Observations
Based on a review of personnel records, the facility failed to follow their written policies and procedures with regard to supervision of staff. Supervisory documentation for November 2022 through March 2023 was reviewed. Per the Clinical Supervision of Counselors policy, individual supervision is to occur at least monthly. Per the New Employee Orientation policy, the supervisor is to meet with new employees weekly for the first 4 weeks of employment. Documentation of supervisory sessions was missing from six out of seven applicable records reviewed.
Employee # 1 was promoted to a counselor position on 1/17/22 and was still acting in that position at the time of the investigation. There was no documentation of supervisory sessions occurring in November or December 2022.
Employee # 2 was hired as a counselor on 4/5/22 and was still acting in that position at the time of the investigation. There was no documentation of supervisory sessions occurring in November or December 2022.
Employee # 4 was hired as a counselor on 5/21/22 and was still acting in that position at the time of the investigation. There was no documentation of supervisory sessions occurring in November or December 2022.
Employee # 5 was hired as a counselor on 1/24/23 and was still acting in that position at the time of the investigation. As a new hire, there are to be weekly supervisory sessions for the first 4 weeks of employment. There was no documentation of supervisory sessions occurring the week of February 5, 2023; February 12, 2023 or February 19, 2023.
Employee # 6 was hired as a counselor on 2/20/23 and was still acting in that position at the time of the investigation. As a new hire, there are to be weekly supervisory sessions for the first 4 weeks of employment. There was no documentation of supervisory sessions occurring the week of March 5, 2023; March 12, 2023 or March 19, 2023.
Employee # 8 was hired as a counselor on 3/15/23 and was still acting in that position at the time of the investigation. As a new hire, there are to be weekly supervisory sessions for the first 4 weeks of employment. There was documentation of one supervisory session in March 2023, however, the day of that session was not cited in the file . There was no documentation of a second supervisory session occurring in March 2023. Documentation was also missing for sessions that should have occurred the week of April 2, 2023 and April 9, 2023.
These findings were reviewed with facility staff during the investigation.
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Plan of Correction
By 5/2/23, the regional project director will send an instructional memo to the supervisory staff program regarding the supervision process. The memo will remind the supervisors to document the existing weekly supervision being completed within the first 4 weeks of hire and is signed by the employee. The memo will also state that all supervision notes must be scanned and stored into the electronic HR file of the employee to serve as proof of completion. The memo will be sent by email. The QI assistant shall review the supervision monthly to ensure all sessions are documented. Any missing document found in the audit review shall be reported to the director for correction. Process will be ongoing and QI review shall start as of 5/15/23 |