SERVICE DELIVERY FILE REVIEW POLICY

PURPOSE: 

This Appendix accompanies the 2024 National Standards noted below. It contains file audit instructions and checklists for Mentor and Mentee files, including audit requirements for closed files.  

The File Audit instructions are required to be implemented as outlined in this document.  

The information obtained via use of the File Audit Instructions is required; however, the File Audit Checklists are provided as examples. Agencies can track this information in another format or modify checklists to reflect agency requirements. Additions to the checklists are permitted. Omissions are only permitted for checklist items that are noted as applicable or recommended or as relating to Striving for Excellence Standards. 

Agencies are accountable for ensuring adherence to 2024 National Standards. 

STANDARD DOC-4 (Mandatory Standard): The agency regularly performs file audits of client files and uses the information obtained to improve their processes and operations.   

STANDARD CL-2 (Mandatory Standard): The agency has systems and structures in place to ensure all documentation related to the match is completed within two weeks after the match closure.   

VERSION HISTORY: 

  • Combined requirements for File Audit Instructions and Closed File Audit Instructions into one Appendix 
  • Removed: 
  • overnight visits 
  • option for physical files 
  • items that are generated automatically in SDP (Volunteer Registry, name, birthdates) 
  • Added:  
  • optional: orientation (recommended for both Mentor and Mentee during the intake process) 
  • optional: before rematching, updating the client’s current circumstances and reinforcement of key messages from pre-match training (recommended to be completed with children/youth prior to rematching) 
  • group files add to the list of files to be audited 
  • documentation of volunteer withdrawal (if applicable) 
  • Next Steps section for assessment of staff competencies 
  • Additional Reminders section noting items that have often been identified as incomplete. 
  • Minor changes to formatting for better flow  
  • Minor changes to language for increased clarity and for alignment with 2024 National Standards 

FILE AUDIT INSTRUCTIONS 

Preamble 

All agencies conduct regular file audits (reviews) at minimum twice a year and use the information obtained to improve their processes and operations. The purpose is to assess service quality and safety for clients and to demonstrate compliance with and knowledge of National Standards and agency policies/procedures. 

The file audit allows agencies to identify areas of potential risk and areas for improvement related to the safety and quality of service delivered to children/youth and volunteers. It also allows supervisors to assess staff competencies, identify training needs, and improve the quality of the service.  

Regular file audits are also conducted as part of the ongoing Quality Assurance Program. 

Frequency and Scope of Reviews: 

Approximately 10-15% of active files (four files per staff) will be reviewed at minimum every 6 months, with the goal of achieving 100% compliance with National Standards and agency policies/procedures.  

The agency must decide on the number of files to be audited.  The number of files chosen must include files from each mentoring program and Service Delivery Staff, which will help with managing risk. Supervisors may increase the number of audits for specific staff based on identified concerns or issues. 

Types of Files to be Reviewed (as available): 

  • Active community-based matches, with files at different stages of development 
  • Active 1:1 and group site-based matches, with files at different stages of development 
  • Re-matched Mentor and Mentee files 
  • Matched files that transitioned from site-based to community-based programs 
  • Files that resulted in premature closure 
  • Files involving staff and/or Board members serving as Mentors 

Conducting Reviews: 

Reviews will be conducted by Service Delivery Staff members who do not own the files being audited. The results of the review will be overlooked and summarized by the Program Manager.  

Review Checklist: 

A checklist of mandatory forms will be completed for each file and preserved for future analysis, accreditation, or any other relevant purposes. The file review will:  

  • encompass all aspects of a file, including closed file requirements 
  • assess compliance with Big Brothers Big Sisters Victoria Capital Region policies/procedures, and adherence to National Standards  
  • ensure required forms exist and that required signatures and dates are present, as applicable  
  • evaluate staff competencies, focusing on understanding indicators of a healthy match and the ability to apply critical thinking in enrollment and match support functions  

Identification and Documentation: 

The file review will include identification and documentation of:  

  • risks related to child and youth protection, including a focus during Match Supervision on the conditions that promote safety and quality: Activities, Consistency, Closeness, Youth-Centeredness, Structure, Duration and Expectations, and Safety. 
  • areas for potential improvement  
  • barriers to match continuation in matches closed in under a year  
  • staff competencies and training needs   
  • the date of review, reviewer’s name and title, and any deficiencies found (improvements in areas with noted deficiencies should be documented in subsequent reviews) 

Additional reminders: 

The following additional reminders are required as noted in the checklists: 

  • Electronic Signatures – double verification process (if applicable)
  • Forms are signed and dated as required 
  • Supervisors sign off on all case note entries made by students performing service delivery functions 

Mentee File Review

File reviews are to be completed every six months by the Service Delivery Team. A random number of files will be selected for review.
Name of Staff Member Completing this File Review(Required)
MM slash DD slash YYYY

MENTEE INTAKE CHECKLIST

Mandatory Forms and Required Documentation for Mentee's Intake
Mentee's Name(Required)
Mentoring Coordinator's Name (i.e. owner of file):
Name of Mentoring Coordinator who manages this file
Program Type:(Required)
Screening Outcome(Required)
Application Form(Required)
Document required by BBBS Victoria for all programs. Application form must be signed by the mentee's Parent/Guardian.
Final Child and Family Assessment(Required)
Required for all clients by BBBS Victoria Capital Region.
Informed Consent Form(Required)
Informed Consent Form must be signed by the mentee's Parent/Guardian. Required document for all programs.
Photo/Media consent Form(Required)
Form does not have to be present for service to be provided. If present, it must be signed by the mentee's Parent/Guardian. If not present, file must be marked as unsuccessful with a note that "photo/media consent was not provided".
Inquiry (optional)(Required)
May not be present - not every file starts as an inquiry
Child Interview Summaries(Required)
Document not required for ISM or B You
Parent Interview Summaries(Required)
Document not required for ISM or B You
Notice of Acceptance/ Letter of Rejection sent(Required)
Standard ITC7 (MS): Applicants to the agency’s programs are informed of their application status and supported (within reason) throughout the process. (Not required for site-based matches or groups). The parent/guardian and/ or youth (if applicable) is notified of their acceptance/rejection into the program. (Note: notice of rejection must be in writing, however, notice of acceptance can be either by letter, in person, by phone or virtually. Notification must be documented and recorded in case notes (including how notification was made, e.g., by phone or in person)).
Orientation Session for Parent/Guardian(Required)
Standard TR2 (MS): The completion of training is documented in the participant’s file. Agencies may choose a method to track completion that meets their needs including a signed attestation of completion or a training checklist signed by parent.
Pre-Match Training for Mentee(Required)
Standard TR1 (MS): The completion of training is documented in the participant’s file. Agencies may choose a method to track completion that meets their needs including a signed attestation of completion or a training checklist signed by staff.
Needs Registry Assessment(Required)

mentee match checklist

Mandatory Forms and Required Documentation for Mentee's Match
Match Introduction Meeting, including Reasons for Match(Required)
Review completed activities under match #. Match introduction notes must name the individuals present in the meeting, where and when the meeting took place, and whether the match is going ahead.
Case Logs(Required)
Standard SUP4 (MS): The agency documents all relevant interactions and information in participants files in a way that supports the match, facilitates service delivery continuity, meets insurance requirements, and complies with legislative requirements in its province of operation.
Match Supervision Guidelines (6 Conditions)(Required)
All scheduled match monitoring tasks are completed. Note if there a pattern of not completing them on time or not filling in all of the details of the task.

Mentee match closure checklist

Mandatory Forms and Required Documentation for Mentee's Match Closure
Evidence that an in-person match closure/graduation meeting was offered(Required)
Match Closure Task Completed in SDP(Required)
Includes documented reason for match closure, recommendations for appropriateness for rematch, and recommendations for re-engagement of P/G, child/youth, and/or volunteer. Should include note regarding delivery of match closure letter to P/G.

Additional Reminders

Forms - Signed and Dated as required?(Required)
In general, were application forms, referral forms, informed consent, media consent, etc. signed and dated as required?
If Applicable: Did a supervisor sign off on all case note entries made by students performing service delivery functions?(Required)
Please document any additional concerns and/or feedback you may have about this individual file review and/or the file review process being implemented.
File Reviewers Signature
MM slash DD slash YYYY