SOP 508.07: Clinical Supervision

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 1 of 6|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

I. Introduction and Summary:

All mental health clinical staff will have an assigned clinical consultant or supervisor.
The purpose of clinical consultation and/or supervision is to provide a mechanism for
monitoring the quality-of-service provision and to assist mental health staff with their
professional growth and development. This procedure is applicable to all Georgia
Department of Corrections (GDC) facilities with mental health staff.

II. Authority:

A. O.C.G.A.: §43-39-1 Georgia State Board of Examiners of Psychologists, §43-39
20, and §43-10A-1 Professional Counselors, Social Workers, and Marriage &
Family Therapist Licensing Law; and

B. Amended Rules of Georgia Composite Board of Professional Counselor, Social

Worker and Marriage and Family Therapists; and

C. Rules and Regulations of the State of Georgia: Chapter 135-5-.01 Associate

Professional Counselors and 135-5-.02 Professional Counselors.

III. Definitions:

A. Clinical Consultation/Supervision - The review of a consultee’s/supervisee's

clinical work, which includes, but is not limited to periodic chart review, patient
contact, and case discussion, for training and quality improvement as well as
facilitation of acquiring professional licensure.

B. Psychologist - An individual who holds a doctoral degree and is currently licensed

by the Georgia Board of Examiners as an applied psychologist.

C. Certified Professional Counselor Supervisor (CPCS) - An individual who is

currently licensed by the Secretary of State Composite Board as a Licensed
Professional Counselor who also holds a CPCS certification awarded by the
Licensed Professional Counselor Association of Georgia.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 2 of 8|
|Authority:
Commissioner
|Originating Division:
Office of Health Services
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

IV. Statement of Policy and Applicable Procedures:

A. Clinical Supervision/Consultation of unlicensed Mental Health Counselors, Mental

Health Technicians, Behavior Specialists and Activity Therapists:

1. All unlicensed mental health counselors, mental health technicians and

behavior specialists will receive a minimum of three hours of clinical
supervision per month from a licensed mental health care provider (e.g.,
psychologist and certified professional counselor supervisor), in addition to a
minimum of one hour of clinical case conceptualization provided as part of a
group format during a mental health program’s monthly case conceptualization
meeting, for a total of four hours of supervision monthly. All activity therapists
will receive a minimum of one hour of clinical consultation a month from a
licensed mental health care provider or through the vendor’s chief activity
therapist supervisor. Supervision/consultation arrangements and assignments
will be determined by the facility’s clinical director or staff psychologist. The
goal of consultation/supervision is to ensure that the unlicensed mental health
counselor/technician, behavior specialist, and activity therapist are providing
adequate and appropriate mental health services, and to increase the clinical
skills of all counselors, mental health technicians, behavior specialists or
activity therapists as part of the provision of treatment, assessment, case
management, crisis intervention, documentation, and program development
services.

2. Clinical supervisors/consultants will be responsible for managing an active

clinical supervision/consultation file for each supervisee/consultee, which
demonstrates supervision/consultation is ongoing, and will include the
following:

a. Supervisee's/consultee’s name;

b. Date of supervision/consultation session;

c. Time of supervision/consultation session;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 3 of 8|
|Authority:
Commissioner
|Originating Division:
Office of Health Services
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

d. Supervision/consultation modality (e.g., group or individual);

e. Names and ID#'s of offenders/cases discussed;

f. Clinical issues and concerns discussed;

g. Supervisee’s clinical strengths and limitations;

i. Semi-Annual Report(s) of Clinical Supervision (form M15-01-02).

3. Documentation will be provided on the Record of Clinical Supervision form

(M15-01-01) or on the Individual Case Consultation form (M15-01-03) and
will include justification in the event a session did not take place as intended,
along with plans to reschedule and make-up missed supervision/consultation
session(s).

B. Clinical supervisors provide the mental health unit manager with a semi-annual

narrative report on Attachment 2, Semi-Annual Report of Clinical Supervision
(form M15-01-02) outlining the supervisee’s clinical strengths and/or limitations.
The clinical supervisor will discuss these reports and relevant findings with the
supervisee. The mental health unit manager and the clinical supervisor will
maintain these reports as part of the supervisee’s file. The mental health unit
manager will use these reports on an annual basis to complete the supervisee’s
annual performance review. The semi-annual clinical supervision report must
contain the following information:

1. The supervisee's attendance of weekly supervision sessions;

2. The supervisee's attitude toward supervision (i.e., resistant vs. cooperative,
apathetic vs. motivated);

3. The supervisee's compliance with the supervisor's instructions;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 4 of 8|
|Authority:
Commissioner
|Originating Division:
Office of Health Services
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

4. The supervisee's observation of professional boundaries with offenders and

other staff;

5. The supervisee's attitude toward offenders (i.e., respectful vs. disrespectful);

6. The supervisee's adherence to the limits of confidentiality;

7. The supervisee's clinical practices (i.e., within the scope of approved clinical
privileges);

8. Any ethical or clinical concerns about the supervisee's clinical practice; and

9. The supervisor's overall impression of the supervisee.

C. When supervisors identify any significant problems or deficiencies that cannot be

resolved or rectified through attempts made during the regular course of
supervision/consultation, and which in their clinical opinion require a restriction of
the supervisee's/consultee’s clinical privileges, they immediately report to the
mental health unit manager. Both the supervisor and mental health unit manager
either restrict and/or place conditions on the supervisee's privileges for a period of
time determined by the clinical supervisor. Additional notification should be
provided to the vendor’s assistant program manager and senior clinical director.

D. In the event that a mental health program’s clinical director or staff psychologist

becomes aware of a licensed mental health counselor demonstrating significant
deficiencies while rendering clinical services, or concerns exist regarding a
licensed mental health counselor’s clinical competence and their ability to perform
clinical functions independently (e.g., evidence of unethical and/or biased practice
regardless of holding a professional license), immediate notification will be
provided to the mental health unit manager and the vendor’s senior clinical
director. Resolution will be attempted to include, but not limited to, initiating a
temporary supervision arrangement/assignment with a clear goal of addressing
observed deficiencies. In the likelihood informal attempts at resolution and/or
short-term supervision arrangements do not produce desired outcomes, a written

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 5 of 8|
|Authority:
Commissioner
|Originating Division:
Office of Health Services
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

corrective action plan will be pursued. This plan will list specific and measurable
goals, steps, and exact timelines for restoring the licensed counselor’s clinical
performance to satisfactory levels and will be completed by the mental health unit
manager in conjunction with input from the assigned clinical supervisor. The
corrective action plan will be submitted to the vendor’s senior clinical director for
final review/approval. In the likelihood deficiencies are pervasive and/or clinical
competence is not restored at the outset of the corrective action plan, progressive
administrative action will be taken to include loss of clinical privileges (see SOP
508.04 section B.1.), formal notification of the GDC statewide mental health
director, and possible notification of the licensed counselor’s equivalent
regulatory/licensing boards.

E. When a clinical supervisor determines that a supervisee should no longer be

assigned as an offender's primary mental health care provider, the supervisor will
refer the offender to the mental health unit manager who will assign the offender
to another provider's caseload.

F. Activity Therapists who receive monthly consultation by the psychologist or

certified professional counselor supervisor will maintain documentation to be
reviewed by the vendor’s activity therapy supervisor on a quarterly basis for
purposes of oversight and ongoing support. Any deficiencies or problems
identified during the consultation process will be immediately reported by the
psychologist or certified professional counselor supervisor to both the mental
health unit manager and the vendor’s activity therapy supervisor.

G. Mental health nurses will receive ongoing consultation/supervision from the

institution's director of nursing and at a minimum one hour of clinical case
consultation monthly from a psychiatrist or psychologist. If the mental health
nurse is leading groups, the psychologist should provide consultation for at least
one hour monthly. This can either replace or be in addition to the once per month
hourly consultation with a psychiatrist. Consultation will be documented using
Attachment 3, Individual Case Consultation (form M15-01-03). Supervisors will
use the consultation, supervision and documentation guidelines outlined in section
IV.A. of this policy.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 6 of 8|
|Authority:
Commissioner
|Originating Division:
Office of Health Services
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

H. The clinical director, a licensed psychologist approved by the warden, mental

health unit manager and state mental health director/designee, will provide clinical
direction and oversight to the facility’s mental health program.

1. Clinical oversight is achieved by:

a. Identifying and facilitating resolution of conflicts between facility and

mental health missions;

b. Identifying and facilitating resolution of conflicts between the facility and

mental health missions and the offender's clinical needs;

c. Identifying staff training needs and arranging appropriate training;

d. Reviewing resource utilization given the mental health mission and
offenders clinical needs;

e. Ensuring that levels of care match levels of need;

f. Ensuring that supportive living unit (SLU) programs are appropriate;

g. Tracking SLU program use;

h. Overseeing the continuous quality improvement (CQI) program in

conjunction with the mental health unit manager;

i. Overseeing the utilization review program in conjunction with the mental

health unit manager;

j. Monitoring interdisciplinary relations; and

k. Overseeing the quality of clinical supervision.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 7 of 8|
|Authority:
Commissioner
|Originating Division:
Office of Health Services
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

G. When the clinical director identifies any problem, a report will be made to the

mental health unit manager, who will work with the clinical director to study and
resolve the problem.

H. Clinical Supervision of Advanced Practice Registered Nurse (APRN) Consultants:

1. The psychiatrist clinically supervises the APRNs.

2. Clinical oversight focuses on prescription practices, legal/medical
interventions, mental health evaluations, diagnosis, mental health
classification, treatment interventions and documentation.

3. The psychiatrist should review the APRN records and document at least
quarterly in the APRN’S credentialing file, to attest that APRN records have
been reviewed.

I. When the psychiatrist identifies problems in an APRN’s clinical practice, they will

take appropriate steps to investigate and correct the problem.

J. Clinical Supervision of Psychiatry and Psychology Consultants:

1. The vendor’s senior clinical director and psychiatric medical director will

clinically supervise psychologists and psychiatrists, respectively.

2. Clinical oversight focuses on prescription practices, legal/medical
interventions, mental health evaluations, diagnosis, mental health triage and
crisis management, mental health classification, psychological testing,
treatment interventions and documentation.

3. When the vendor's senior clinical director or psychiatric medical director

identifies problems in a psychologist or psychiatric provider’s clinical practice,
they will take appropriate steps to investigate and correct the problem.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|Policy Name:Clinical Supervision|
|Policy Number: 508.07|Effective Date: 8/15/2022|Page Number: 8 of 8|
|Authority:
Commissioner
|Originating Division:
Office of Health Services
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

K. Clinical oversight of the mental health programs, to include the performance of all

Georgia Department of Correction staff and vendors, will be performed by central
office mental health staff via monthly utilization reports, quarterly CQI reports,
quarterly site visits, annual self-audits with corrective action plans and annual
central office audits with corrective action plans.

L. Group Case Conference:

1. The clinical director or staff psychologist will maintain a file documenting

monthly two-hour case conferences for mental health staff using Attachment 4,
Clinical Group Case Conference (form M15-01-04). Relevant clinical issues
with the names and ID numbers of offenders/cases should be included in the
documentation.

2. The Group Case Conference will be facilitated by a
psychologist/psychiatrist/APRN.

3. Mental health counselors (licensed and unlicensed), mental health technicians,

behavior specialists, activity therapists, multifunctional correctional officers,
and mental health nurses are expected to attend the monthly case conference.

V. Attachments :

Attachment 1: Record of Clinical Supervision (M15-01-01)
Attachment 2: Semi-Annual Report of Clinical Supervision (M15-01-02)
Attachment 3: Individual Case Consultation (M15-01-03)
Attachment 4: Clinical Group Case Conference (M15-01-04)

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachments 1 and 2 will be placed in the staff member’s
supervision file and Attachments 3 and 4 will be maintained by the mental health unit
manager and/or consultant until obsolete or replaced.