Supervision Note
Due by the 15th of every month
Date of Meeting
*
/
Month
/
Day
Year
Date
Start Time:
*
Hour Minutes
AM
PM
AM/PM Option
End Time:
*
Hour Minutes
AM
PM
AM/PM Option
Total Hours?
*
Service Provider Name
*
Email
example@example.com
Service Provider
*
Intake Coordinator (Meets Monthly)
Service Coordinator (Meets Monthly)
Independent Living Skills Trainer (Meets Bi-Weekly)
Positive Behavioral Intervention Specialist (Meets Bi-Weekly)
Community Integration Counselor (Meets Bi-Weekly)
Incident Committee Coordinator (Meets Monthly)
Medical Records Coordinator
Service Plan Submission Coordinator
Subsidy Accounts Manager
Supervisor's Name
*
Type Contact:
*
Phone Call
Meeting
Written
The following items have been reviewed with the provider:
*
Caseload Review & Compliance Certification Checklist
Review of participant’s goals/outcomes – progress and/or barriers
Questions/concerns regarding the participant or treatment team
Concerns regarding the provider’s schedule or ability to provide the approved # of hrs. to the participant
Suggestions for changes to goals, interventions, schedule, or number of hours
Follow up on any assessments, behavioral plans, or ISRs needed
5 day policy – all staff must submit session notes within 5 days of providing the service Documentation of any non-billable time or justification for gaps in service
Review of incidents, non-recordable incidents and risk concerns, as needed.
Team meetings – the importance of attending semi-annual meetings & documenting attendance at team meetings in session notes and ISRs
Request of team meetings and documentation of request for team meeting, as needed
Return of signed Grievance Policy, Rights and Responsibilities, and Receipt of Documentation form
Return of Basic Orientation and Service Specific training sign-in sheets, as needed
Attendance at Bi-Annual Required Annual Training, as needed
Review of EEO Policies and signed ackn. annually, as needed
Review of any new policies and procedures.
Other
Issues Discussed:
*
Staff Action Needed:
*
Desired outcome
*
Due date
*
-
Month
-
Day
Year
Date
Supervisor Follow-Up:
*
Staff comments:
*
Date of Next Contact
*
-
Month
-
Day
Year
Date
Time of Next Contact:
*
Hour Minutes
AM
PM
AM/PM Option
Employee Signature
Date
-
Month
-
Day
Year
Date
Supervisor Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: