Article Published: 8/23/2023
Supervisors are a vital resource for counselors; their guidance and feedback help to ensure that their supervisees are providing their services safely and upholding the highest ethical standards in order to do their best work. This month, we spoke with Anthony P. Onorato, MA, LPC, ALPS, AADC, about the significance of detailed recordkeeping for supervisors and their supervisees, the potential issues that may arise from improper or inadequate documentation, and important things to bear in mind during the process.
What are some of the more common oversights or inaccuracies you see among clinicians documenting their supervision? And supervisors?
If we are primarily talking about supervision in the context of licensure, I think there are two basic components to this issue; the first is the clinical notes. While it seems like most supervision time is spent on clinical skill building, I’m not sure how consistently supervisors review the documentation unless they need to do so as part of their organizational role. I say that from a pure logistics and practicality standpoint. Confidentiality and HIPAA being what it is, it’s easy to view live or recorded sessions and sample written work product when everyone is part of the same entity. The video/sound and written work product is every bit as important if the supervisor and aspiring licensee work for different entities. It simply needs to be accounted for differently.
Since the clinical documentation is directly tied to reimbursement and regulatory compliance with agencies such as the Joint Commission, most organizations make sure they are training clinicians to meet those standards.
The second relates to what the licensing board needs to ensure the requirements are met to become fully, independently licensed.
Example 1: One challenge seems to be properly tracking the supervision hours in relation to the ratio of clinical to supervision hours mandated by each state’s licensing board. So, for example, in West Virginia we have a 20:1 ratio. Every 20 clinical or direct client counseling hours requires 1 hour of corresponding supervision. If a supervisee is accumulating 30 hours of direct counseling sessions per week, that would mean that they are going to need 3 supervision sessions within a 2-week period to meet the 20:1 ratio. Many times, the documentation the Board receives does not reflect that.
Example 2: The notes the supervisor makes about how the supervision is going. It’s important to document the issues that arise and the feedback giving to the supervisee. Otherwise, there is no record of the supervisor’s perspective and communication with the supervisee about their progress or lack thereof.
What are the possible consequences of improper documentation, including legal issues?
In example 1, the problem is that hours that don’t comply with that ratio don’t count toward being licensed. Using the above example, if it only looks like the supervisee gets 1 hour of supervision per week, that’s a 30:1 ratio and they ultimately only get credit for 20 hours toward being independently licensed—meaning they are losing one-third of their hours. If you play that out over a total of 3,000 hours of supervision, the supervisee thinks they are done and hands in the documentation, and then the board says only 2,000 hours count. The supervisee is not going to be a happy camper.
Ultimately, it is the responsibility of both the supervisor and supervisee to make sure that requirement is not only met, but that it is properly documented. Could an issue like this potentially lead to a lawsuit at some point? Possibly.
In example 2, the issue is mostly relevant when a supervisor is inclined to not recommend the supervisee for independent licensure. Probably similar to an employment issue when an employee has been given an improvement period with specific goals to meet or face termination from their job, a lack of knowledge, skill, or compliance better be well-documented along with the attempts made to address those shortfalls throughout the supervision process. The gatekeeper role is important, as the licensing board relies on supervisors to protect the public from clinicians who aren’t ready to be out on their own.
That situation is ripe with potential legal issues, whether a supervisee is not recommended for licensure or even if a supervisor recommends someone they know isn’t ready.
What do supervisors and supervisees need to understand to uphold the highest ethical standards regarding documentation?
In general, ethics or principles guide how someone makes decisions. They aren’t something you turn off and on. They are a philosophy, an ethos, or a way of living. They are the minimum standard of conduct that is embedded in our professionalism. They permeate every aspect of how we conduct ourselves. They are the foundation of everything we do. They are what we do in the light of day in front of everyone, as well as in the darkness when no one else is present.
In the example of documenting supervision hours, the temptation to fudge or alter those documents when you start to do the math and realize there is a problem, that is real. That’s when we learn more about who we are, at least at that moment. The issue is that once I start to compromise my ethics and integrity, it’s easier to do it again. It might not be contained within or limited to documentation; it may leak into other aspects of how we practice.
Why uphold the highest standards for documentation? Because it’s not really about the documents; it’s a reflection of who you are.
How do you effectively set the expectations for documentation in the supervision relationship?
Every relationship is about expectations and boundaries. Supervision is the same. In the case of licensure supervision, there needs to be a written contract with the expectations and responsibilities of each party clearly defined and well understood.
Why is it important for a clinician to understand who ultimately controls the record (the supervisor, agency, or facility)?
I think that concept is important with everything we do, not just supervision. That determines who is entitled to access and who needs permission to have access. Giving access to the wrong person without permission brings a host of problems that could include a licensing board complaint, a lawsuit, and even fines from other regulatory agencies for HIPAA breaches. I can’t say any of those sound appealing.
How long should this documentation be retained, and why?
That’s a good question. I had to reach out to a few colleagues from various jurisdictions around the country to get a better idea of that. The consensus is to keep them for 7 years. Some states have it spelled out directly in their rules, many don’t. However, it’s probably a good idea to err on the side of caution and treat them like clinical records, even if you think you can make an argument that they aren’t. I’m glad you asked that question. It helped me learn something.
Are there any helpful resources or trainings for supervision documentation that you’d recommend?
I don’t know that the specific trainings are as important as the mindset one uses when they attend. It doesn’t matter how knowledgeable, organized, and engaging the presenter is if you passively attend just so you can check the box to either obtain or maintain a supervision credential. Actively attend with the intent to participate and learn something new or even a wrinkle to something you’ve always known.
Any final thoughts on documentation, or supervision in general?
Supervision is an opportunity to impart some wisdom to emerging professionals about the science and art of the craft. If you choose to do it, work at being good at it. Be the professional you aspire to be so that your words and actions align in a way that models excellence in the field.
Details matter. They matter when identifying the nuances in human behavior. They matter when we help people better understand themselves so they can live in a manner that is more meaningful and fulfilling to them. And they matter when we document our encounters.
Anthony P. Onorato, MA, LPC , ALPS, AADC, is a Licensed Professional Counselor and performance consultant in private practice in Morgantown, West Virginia. He is an Approved Licensed Professional Supervisor (ALPS) and an Advanced Alcohol Drug and Alcohol Counselor (AADC). He is also a Director at Large for the American Mental Health Counselors Association (AMHCA) and is a board member of the West Virginia Licensed Professional Counselors Association.
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