Adopted 8:43K-6.1(c) provides that "A facility seeking licensure to provide behavioral health services at a level of care listed at (b) above is subject to compliance with: 1. Applicable standards and requirements of DMHAS at N.J.A.C. 10:36" and "2. Applicable DMHAS requirements to enter into a contract or an affiliation agreement with DMHAS." If you hold no DMHAS contract or affiliation agreement and DMHAS requires one for your level of care, that is a licensure condition, not a funding question. The cross-reference itself was narrowed on adoption from an open-ended pointer to all of Title 10.

N.J.A.C. 10:36 sets no minimum staff qualifications of its own for a named position. It defers to the Department of Health's standards at N.J.A.C. 8:43K and to Federal standards, "including at 42 CFR Part 8 (describing staffing requirements for OTPs)." Do not go looking for counselor ratios there. It is not credential-free, though: 10:36 keys several duties to credentials, including 10:36-5.2(b) on who may perform evaluations using screening and assessment tools, and the requirement that the behavioral health care plan, discharge instructions and discharge summary each be signed by an appropriately licensed and credentialed member of the interdisciplinary team. If you run an opioid treatment program, 42 CFR Part 8 is a separate staffing authority this guide does not cover. On peers, 10:36's own adoption notice routes the question back to the Department of Health: "peers and peer support services are outside the scope of this rulemaking and are addressed by DOH at N.J.A.C. 8:43K; see, for example, N.J.A.C. 8:43K-6.6".

The N.J.A.C. 8:111 personnel file requirements for a residential facility start at one section, 8:111-3.5, and the single most consequential fact for a residential file audit is that nothing in its personnel record list changed. The readoption records "8:111-3.5 Personnel (a) (No change.)", so the entire list and all six numbered paragraphs carried over from 10:161A-3.5(a) verbatim. Only the citation number changed.

The opening duty is broad: "The facility shall maintain personnel records for each employee including, but not limited to, the employee's name, address, Social Security number, proof of identification, previous employment history (including verification), educational background, credentials (including progress toward acquiring the CADC or LCADC)". Note "including, but not limited to." This is a floor.

The rule names the items in one unnumbered sentence; we count sixteen, though a surveyor reading "documentation of staff orientation and staff education received" as two items could count seventeen. Walk them in order.

1 through 4. Name, address, Social Security number, proof of identification.

1. Previous employment history, including verification. The parenthetical is doing real work. A resume in the file is not compliance; the file has to show the prior employment was verified.

1. Educational background. This is where a high school or equivalency diploma lives for a residential aide or monitor, which matters because 8:111-3.5(f)4 requires that "Non-counseling staff responsible for supervision during day or evening hours shall, at a minimum: i. Be 18 years of age; ii. Possess a high school or high school equivalency diploma." The rule sets no parallel minimum for overnight non-counseling staff.

7 through 10. Credentials, license number with dates, certification, verification. The rule requires "credentials (including progress toward acquiring the CADC or LCADC), professional license number with effective date and date of expiration (if applicable), certification (if applicable), verification of credentials". Both dates, effective and expiration. That is your hook for expiration tracking. Verification has its own paragraph at 8:111-3.5(a)6: "Facilities shall document verification and confirmation of licenses/certifications and educational degrees for all staff in accordance with facility policy and requirements established for the position by this chapter to determine that they are both current and not under suspension". Two tests, current and not under sanction. A photocopy answers only the first.

11 and 12. A record of voluntarily disclosed criminal convictions, and the results of criminal history background checks. Two distinct file items fed by two distinct streams, and the rule requires results in the file, not merely evidence that a check was run.

13 through 16. Records of physical examinations, job descriptions, documentation of staff orientation and staff education received, and evaluations of performance. Frequency for the last is fixed: "The facility shall complete performance evaluations on staff a minimum of once per year after initial employment."

Two further items are easy to miss. Every staff member gets a photo identification card including "at a minimum, the staff member's first name and last initial, job title, degree and/or certification." First name and last initial only, and because the card carries the credential, a credential change is a practical reason to reissue it. And under 8:111-3.5(d) the facility "shall employ only those personnel who are currently licensed, currently certified or authorized under the appropriate laws or rules of the State of New Jersey or under the applicable standards of the appropriate recognized credentialing body". The word "currently" turns a lapsed credential into a licensure exposure rather than a paperwork gap.

One scope-of-practice limit sits outside 3.5 and belongs in the same file. Residential (8:111) provides at 1.9(c) that "Only staff possessing the appropriate clinical background and educational qualifications from the appropriate clinical discipline may provide the diagnosis, assessment and treatment of clients with co-occurring disorders." Like the outpatient version at 8:43K-6.2(a)2, it means the file has to show which discipline each such staff member holds.

Outpatient (8:43K) splits personnel duties across two subchapters, and the split governs which rules reach you.

Subchapter 4 reaches every outpatient licensee. N.J.A.C. 8:43K-4.11, Personnel general requirements, was adopted exactly as proposed. It requires a facility to "Develop written job descriptions;" and to "Assign duties to an employee based on, as applicable to the position, the employee's credential and associated scope of practice, education, training, and competencies;" and to "Maintain personnel schedules to ensure continuity of care within the facility;".

The personnel-file rule itself is short. The facility must "Maintain personnel records for each employee, which include, copies of the employee's credentials, if applicable to the employee's position;". That is markedly thinner than the residential itemized list. Two duties in the same paragraph are easy to miss. You must "Have at least one person always present during operating hours who holds certification in basic cardiac life support;", and you must "Maintain compliance with applicable State and Federal labor law and be in good standing with applicable labor law enforcement authorities;". That second one converts an ordinary wage and hour failure into a named licensure deficiency and adds a good-standing test with labor law enforcement authorities. Residential has no express labor-law provision, only the general compliance clause at 8:111-3.2(a), so the outpatient duty is the more specific and the more auditable of the two. The rule names no documents. A workable way to evidence it, and this is recommended practice rather than law, is keeping current wage and hour records, written exempt and non-exempt classification determinations, and a documented check that no unresolved State or Federal wage claim or judgment is outstanding.

Subchapter 6 reaches only behavioral health services facilities. Read 8:43K-6.1(a) first: "This subchapter applies to a facility that the Department licenses to provide behavioral health services." Those levels of care are SUD or other addiction outpatient treatment, mental health outpatient treatment, SUD or other addiction intensive outpatient treatment, SUD or other addiction treatment partial care, and mental health partial care. Opioid treatment programs are addressed at 8:43K-8, not here. If you deliver any of the listed levels, subchapter 6 applies on top of subchapter 4.

Subchapter 6 is where the real outpatient personnel file lives. Under 8:43K-6.2(a) a behavioral health services facility must "Employ staff who are appropriately credentialed and sufficiently trained to provide services;" and must "Maintain current and proper documentation of staff credentials, education, licensure, training, and qualifications in personnel files;". That second duty is the outpatient counterpart to the residential itemized list. It is a standard rather than a checklist, and the word "current" is what makes an expired license a citation.

The same subsection restricts who may act and separately requires you to write down who that is. It requires the facility to "Ensure that only staff possessing the appropriate clinical background, education, credentials, and/or qualifications perform and provide diagnosis, screening, assessment, treatment, and recovery support of patients", including patients with co-occurring disorders, and to "Identify staff responsible for and qualified to perform diagnosis, screening, assessment, and treatment of patients, including those with co-occurring mental health and addiction disorders;". The first limits practice. The second requires a written designation.

Three roles must be designated: "Employ and designate the following staff: i. Program director; ii. Clinical supervisor; and iii. Counseling and/or therapy staff." Where the facility offers medication management, it must also "employ, either directly or through contract, a medical doctor or advanced practitioner credentialed and licensed in New Jersey to prescribe medications". A drafting note: 8:43K-6.2(a) carries two paragraphs numbered 5, and because 6.2 was adopted without change the Department did not renumber them. Cite those two by their quoted text rather than by number. The other paragraphs of 6.2(a), including (a)3 and (a)4, are unambiguous.

Two outpatient duties belong in your calendar now. Adopted 8:43K-4.13(c)1 requires a report of "The resignation or termination of the administrator and medical director, as applicable, and the name of the replacement within three days". Three days, not seven. And if you transport patients, 8:43K-4.14(a)4 requires the facility to "Confirm the validity or status of the driver's license of each operator who engages in patient transportation at least every six months, and maintain on file, a copy of each operator's driver license." That is a six-month recurring item per driver, and it sits in the same drawer as the credential expirations.

If you also operate in Florida, the parallel state analysis is in our Florida DCF 65D-30 personnel requirements guide.

This is the sharpest divergence between the two settings, and a dual-licensed provider has to run two different processes.

Residential (8:111) mandates the check. "The facility shall initiate State-level criminal history background checks supported by fingerprints not later than the time of hiring all staff, including student interns and volunteers." Read that precisely. The duty is to initiate by the time of hiring, not to have results in hand, so your compliance artifact is a documented initiation date. The rule says State-level and does not on its face require a federal check. That is a statement about this chapter only. Contracts and credentialing bodies outside it routinely do require a national check, including DCF or DCP&P agreements for adolescent and women-and-children programs, Medicaid and managed-care credentialing, and county contracts. Inventory those obligations separately; 8:111 is a floor, not a ceiling. Coverage under the chapter is universal, and volunteers are named again at 8:111-23.2(c). The rule names no vendor, no form and no turnaround time, so confirm current fingerprinting mechanics with the Department before writing them into a procedure.

Outpatient (8:43K) mandates only the policy, for staff generally. The facility must "Develop policies and procedures identifying the circumstances pursuant to which: i. The facility will conduct a criminal history record review history of prospective and current employees, and the methods by which it will conduct the assessment;". The doubled word is in the rule as published. There is no fingerprint requirement, no timing requirement and no universal coverage of interns and volunteers. A commenter asked the Department to issue guidance so that policies would not exclude people with criminal-legal histories or peers in recovery. The Department declined: "Each facility is in the best position to know what specific policies will serve the community in which the facility operates."

Two outpatient duties sit outside that policy and are not yours to write. At the top of the org chart, 8:43K-4.3(a)1 provides that "The governing authority shall ensure the administrator has not been convicted of a crime relating adversely to the administration of the facility unless there is evidence of rehabilitation pursuant to N.J.S.A. 2A:168A-1 et seq." And under 8:43K-4.13(c)4 a staff criminal conviction, or a credentialing board's disciplinary sanction, arising since your initial license application or last renewal application is a written report to the Office. Set up the reporting route before you need it.

The same paragraph does the same thing for drug screening in outpatient (8:43K). Your policy must identify the circumstances under which "The facility will require pre-employment and random drug screening and respond to a positive drug screening;".

Residential (8:111) is more prescriptive here too. Under 8:111-3.7(f) the facility "shall establish policies and procedures that provide for pre-employment drug screening, and shall include the random drug screening of staff including the screening of staff suspected of substance abuse." Three modes, not one, and the policy must state the facility's response to a positive result.

The residential hiring standard has teeth in both directions. The administrator must "make reasonable efforts to adhere to facility policies regarding the hiring of staff to ensure that staff are in good physical and mental health, emotionally stable, concerned for the safety and well-being of clients", and to ensure staff "have not been convicted of a crime relating adversely to the person's ability to provide care or interact with clients and families, either directly or indirectly, such as, but not limited to, drug-related offenses, homicide, aggravated assault, kidnapping, sexual offenses". The sentence continues with robbery and crimes against the family, children or incompetents. That list is illustrative, not a disqualification schedule. Reasonable efforts are themselves defined: ""Reasonable efforts" shall include, but need not be limited to, an inquiry on the employment application, reference checks and/or criminal history record background checks where indicated or necessary."

Then comes the clause that matters most in a field that hires people in recovery. The rule continues "except where the applicant or employee with a criminal history has demonstrated rehabilitation in order to qualify for employment. Such procedures for hiring employees with past criminal histories include, but are not limited to, this paragraph, shall be clearly written." The syntax is garbled in the published rule and we quote it as printed. The obligation is not: the procedure must be written.

The review policy is separately required. Facilities "shall have a policy governing the review of criminal convictions identified by criminal history background checks or voluntary disclosure by prospective employees that shall include the process and standards by which convictions are reviewed". And the policy has an outer limit: "Such policy shall not preclude the hiring of persons with criminal convictions, but may reasonably balance the type and severity of the crime, history of rehabilitation and nature of employment duties." A blanket ban on hiring anyone with a conviction is affirmatively non-compliant in residential (8:111).

A criminal history check is not an exclusion check. If the facility bills Medicaid or any other federal health care program, exclusion screening is a separate question with its own file artifacts: no federal health care program payment may be made for items or services furnished by an excluded person, and OIG recommends, rather than mandates, checking its List of Excluded Individuals/Entities, with SAM.gov as a second list. Neither a clean fingerprint result nor a written conviction-review policy answers it. The cycle, the sources and the log that proves it ran are in our OIG exclusion screening guide for healthcare employers.

Administrator, residential (8:111). "Each facility shall hire an administrator who has, at a minimum, a Master's degree and two years of full-time, or full-time equivalent, administrative or supervisory experience in a licensed substance use disorders treatment facility." The alternative at 8:111-1.7(b) is a Bachelor's degree plus five years of the same experience. The experience must be in a licensed SUD treatment facility. The governing authority owns this file, not HR: it is responsible for "Appointing and supervising an administrator (that is, president, CEO, executive director, etc.) whose references, credentials, professional license and criminal background are reviewed and verified, and reconciled with the organization's mission and administrator's scope of work." It must also evaluate the administrator "at least annually" including "establishing requirements for the administrator's continuing education and professional development", approve an alternate in writing, and advise the administrator to disclose disciplinary outcomes to the governing authority at the time of initial employment and/or during employment if the action occurs after hire.

Administrator, outpatient (8:43K). Do not copy the residential file across. The bar is different and lower. Under 8:43K-4.3(a) "A governing authority shall appoint an administrator who is accountable to the governing authority", and at (a)1 it "shall ensure the administrator has not been convicted of a crime relating adversely to the administration of the facility unless there is evidence of rehabilitation pursuant to N.J.S.A. 2A:168A-1 et seq." The qualification routes at (b) are two: "1. An associate degree and two years of full-time, or full-time equivalent, administrative experience in a clinical setting; or 2. Four years of full-time, or full-time equivalent, administrative experience in a clinical setting." An associate degree, or no degree at all with four years, against a residential master's plus two years. Subsection (c) adds a written designation: "The administrator shall designate, in writing, one or more alternates, who have credentials that are equivalent or comparable to those at (b) above, to act in the absence of the administrator", and "The administrator, or the administrator's designee, shall be always available when patients are on site at the facility."

Program director, outpatient (8:43K). The program director of a behavioral health services facility must "Possess, at a minimum, a master's degree and two years of administrative and/or supervisory experience in behavioral health program services;" and be on site at all times when patients are present and during operating hours unless a designated alternate is on site. The alternate is a file item, not a practice: the program director "shall designate, in writing, at least one alternate who, in the absence of the program director:" acts as the program director, holds equivalent or comparable credentials, and is available at all times when patients are on site. The program director also owns the credential file: 8:43K-6.3(a)7 requires them to "Ensure that staff members have the proper credentials, education, qualifications, supervision, and training for their positions and duties." Under 6.3(c) the program director may serve concurrently as facility administrator. Answering a question about dual roles, the Department said it "interprets these roles as being full-time positions," that apart from the program director and administrator pairing the chapter "would not allow concurrent appointments," and that a facility wanting one must seek a waiver under 8:43K-2.10. That is an interpretation stated in a comment response, not rule text. If you are a small provider planning to combine roles, get it confirmed by the Division in writing.

Clinical supervisor, outpatient (8:43K). N.J.A.C. 8:43K-6.4(a) lists six licensed professions at (a)1 through 6: an advanced practice nurse, a licensed clinical social worker, a physician or psychiatrist, a licensed professional counselor, a licensed marriage and family therapist, and a licensed psychologist. It is expressly made subject to subsection (b). Subsection (b) is the conversion trap: "If a behavioral health services facility provides only SUD treatment services, the behavioral health services facility program clinical supervisor shall be either a professional listed at (a)1 through 6 above or a licensed clinical alcohol and drug counselor." The LCADC route is conditioned on the facility providing only SUD treatment. Add mental health outpatient services under an integrated license and you lose that route. Note also that the rule names the LCADC, not the CADC.

Partial care, outpatient (8:43K). A partial care program designates three additional staff at 6.12(a): a medical services supervisor, medical staff, and a primary case coordinator. The medical services supervisor must be a board-certified general psychiatrist or a psychiatric-certified APN, or one holding another commensurate certification with prior DMHAS approval, each with at least one year of full-time or full-time equivalent experience in a behavioral health treatment program setting, 6.12(b)1 and 2. That board certification is a hard gate, and it belongs in your credential tracker with an expiration date.

Director of substance abuse counseling, residential (8:111). Every facility must appoint one: "Every facility shall appoint a director of substance abuse counseling services with the qualifications and responsibilities specified in N.J.A.C. 8:111-1.8". There are seven qualification routes at 1.8(a). In short: a New Jersey licensed psychologist with five years in addiction services, two supervisory, who holds either the American Psychological Association Certification of Proficiency or the Certified Clinical Supervisor certificate from the Addictions Professionals Certification Board of New Jersey (APCBNJ); a licensed clinical social worker on the same experience terms who is an APCBNJ certified clinical supervisor; a licensed professional counselor or licensed marriage and family therapist on the same terms who is an APCBNJ certified clinical supervisor; an LCADC with five years in addiction services, two supervisory, who also holds a clinical master's degree recognized by the State Board of Marriage and Family Therapy Examiners; a licensed physician certified by the American Society of Addiction Medicine or a Board-certified psychiatrist with two years of supervisory experience in addiction services; a licensed advanced practice nurse on the same experience terms who is an APCBNJ certified clinical supervisor; or a doctoral degree in human services, mental health or social work with at least two years of supervisory experience. Routes 2, 3 and 6 make the APCBNJ Certified Clinical Supervisor certificate mandatory and route 1 offers it as one of two alternatives, so for most incumbents it is an expiring private-board credential your tracker has to carry alongside the State license. Incumbents holding only a master's in counseling or social work were required to "obtain LCADC status or another health professional license... by July 15, 2016." That deadline has long passed, so treat it as a standing qualification, not a live grace period.

Medical director, residential (8:111). Where a medical director is required, at hospital-based and non-hospital-based detoxification, short-term residential and long-term residential facilities, the rule provides: "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." An alternative at 8:111-1.4(a)1 covers a New Jersey licensed physician with at least five years in a SUD treatment facility at 20 or more hours per week who has completed the ASAM/ABAM/American Association for the Treatment of Opioid Dependence (AATOD) clinicians training course. One caution before you disqualify a candidate on this. A 2022 rulemaking petition was granted and a 2023 proposal published that would add the American Osteopathic Association as a certifying board at 8:111-1.3 and 1.4; we could not confirm whether it was adopted, and the current published text still shows ASAM/ABAM alone. Treat ASAM/ABAM as the rule, and confirm the certifying bodies the Division currently accepts before you rule a physician out. Facility physicians who are not the medical director must be currently licensed in New Jersey, have at least two full years of experience employed as a physician, and be in good standing.

Nursing, pharmacy, dietary and the medical liaison, residential (8:111). The director of nursing must "Be a registered professional nurse pursuant to N.J.S.A. 45:11-26 et seq. with at least one year in nursing supervision or nursing administration; and 2. One year full-time experience with the management of addictions in a licensed substance use disorders treatment facility." A detoxification facility adds an experience element at 1.5(b). All nursing personnel must hold the appropriate current license and be in good standing, and only a registered professional nurse may assess nursing care needs. Pharmacists must be currently licensed by the New Jersey State Board of Pharmacy and in good standing, 8:111-1.6, and the facility must engage at least one dietitian registered by the Commission on Dietetic Registration, 8:111-1.10(a); both are credential-roster items rather than separate files. Extended care facilities and halfway houses, which need no medical director, must instead designate a medical liaison identified by a licensed physician who possesses "at least a B.A. with at least one year of experience" in a substance abuse treatment facility.

Non-clinical staff still generate files. Residential (8:111) requires at 21.2(b) that "The facility shall ensure that all housekeeping personnel are trained in cleaning procedures, including the use, cleaning, and care of equipment."

Two credentials do most of the work in this field. The licensed clinical alcohol and drug counselor (LCADC) holds a master's degree and may diagnose and supervise. The certified alcohol and drug counselor (CADC) does not require a graduate degree, works under supervision and may not diagnose. That difference is the reason the residential ratio rule exists, and the reason a CADC's signature cannot carry a diagnosis in either setting.

Residential (8:111) keeps a hard ratio and a hard clock. The facility must ensure "the ratios of substance abuse counseling staff are maintained so that 50 percent of the staff are LCADC or CADC or other licensed clinical professionals doing work of an alcohol and drug counseling nature within their scope of practice by July 15, 2016 and at all times thereafter." The phrase "at all times thereafter" makes it a standing headcount test. The remaining half may be counselor-interns, who may work toward LCADC or CADC status for no more than three years. The director of counseling counts toward the ratio only while carrying an active client caseload.

Each uncredentialed counselor also carries a personal deadline: "Counseling staff employed in a residential substance use disorders treatment facility subsequent to July 15, 2013 shall have three years from the date of employment to become certified as an LCADC or CADC, or another clinical licensed professional".

Interns in residential (8:111) must "Be enrolled in a course of study leading to a CADC or LCADC, or another New Jersey clinical professional license... without regard to changes in employment, with progress towards certification or licensing on file, reviewed by the facility at least semi-annually and documented". Semi-annual is the only twice-yearly cadence in the chapter's personnel rules, and it is the one that falls off an annual review calendar. Interns must also "Be trained, evaluated and receive continuing formal clinical supervision by the director of substance abuse counseling or designee, pursuant to the clinical supervision rules of the State health professional licensing board for the course of study in which they are enrolled", so a single generic supervision log across a mixed intern cohort will not demonstrate compliance.

The residential scope-of-practice limit is flat: "A CADC must work under the supervision of an LCADC or another New Jersey licensed clinical professional designated as a qualified clinical supervisor per N.J.A.C. 13:34C-6.2. ii. A CADC cannot diagnose substance abuse." One navigation note: the chapter's cross-reference points to 13:34C-6.2, which governs supervision of interns; the supervisor qualifications for a CADC in supervised practice are at 13:34C-6.3.

Outpatient (8:43K) names no counselor credential in its counseling duties section. N.J.A.C. 8:43K-6.5 is a duties section. It requires counseling and therapy staff to assess counseling needs using evidence-based tools, present at case conferences, "Diagnose and/or develop clinical impressions of patients using the DSM-5;", sit on the interdisciplinary team, provide counseling per the plan of care, obtain historical records, reassess throughout the episode, serve as a referral contact, and determine level of care. It lists no credentials, and it was adopted without change despite three comments asking for some. The Department answered each time that 6.5 sets forth responsibilities while 6.2 requires proper credentials, which "are set forth by each respective professional licensing board within the Division of Consumer Affairs."

There is also no intern clock in outpatient. Asked for one, the Department replied that "nothing at proposed new N.J.A.C. 8:43K impedes a facility from establishing their own policies for how long someone can work at the facility as an intern". A converting facility should adopt an intern tenure policy on purpose rather than by default. Do not read any of this as meaning 8:43K imposes no credential duty. It does, at 6.2(a)1 and (a)3. It leaves the naming of credentials to the boards.

The board rules bind the individual in both settings. Under N.J.A.C. 13:34C-6.3(l), "All diagnoses shall be made by the qualified clinical supervisor and shall not be delegated to a certified alcohol and drug counselor." LCADC licensure requires that the applicant have "Received a master's degree in counseling from an accredited institution of higher education" or a related addictions or counseling master's including at least 18 graduate semester hours in counseling, plus, among other things, the CADC requirement set. CADC certification requires a bachelor's, associate's or high school diploma or equivalency plus "300 hours of supervised practical training in alcohol and drug counseling distributed among all of the following 12 core functions:" screening, intake, orientation, assessment, treatment planning, counseling (individual, group and family), case management, crisis intervention, client education, referral, consultation and recordkeeping. Add to that 270 hours of alcohol and drug education, two years of supervised work experience within five consecutive years, 30 self-help meetings, and the International Certification and Reciprocity Consortium (ICRC) written and oral examinations.

One narrow outpatient exception is worth knowing. In a partial care program, 8:43K-6.12(e)1v accepts "A relevant professional credential, such as certified psychiatric rehabilitation practitioner, certified rehabilitation counselor, certified alcohol and drug counselor, certified alcohol and drug counselor counselor-intern, or community mental health associate" as one qualifying route for the primary case coordinator. That is the only place in 8:43K where the CADC or the counselor-intern is named as a qualifying credential.

Supervision is where facility rules and board rules stack, and both have to be evidenced.

Residential (8:111) sets a weekly number. The director of substance abuse counseling is responsible for "Providing or ensuring, and documenting, that direct clinical supervision is provided at least one hour per week to all clinical staff, individually or in a group setting, with group supervision not to exceed 50 percent of supervision time", as well as any clinical supervision requirements under N.J.A.C. 13:34C. Three separately checkable elements: one hour weekly, per clinical staff member, and a 50 percent cap on group time. The word "documenting" is in the rule, so undocumented supervision is non-compliance. Where the director does not personally supervise, "the administrator, in conjunction with the director of substance abuse counseling, must ensure that direct clinical supervision is provided by a staff person who meets the qualifications specified by and recognized as direct clinical supervision pursuant to the rules of the State Board of Marriage and Family Therapy Examiners, Alcohol and Drug Counselor Committee, New Jersey Department of Law and Public Safety at N.J.A.C. 13:34C-6.3." So the chapter itself points to 13:34C-6.3 for a substitute supervisor's qualifications, even though 8:111-1.9(a)1i points at 13:34C-6.2.

The board rule applies in both settings, and it runs to the supervisor. Under N.J.A.C. 13:34C-6.3(b), qualified clinical supervisors must have a written agreement with each CADC describing planned hours of practice, the supervision schedule and the nature of work assignments. The dosage is fixed at (k): "Clinical supervision shall include at least 50 hours of face-to-face supervision per year, averaging one hour per week, with no more than 10 percent being real-time interactive video conferencing." Counselors with more than five years of experience as a CADC may be supervised less frequently, but no less than two hours per month.

In residential those two obligations stack. The chapter's weekly hour reaches all clinical staff, and the board's 50 hours reaches CADCs in supervised practice through the credential. In outpatient (8:43K) the chapter names no supervision frequency for counseling staff, so for a CADC the operative number comes from 13:34C alone.

Outpatient (8:43K) sets no frequency but does set a documentation duty. Under 8:43K-6.4(c) the clinical supervisor must "Directly provide or arrange: i. The clinical supervision of staff in accordance with applicable professional licensure requirements; and ii. The education, orientation, and training of staff", and must ensure "ii. The proper credentialing and supervision of behavioral health services clinical staff; iii. The maintenance of behavioral health services clinical program staff supervision documentation; and iv. The conduct of quality improvement activities." So the cadence comes from the supervisee's own board, but the supervision log, the credentialing check and the quality-improvement record are chapter duties owned by a named person.

One more residential gate belongs in the file before a caseload is assigned. The director is responsible for "Providing orientation to and evaluation of new counseling staff prior to assigning them counseling responsibilities;". "Prior to assigning" means a new counselor cannot carry a caseload until orientation and an evaluation are complete and documented.

Peer support is the newest personnel category in New Jersey SUD licensure, and it exists only on the outpatient side.

In outpatient (8:43K), a peer is defined as "a person who has lived experience of recovery from a mental health condition and/or an addictive disorder who provides non-clinical assistance and support to a patient who is in recovery or treatment." The word non-clinical should shape the job description.

The credential rule is a hard gate: "A peer shall have lived experience and an appropriate certification to provide peer support services consistent with certifications required pursuant to DMAHS, another State licensing or credentialing authority, or as otherwise approved by DMHAS." Two acronyms one letter apart appear in that sentence. DMHAS is the Division of Mental Health and Addiction Services. DMAHS is the Division of Medical Assistance and Health Services, which administers Medicaid. So the file needs a certification that satisfies DMAHS (Medicaid) requirements, another State licensing or credentialing authority, or a DMHAS-approved alternative.

The rule names no specific credential. In practice the credential providers encounter is the Certified Peer Recovery Specialist, issued by a private nonprofit certification board rather than by a State licensing board, and no chapter of N.J.A.C. Title 13 licenses or certifies peer recovery specialists. We could not locate a codified DMAHS list of qualifying peer certifications. Because 6.6(a) keys to what DMAHS requires or DMHAS approves, ask DMHAS in writing which certifications it currently accepts, and if the position is Medicaid-billable ask DMAHS which peer credential its provider requirements specify, before you assign peer duties. Keep that confirmation in the file next to the certificate and the job description. The State's own materials use more than one name for the certifying body, which is a further reason to get the answer in writing.

This subsection was adopted without change. A commenter asked that people working toward certification be recognized as candidates and included in the workforce, and the Department refused, saying the rule "would intentionally restrict the peer workforce to those who hold a peer certification." There is no peer equivalent of the counselor-intern model. Both elements are required, so the file needs documentation of lived experience under your policy and a current certification.

Direction and supervision are different duties with different rules. Direction is limited to licensed staff: "An appropriately licensed and credentialed behavioral health services facility staff member shall direct the provision of peer support services." Supervision is broader, and this is the one provision in 8:43K-6.6 that changed on adoption: "An appropriately licensed and credentialed behavioral health services facility staff member or a peer with certification consistent with (a) above shall supervise the provision of peer support services", including group supervision, unless otherwise prohibited by Federal or State law. A certified peer may supervise. A certified peer may not direct. Because both paragraphs now use the same words to describe the staff member, that distinction rests entirely on the added words "or a peer with certification." The Department declined to define "appropriately licensed and credentialed," pointing back to 6.2, so the facility has to document its own reading of who qualifies.

Peers are chart-documenting staff. "A peer shall document in the patient's treatment record, the peer support services that the peer provides." That makes the confidentiality topic in the 8:43K-4.11(a)9 orientation list non-optional for peer onboarding.

Do not go looking for a second, DMHAS set of peer rules for an outpatient program. In adopting N.J.A.C. 10:36, DMHAS stated that "peers and peer support services are outside the scope of this rulemaking and are addressed by DOH at N.J.A.C. 8:43K; see, for example, N.J.A.C. 8:43K-6.6". That is the Division's stated jurisdictional position in an adoption notice, not codified rule text, but it answers the question cleanly for outpatient programs. It says nothing about residential (8:111), which contains no peer staff provision at all.

Orientation and education plans. Residential (8:111) requires two plans, not one: "The facility shall develop and implement a staff orientation plan and a staff education plan, that includes written plans for each service and designation of person(s) responsible for training as follows:". Outpatient (8:43K) states it almost identically: "Establish and implement a staff orientation plan and a staff education plan, including plans for each service and designation of personnel responsible to provide training; and". A multi-service integrated facility needs a plan per service line and a named trainer for each.

The training list, residential (8:111). "All staff shall receive orientation at the time of employment and at least annual in-service education regarding, at a minimum, the facility's emergency plans and procedures, the infection prevention and control program, universal precautions", and the list continues with conflicts of interest, ethics and confidentiality, client rights, treating individuals with co-occurring disorders, cultural competence, and where appropriate identifying and responding to child abuse and elder abuse. Three more dated duties sit elsewhere in the chapter: fire and evacuation training "as part of their initial orientation and at least annually thereafter"; client rights in-service "and as part of new employee orientation"; and abuse identification and reporting training at least annually. A fourth, ADA compliance training at 8:111-3.6(b)16ii, carries no stated cadence, so run it at orientation and schedule it through your staff education plan.

The training list, outpatient (8:43K). The rule requires the facility to "Require all personnel to receive orientation at the time of employment and at least annual in-service education, which activities the facility shall document in each employee's employment record, addressing, at a minimum:" thirteen topics. They are emergency plans and procedures; the infection prevention and control program; standard precautions; policies on patient and staff rights; use of new clinical procedures, equipment and innovative technologies; cultural competency and cultural humility; conflict of interest policies; confidentiality; areas the quality assurance and performance improvement (QAPI) program identifies; human trafficking; pain management; child and elder abuse identification, reporting and documentation; and lactation rooms. Several of those carry a condition in the rule as printed: "if required" for infection prevention and control, "where required" for new clinical procedures and technologies, "if applicable" for human trafficking, pain management and lactation rooms, and "if appropriate, given the patient population" for child and elder abuse. Your training matrix should record why a conditional topic was omitted, not just that it was; the rule requires the activities to be documented in the employment record, and it reaches "all personnel," not only direct employees.

Physical examinations. Residential (8:111) requires that "The policy and procedure manual shall include policies and procedures to ensure that physical examinations of staff are performed upon initial employment and at subsequent intervals." Outpatient (8:43K) requires policies "to ensure that physical examinations of employees are performed upon employment and subsequently shall specify:" the circumstances for other direct-care persons and the content and frequency for both groups. In both settings the exam is mandatory at hire and the interval is yours to write down.

Rubella and measles. Residential (8:111) provides that "The facility shall require all staff employed as of July 15, 2013, and all staff hired thereafter, to submit to screening tests for rubella and measles." Only employees born in 1957 or later must be screened for measles, and documented immunity or vaccination exempts. Three duties follow: "The facility shall inform each employee of the results of each screening test, record all tests performed and the results thereof in each employee's personnel record and maintain a list of all employees who are seronegative and unvaccinated." Seronegative means the blood test found no antibodies, so the employee is not immune; the standing list is simply everyone who is neither immune nor vaccinated. It is a separate artifact from the individual files and is the thing most often missing.

Outpatient (8:43K) has the same architecture with one hard date. Rubella screening is on employment for each employee who cannot document a prior result, with the same written notice, the same filing duty ("A facility shall ensure that each employee's personnel record includes documentation of all tests performed and the results.") and the same seronegative list. For measles, adoption replaced a placeholder with a literal deadline: screening was due by "October 3, 2026, with respect to an existing employee, and upon employment, with respect to a new employee upon employment." That date has passed. It was the only new dated personnel deadline in the chapter, and a facility whose record for an existing employee born in 1957 or later still holds no result or documented exemption is now out of compliance with 4.12(c). Complete the screening, file the result, and date the entry when the screening actually occurs; a late record is a gap you can close, a backdated one is not.

Tuberculosis, residential (8:111). The facility must require all employees, including medical staff members, to submit to tuberculosis testing using a two-step Mantoux in accordance with the Tuberculosis Surveillance Procedures for Substance Abuse Treatment Facilities, incorporated by reference at 8:111 Appendix A. (The readoption struck the words identifying DMHAS as the publisher, and the bracketing in the published notice cannot be read cleanly, so we paraphrase rather than quote that sentence.) Get the appendix itself. It is a separate document incorporated into the chapter, and it is not reliably reproduced in the free sources. Request the current version from the Division of Certificate of Need and Licensing and keep a dated copy with your tuberculosis policy, because your Mantoux protocol has to be in accordance with whatever that document now says.

The mechanics are short and easy to blow: "If the initial Mantoux test result is negative (less than 10 millimeters of induration or less than five millimeters of induration if immunosuppressed), the employee shall submit to a repeat Mantoux skin test within three weeks of the initial test." A positive on either step means a chest x-ray and referral. Then, annually: "The Mantoux skin test shall be repeated on an annual basis for all employees whose previous skin test results were negative, unless contraindicated."

Residential has its own documented exceptions, and they are file items in their own right. An employee with a documented negative Mantoux in the prior 12 months "need only one Mantoux skin test" (3.7(d)4). An employee who documents a previous positive, or documents having received and completed treatment for tuberculosis disease and latent tuberculosis infection, is not required to be skin tested at all (3.7(d)5i and ii). And 3.7(d)7 overrides a negative: "All symptomatic employees should have a chest x-ray and be medically cleared regardless of the skin test result." Keep the documentation that supports each exception in the file; an unexplained missing test reads as a gap.

Tuberculosis, outpatient (8:43K). Coverage is broader than W-2 employees. The facility must "screen and test every personnel member who is to provide direct care to patients for tuberculosis in accordance the tuberculosis guidelines, regardless of the member's status as being directly employed, under contract, and/or volunteering." Contracted prescribers, per diem counselors and volunteers all need a tuberculosis record. The exposure control plan may rest on the 2005 CDC guidelines and, added on adoption, "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019". The Department added that alternative in response to a comment asking that CDC-approved blood tests be permitted, and pointed to its January 6, 2023 memorandum allowing any FDA-approved tuberculosis test in lieu of tests named in Department rules. The rule text at 8:43K-4.12(e) still literally says two-step Mantoux, so treat the blood-test substitution as Department guidance rather than as rule text. Note the window difference between settings: the residential repeat test is due within three weeks of the initial test, 8:111-3.7(d)2, while outpatient requires a second Mantoux one to three weeks after the first, 8:43K-4.12(e)1.

Two outpatient details deserve their own tickler. First, a positive result gates the start date: "A facility shall permit an employee who has a positive Mantoux test result to begin working after the employee submits written medical clearance to the facility." Second, one of the four documented exceptions to the two-step baseline creates a per-employee future due date. An employee with two documented negatives in the 12 months preceding the start of employment and no signs or symptoms needs no test on hire, but the facility "shall require the employee to receive a Mantoux skin test within 12 months of the last tuberculin skin test." Thereafter, "The facility shall administer a Mantoux skin test to all tuberculin-negative employees at least annually;" at the frequency the facility's plan sets by risk level, and must maintain records of the results. Cite these from the adopted lettering at 8:43K-4.12(e) and (f), not from the proposal, which numbered them differently.

Employee safety, both settings. Residential (8:111-3.7(e)) requires policies and procedures regarding employee safety including procedures for the care of employees who become ill or are injured at the facility. Outpatient carries the identical duty: proposed 8:43K-4.12(e) provides that "A facility shall establish policies and procedures to address employee safety, which include procedures for the care of employees who become ill, or are injured, at the facility," and it was adopted with no change in text but re-lettered as 4.12(h). Because the Notice of Adoption prints only the lettering change, quote the wording from the Notice of Proposal.

What if an employee refuses? Neither chapter says. Both put the duty on the facility, residential 8:111-3.7(b) and (d) requiring the facility to "require all staff... to submit," and outpatient 8:43K-4.12(b), (c) and (e) running the same way, and neither provides an exception, an accommodation route or a documented-refusal option, the way 8:111-3.8(b)4ii and 8:43K-4.13(d)1 do for a staff member who declines to notify police about a crime. Practically, an unscreened employee is a facility deficiency, not an employee problem. Do not invent a waiver. Handle the employment side under your own policy, keep the refusal in writing in the personnel record, and confirm the Department's expectation with the Division of Certificate of Need and Licensing before letting the person work.

Many programs treat volunteers as informal. Residential (8:111) does not.

The controlling sentence is 8:111-23.2(c): "Volunteers shall be considered as staff with regard to meeting the requirements for criminal history background checks, physical examination and testing, verification of credentials, photo identification cards and program policies and procedures relating to staff conduct." Combine that with 8:111-3.5(a)2, which names volunteers and student interns expressly, and a volunteer file needs a fingerprint-supported State criminal history check, physical examination and testing, credential verification, and a photo identification card that states the volunteer's first name, last initial and volunteer status, 23.2(a)3. That is not the staff card format at 3.5(a)3, which carries job title, degree and certification. Volunteers also "shall not be used by the facility to supplant paid staff."

Two more details in the volunteer policy are easy to miss. The policy must set "Minimum age and physical examination requirements for volunteers" (23.2(a)1i). And it must state your methods for obtaining each volunteer's "education, credentials, employment experience, driver abstracts, sanctions by licensing boards and arrests or convictions" (23.2(a)2). Driver abstracts and licensing-board sanctions are named there and nowhere in the paid-staff rule.

The volunteer policy also sets a floor the paid-staff rule does not. It must state "The minimum period of time (of at least one year) during which individuals with a prior history of substance abuse (alcohol, tobacco and other drugs) shall be continuously substance free before being accepted as volunteers;". Compare 8:111-3.5(b), where the administrator must "establish written policies and procedures addressing the period of time during which staff in recovery are determined to be continuously substance-free (alcohol and/or other drug) before being employed in the facility" with no number stated. For paid staff you choose the period and write it down. For volunteers the rule fixes at least one year.

Volunteers have their own training file: "The facility shall provide initial orientation and continuing in-service education for volunteers including, but not limited to, the following topics: 1. Emergency plans and procedures; 2. Client confidentiality; 3. The infection prevention and control program;" plus policies relating to the tasks they will perform. Their job descriptions must state three prohibitions: "Volunteers shall not provide direct client care or treatment services in lieu of staff as required by this chapter. 2. Volunteers shall not administer medications. 3. Volunteers shall not be used to restrain clients." The program must be approved by the governing authority and delivered "under the supervision of appropriately trained and qualified staff, in accordance with client treatment plans and the rules of this chapter."

Where a volunteer is also a counselor-intern, the two file types converge: "Volunteers who function as counselor-interns will perform their duties in accordance with established professional training, clinical care, supervision requirements and the rules set forth in this subchapter." The enrollment proof, the semi-annual documented progress review and the weekly supervision hour apply to an unpaid intern too.

Outpatient (8:43K) has no comparable volunteer subchapter. Volunteers reach the outpatient personnel file through one route: if they provide direct patient care, they must be screened and tested for tuberculosis under 8:43K-4.11(b), which reaches personnel "regardless of the member's status as being directly employed, under contract, and/or volunteering." Interns are addressed in the DMHAS companion chapter that applies to adult outpatient behavioral health programs: under N.J.A.C. 10:36-5.2(b) a program must ensure only appropriately qualified staff perform evaluations using screening and assessment tools, and "Subject to appropriate clinical supervision and consistent with their scope of practice, interns may perform evaluations using screening and assessment tools that do not require a clinical degree or license." That is a task-level restriction, not a tenure clock, and it states no recordkeeping duty of its own.

Contracted, agency and per diem staff. Residential (8:111) does not exempt them. 8:111-3.5(e) requires the facility to "ensure that substitute staff possess appropriate equivalent qualifications needed to function in that capacity," 8:111-3.5(c) requires job descriptions "for all facility staff, including volunteers," and 8:111-23.2(c) pulls volunteers into checks, exams, credential verification and photo ID. At licensure, 8:111-2.3(i)3 makes you disclose "contract arrangements with outside agencies" as part of your staffing patterns, criteria and credentials. Outpatient (8:43K) reaches non-employees expressly in exactly one place, 4.11(b), which requires tuberculosis screening and testing of every direct-care personnel member "regardless of the member's status as being directly employed, under contract, and/or volunteering," and one place implicitly, 6.2(a), where the prescriber may be employed "either directly or through contract." Beyond those, the chapters do not say. The defensible position is to hold a contracted or per diem clinician to the same credential-verification, tuberculosis and orientation rows as an employee, and to keep the contract itself in the file in place of the employment record.

Your personnel file is a licensure exhibit, not an HR artifact. In residential (8:111), an applicant proposing multiple levels of care in one facility "shall designate the number of beds for each level of care and shall document that the facility meets the appropriate staffing and other requirements applicable to each level of care provided."

Expect the surveyor to work in these directions.

Credential currency. Not whether a license is in the file, but whether it is current and free of sanction. That is the two-part test at 8:111-3.5(a)6, and it is why an annual facility-level audit is required: the quality assurance plan must include "an annual review of staff qualifications and credentials, and staff orientation and education that includes core functions addressing ASAM criteria (ASAM PPC), medication-assisted treatment, and professional ethics."

Coverage, shift by shift. In residential (8:111), "facilities serving adults shall have at least one staff member responsible for the supervision of each 24 adult clients during waking hours, and at least one staff member responsible for each 30 adult clients during sleeping hours", with no fewer than two staff present and awake. The one carve-out: "Halfway houses with 24 or fewer beds shall have at least one overnight staff on duty and awake to whom residents have immediate access in case of emergency;". Adolescent programs run roughly double the adult intensity, at one staff member per 10 adolescent clients during waking hours and one per 20 during sleeping hours under 8:111-3.5(f)2, with not fewer than two staff present at all times. Those ratios remain codified and operative, so comply with them. Note that the 2021 recodification struck "and adolescents" from the chapter's scope clause at 8:111-1.1(a) while leaving them in place, so if you license an adolescent program, confirm scope with the Division rather than inferring it. Women-and-children programs carry a third schedule at 8:111-3.5(f)3: the adult ratios apply to the women, and separately, when children are not under the direct care of their mothers, one staff member for every five children under 2 1/2 and one per 10 children aged 2 1/2 to six during waking hours, and one per 10 and one per 20 respectively during rest or sleeping hours. Mixed age groups are computed separately to the nearest tenth, and any fraction above a whole number adds a staff member. Separately, "At least one staff person who is currently certified in basic cardiac life support by the American Heart Association and the American Red Cross shall be present in the facility at all times during the facility's hours of operation." The rule names both bodies conjunctively as printed; confirm accepted certifications with the Division rather than assuming. At least one person trained and qualified in the emergency equipment maintained on site must also be available whenever a client is on site.

Caseloads and group size, residential (8:111). Counselor caseload ratios are computed on daily census, are additional to the supervision ratios above, and are set out in the checklist row citing 8:111-10.1(b). Group counseling sessions carry their own separate caps, which do not line up with the caseload ratios: one counselor for eight or fewer clients in short-term residential, 12 or fewer in long-term residential and extended care, and 15 or fewer in halfway houses, at 8:111-10.1(b)6. Educational and family counseling sessions are excluded. A mixed-modality campus has to show it satisfies these, the supervision ratios at 8:111-3.5(f) and the nursing coverage at 8:111-8.1 separately for each level of care.

Supervision logs. The residential weekly hour, the group cap and the semi-annual intern review are all documentation duties, and the quality assurance program must separately include "Review of policies, procedures, and practices relating to the provision of clinical supervision of staff, including the methods and frequency by which staff receive clinical supervision;". On the outpatient side the log itself is a named duty of the clinical supervisor under 8:43K-6.4(c)3iii.

Reporting that HR has to route. A personnel action is a reportable event in both settings. In residential (8:111) the facility must immediately report "All disciplinary actions of staff, including termination, resulting from inappropriate staff interaction with clients; and" as well as "All criminal convictions or disciplinary sanctions imposed on staff, board members or representatives of the governing authority by licensing or credentialing boards since the prior application for licensure." Outpatient carries the same two duties in writing to the Office, at 8:43K-4.13(c)3 and (c)4, and (c)4 runs "since the most recent of either the facility's initial license application or last application for renewal of licensure."

A crime against a staff member also generates a personnel-file document. In residential, 8:111-3.8(b)4i and ii require that the staff member be advised of the right to report to local police and that "Notification, or the refusal to notify police authorities, shall be documented in writing in the client or staff record," with the administrator notified. Outpatient 8:43K-4.13(d) and (d)1 impose the same duty and name the "staff member's personnel record" expressly, including documentation of a declination or refusal.

Leadership departures carry a seven-day written deadline, and it is the one most often missed because nobody owns it: "The facility shall notify the Division in writing of the resignation or termination of employment of the administrator, medical director, director of nursing or the director of substance abuse counseling services... no later than seven days following the date of resignation(s) or termination(s)." Acting replacements count, and their qualifications go with the notice. It is not the tightest clock in the section, though. The staff disciplinary actions at 3.8(b)5 and the convictions and board sanctions at 3.8(b)6 must be reported immediately by telephone and fax, with the written report following within five business days. Offboarding runs outward too: "The facility shall comply with all requirements of professional licensing and credentialing boards for reporting termination, suspension, revocation or reduction of privileges of any employee licensed or credentialed in the State of New Jersey."

The failures that repeat are dull and preventable. An expired license that nobody re-verified. A missing seronegative and unvaccinated list. A second-step Mantoux outside its window, which is within three weeks in residential (8:111-3.7(d)2) and one to three weeks in outpatient (8:43K-4.12(e)1). An intern progress review done annually instead of semi-annually (residential, 8:111-1.9(a)2i; 8:43K imposes none). A conviction-review policy that exists in principle but was never written (residential, 8:111-3.5(a)5; outpatient requires only the criminal history record review policy at 8:43K-4.11(a)7i). A patient-transport driver whose license was last checked more than six months ago (outpatient, 8:43K-4.14(a)4). And, in 2026, a policy manual that still cites 10:161A or 10:161B.

Retention is not answered by these chapters. N.J.A.C. 8:111 sets retention periods only for clinical records, at 8:111-19.6, and 8:43K-4.11 sets none. Your retention schedule therefore comes from outside the licensure rules: New Jersey wage and hour recordkeeping, federal employment-law rules, occupational safety rules on employee exposure and medical records, and your own contracts and funder agreements. This guide deliberately gives no number, because none of the sources cited here sets one. The workable method, and it is recommended practice rather than law, is to identify the longest applicable period among those outside authorities and build a single schedule to it. Do not attribute a personnel-file retention period to 8:111 or 8:43K, and do not shorten one on the strength of their silence.

Repoint your citations. This is the cheapest compliance work available to you right now. Every internal policy, form header, job description, audit tool and orientation deck that cites N.J.A.C. 10:161A should cite N.J.A.C. 8:111 with the same section number. Every one that cites N.J.A.C. 10:161B should point to N.J.A.C. 8:43K, understanding that the substance often changed and is not a straight renumbering. Every posted notice, consent form and complaint sign that names the Department of Human Services, DMHAS or the Office of Licensing should name the Department of Health and the Division of Certificate of Need and Licensing. On the complaint sign specifically, 8:111-17.3 requires you to give clients and their families the name, address and telephone number of a named State office, so confirm the current office and address with the Division before you print. This guide does not state that address.

Expect to meet at least three stale cross-references and not be thrown by them. The current text of 8:111-1.4(a) still refers to facilities required under "N.J.A.C. 10:161A-7" to hire a medical director. 8:111-20.1(c)5 still refers to employee health "in accordance with N.J.A.C. 10:161A-3.7." And the definition of "Clinical note" at 8:111-1.3 still points to an approved counselor-in-training "pursuant to" 10:161A-1.9(a)2. The first two sit inside paragraphs the readoption marked "(No change.)", and the readoption never reprinted the third definition at all, so the technical-change pass missed all three. Read them as 8:111-7, 8:111-3.7 and 8:111-1.9(a)2.

Check the date on any free source. As of October 13, 2026, Cornell LII had not ingested N.J.A.C. 8:43K and still displayed N.J.A.C. 10:161B with no repeal notation, so read outpatient text from the Department's Notice of Adoption and check anything drawn from the Notice of Proposal against it. Whole subchapters moved on adoption, not just subsections. Because most of proposed subchapter 9, Adjunctive Services, was not adopted, proposed subchapter 10 became 9, 11 became 10 and 12 became 11, proposed 7.9 through 7.21 shifted down to 7.8 through 7.20, and proposed 8:43K-9.7 was recodified into subchapter 6 as 6.13. Subchapters 1 through 6, and 7.1 through 7.7, kept their numbers, so the personnel rules at 4.11, 4.12, 4.13 and 6.2 through 6.6 are where the proposal put them. Re-verify any 8:43K citation against the codified chapter once the Office of Administrative Law publishes it. Two mechanical cautions when you read those PDFs: the text layer drops possessive apostrophes, so "employee's" prints as "employees", which we have restored in the quotations above. Some drafting artifacts are genuinely in the rule, including the doubled "record review history" in the criminal history policy and the two paragraphs numbered 5 in 8:43K-6.2(a).

Organize the file so a surveyor can walk it. Group by the rule's own categories rather than by chronology: identity and employment history, credentials with expiration dates, criminal history, employee health, orientation and training, job description and duty assignment, performance and supervision. Where a requirement is conditional, keep the record of why it did not apply. Keeping a per-employee due-date view of every expiring item, meaning license, certification, annual in-service, annual Mantoux, annual evaluation, BCLS card, semi-annual intern review and the outpatient six-month driver license check, is recommended practice, not law, but it is the difference between a clean file review and a plan of correction.