Observations
Based on the review of six personnel records, the project failed to ensure that clinical supervisors and lead counselors, who have not functioning for two years as a supervisor in the provision of clinical services, complete a core curriculum in clinical supervision.
Employee #3 was promoted to a clinical supervisor on September 19, 2019 with no clinical supervision experience. There was no documentation of the completion of the core curriculum in the personnel file at the time of the inspection.
Employee #4 was promoted to a lead counselor on March 9, 2020 with no clinical supervision experience. There was no documentation of the completion of the core curriculum in the personnel file at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has completed the training since the inspection. The lead counselor is now scheduled for the training online. COVID had caused issues with training as it was rescheduled previously. The CEO will monitor this issue by inspecting training manuals on a monthly basis to ensure these requirements are completed in the proper time frame. DDAP was kind enough to share an online curriculum for us to utilize when necessary throughout the pandemic. This issue will also be discussed at all Supervisory meetings which are held weekly. The situation has been rectified. |
Observations
Based on the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client #2 was admitted on March 9, 2020 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, completed on March 9, 2020, indicated that the client was to receive one individual counseling session biweekly (two per month). There was no documentation of the client receiving one of the two individual counseling sessions nor was there documentation of no shows or cancellations for the months of October 2020 and December 2020.
Client #3 was admitted on February 13, 2020 and was a current client at the time of the A comprehensive treatment and rehabilitation plan, completed on February 13, 2020, indicated that the client was to receive one individual counseling session per week. There was no documentation of the client receiving individual counseling sessions nor was there documentation of no shows or cancellations for the weeks of May 3, 2020 through May 9, 2020, May 17, 2020 through May 23, 2020, May 31, 2020 through June 6, 2020 and June 7, 2020 through June 13, 2020. inspection.
Client #4 was admitted on May 11, 2020 and was discharged on November 27, 2020. A comprehensive treatment and rehabilitation plan, completed on May 11, 2020, indicated that the client was to receive one individual counseling per week. There was no documentation of the client receiving individual counseling sessions nor was there documentation of no shows or cancellations for the weeks of October 12, 2020 through October 17, 2020, October 18, 2020 through October 24, 2020, October 25, 2020 through October 31, 2020, November 1, 2020 through November 7,. 2020, November 8, 2020 through November 14, 2020 and November 15, 2020 through November 21, 2020.
Client #5 was admitted on July 16, 2020 and was discharged on January 4, 2020. An updated treatment and rehabilitation plan, completed on November 4, 2020, indicated that the client was to receive one individual counseling per week. There was no documentation of the client receiving individual counseling sessions nor was there documentation of no shows or cancellations for the weeks of November 29 through December 5, 2020, December 6, 2020 through December 12, 2020, December 13, 2020 through December 19, 2020, December 20, 2020 through December 26, 2020 and December 27, 2020 through January 2, 2021.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Supervisory team has rectified this situation this past week in supervision and staff meetings. It was determined that this would be monitored through weekly chart reviews done by the Clinical Supervisor and Lead Counselor. It was made clear that missed/rescheduled appointments need to be documented in the client's chart. It was also made clear to staff that any contact needs to be documented in the client chart. Again, this will be monitored through weekly chart reviews. |