Observations
Based on a review of the facility's policies and personnel records, the facility failed to follow its Supervision Policy as evidenced by:
The facility's Supervision Policy indicates that a Counselor Assistant with a High School Diploma or GED equivalent will be supervised by the Clinical Supervisor or full-time Counselor by providing direct observation and completing weekly supervision notes relating to the counselor assistant.
Employee #1 was hired as a Counselor Assistant on March 11, 2024, and employment ended on August 18, 2024. There were no weekly supervision notes in the personnel record for the weeks of April 8, April 22, April 29, and July 8.
This was discussed with facility staff at the time of the investigation.
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Plan of Correction
The Clinical Supervisor responsible for the missing supervision notes discovered during this review was retrained in the expectations of frequency of supervision notes required for all levels of counselor and in Blueprints' supervision policies. This retraining occurred on 10/17/2024 and was facilitated by the Human Resources Director and also the Compliance Officer.
On 10/29/2024 Site Directors were informed of their responsibility to check supervision note folders weekly to ensure that require supervision notes are present and completed. "Supervision note folders" are SharePoint folders maintained by Clinical Supervisors and shared with the Site Director (Facility Director) they report to, with the Human Resources Director, and with the Compliance Officer. They contain the draft and/or final copies of all supervision notes for which the clinical supervisors are responsible. Previously established, the Human Resources Director also reviews supervision notes for all notes required by company policy monthly to ensure accuracy and to catch any non-compliance by Site Directors in their review of Clinical Supervisor's documentation. The Compliance Officer reviews all required supervision notes for their presence and submission to an internal Human Resources Supervision tracker quarterly.
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