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SUPERVISORY AGREEMENT FOR PROVIDING SUPERVISION AND DIRECTION FOR SPEECH CLINICIANS (CFY Only)
I agree to provide direction and supervision to speech clinicians according to ASHA and LLR Directives. I understand that the term “under the direction of’ means that I am individually involved with the patient and accept ultimate legal responsibility for the services rendered by the individuals that I agree to direct. I am responsible for all the services provided or omitted by the individual that I agree to directly supervise. I understand that at no time may the individuals being supervised perform tasks when I cannot be reached by personal contact, phone, pager, or other immediate means. I understand that I must make provisions in writing for emergency situations including designation of another qualified provider who has agreed to be available on an as-needed basis to provide supervision and consultation to the individual when I am not available. I understand that I must be readily available to offer continuing supervision. “Readily available” means that I must be physically accessible to the individual being supervised within a certain response time based upon the medical history and condition of the beneficiary and competency of personnel. I understand that supervision should involve specific instructions from the supervisor to the individual regarding the treatment regimen, responses to indications of adverse beneficiary reactions.
1. I agree to sign Referrals for speech-language pathology services.
2. I agree to provide direction and supervision for school-based speech clinicians who do not have the ASHA Certificate of Clinical Competence following Medicaid guidelines and to document that supervision and direction. This will include approving evaluations, approving IEPs as the treatment plans, individual involvement with each student receiving therapy, and checking a sample of clinical services notes.
3. I agree to provide staff development to District speech clinicians.
4. I agree to provide written instructions to the clinicians regarding evaluation procedures, development of the IEPs, planning and implementation therapy, responses to adverse beneficiary reactions, and documenting the provision of services through Clinical Service Notes.
5. I agree to be readily available to provide continuing supervision and consultation to those clinicians working under my direction as well as to other clinicians as needed.
Clinicians working under my direction:
Signed______Date______
Pool/sped documents/Medicaid Forms/Medicaid Documentation of Supervision