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 eight full-time equivalent (FTE) counselors in the project.
The FTE for the project was calculated to be 12.2 which would require the project to employ one full-time clinical supervisor. As of July1, 2017 the only full-time clinical supervisor was promoted to the position of project director and facility director of the Elizabethtown site.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director has submitted an exception request for 704.6(a).
Upon receiving the results of the exception request, the Project will act in one of two ways.
1. If the exception is approved: Clinical supervision will continue as outlined in the exception request. Lead Counselors will continue to provide ongoing individual/and or group supervision weekly. Lead Counselors will provide quality assurance chart checks and review these chart checks with counselors during supervision. Lead Counselor caseloads will be adjusted down, as needed, at facilities with higher client loads. The Project Director/Facility Director is a qualified Clinical Supervisor and will continue to provide supervision to Lead Counselors and counselors on a regular basis and as needed. If, at any time, a facility would cross over the 8 counselor threshold, a full time Clinical Supervisor will be hired. If, at any time, the quality of our care appears to be negatively impacted by this structure, we will seek to hire a full-time clinical supervisor. In April 2018, a thorough internal review of the exception will be conducted by the Project Director. Parameters to be considered will include: client satisfaction and outcomes, charting compliance, staff satisfaction, and Project growth or decline. If these results are congruent with our standards, and the Project remains at or near its current size, an exception request will be submitted to extend the exception. If factors indicate a negative impact on the Project from the exception, the Project will begin a search for a full-time Clinical Supervisor, to be compliant with 704.6 prior to the end of the trial period on 6/30/18.
2. If the exception is denied: The project will conduct an internal and external search for a full-time Clinical Supervisor by the Project Director. The Clinical Supervisor will be hired in accordance to all provisions outlined in 704.6. The Project will be compliant by 1/1/18.
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