Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for all of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The SRFSR for the fourteen facilities that make up the project list a total of 57 counselors (some full time and some part time) and fourteen part-time clinical supervisors. The total of the hours per week provided to the project by counselors equates to 46 FTE counselor positions within the project.
The SRFSR for the fourteen facilities within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed each of the fourteen part-time clinical supervisors as facility directors; therefore they are unable to provide full-time clinical supervision. In addition nine of those part-time clinical supervisors carried a caseload above five clients, which further prevents their ability to provide full-time clinical supervision to their staff. A full-time equivalency of 46 counselors would require a minimum of 5 full-time clinical supervisors and one part-time clinical supervisor within the project.
This finding was confirmed with the project director during the administrative review.
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Plan of Correction
The facility is requesting an exception to this standard. If an exception is not granted, the project will ensure that there is one full time Clinical Supervisor for every 8 FTEs. Should the exception not be granted, the Project Director will monitor the staff schedules to ensure compliance with the licensing standard 704.6 (a). |