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 

Mentor File Review

File reviews are to be completed every six months.
Name of Staff Member Completing this File Review(Required)
MM slash DD slash YYYY

MENTOR SCREENING CHECKLIST

Mandatory Forms and Required Documentation for Mentors
Mentor's Name(Required)
Mentoring Coordinator's Name:(Required)
Name of Mentoring Coordinator who manages this file
Program Type:(Required)
Screening Checklist ("Blue Sheet" found hard files only)(Required)
Required if hard file contains more than one document
Screening Outcome(Required)
Name and Birthdate Submitted to the Volunteer Registry. This happens when "Screening Outcome" is changed to “ACCEPTED CB OR ACCEPTED SB.”
Application Form(Required)
Document required by BBBS Victoria. Must be signed by Mentor (and Parent/Guardian if mentor is under the age of 19)
Permission and Release Form(Required)
Must be signed by Mentor (and Parent/Guardian if mentor is under the age of 19)
Photo/Media Consent Form(Required)
Form does not have to be present for service to be provided. If present, must be signed by Mentor (and Parent/Guardian if mentor is under the age of 19). If not present, file must be marked as unsuccessful with a note that "photo/media consent was not provided"
Volunteer Code of Conduct(Required)
Must be signed by Mentor
Confidentiality Agreement(Required)
Must be signed by Mentor
Fitness to Mentor(Required)
Home Assessment (Community-Based Program)(Required)
Completed as part of the interview. Note: Teen Mentors do not need to have a home assessment completed. Exempt in ISM and B You.
Interview Summary(Required)
Ensure that volunteer summary is located and completed within SDP and/or hard file.
Notice of Acceptance/ Letter of Rejection sent(Required)
Verbal Notice of Acceptance is permitted but must be documented in SDP as screening outcome details. Letter of Rejection must be sent in writing and documentation of email/posting noted. If withdrawn during screening process, documentation of withdrawal must be on file in POI.
Criminal Record Check (must include Vulnerable Sector Check as well)(Required)
For teen mentors only: Criminal Record Check or the “In Lieu of CRC from School” must be present.
Three Reference Checks(Required)
Minimum of three provided. One Personal reference; One Vulnerable Sector / Employment / Education Reference; One Significant other / Family Reference
Online Training (DR)(Required)
Ideally, the name of staff member who hosted the DR session and the delivery method should also be documented in "outcome details"
Pre-Match Training (SFTS)(Required)
Statement of Completion must be documented
Program-Specific Training (B You & BS2S)(Required)
Ideally, the name of staff member who hosted the orientation session and the delivery method should also be documented in "outcome details." NOT APPLICABLE for Community or ISM).
Cross-referenced against the Volunteer Registry(Required)
Has this step been documented? If applicant has volunteered in another agency, inter-agency reference must be completed.
Annual Offence Declaration(Required)
Must be completed annually by mentors who volunteer beyond their first year.

Volunteer re-match (If Applicable)

Documentation of a review of the volunteer's full involvement with the agency, including concerns/strengths(Required)
Standard ITV6 (MS): The agency has processes in place to update information and documentation for volunteers that are: • being rematched with a new mentee following the closure of their previous match (not applicable to site-based group volunteers that are being rematched within a school year, only if site-based group volunteers are being re-matched in a new school year); • have been on the agency waiting list for one year; • have not had active contact or actively participated in agency programming for one year.
New Criminal Record Check (must include Vulnerable Sector Check as well)(Required)
For teen mentors only: Criminal Record Check or the “In Lieu of CRC from School” must be present.
Reinforcement/Updates to Pre-Match Training (SFTS)(Required)
Reinforcement of key messages and boundaries from SFTS. Statement of Completion must be documented.
Rescreen Interview Summary(Required)
Updates volunteer's current circumstances. Updated 2024 appendix still unavailable as of 11/2024. Ensure that volunteer summary is located and completed within SDP and/or hard file.
New Reference Check(Required)
One new reference provided of applicant's choosing (i.e. personal, employer/VS, family/SO).
Full New Screening for files closed due to inactivity (greater than one year)(Required)
Would require ALL standard initial screening items.

The Match

Match Introduction Meeting(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. Should include reasons for match.
Case Logs(Required)
Are there case notes that document the progress of the match and highlights any concerns or referrals made?
Match Supervision Guidelines (6 Conditions)(Required)
Are all scheduled match monitoring tasks completed? Is there a pattern of not completing them on time or not filling in all of the details of the task?
(If Applicable) Allegations of Abuse Reporting Form(Required)
Only applicable if allegation of abuse has been opened against the volunteer.

Match Closure

Documentation that an in-person match closure/graduation meeting was offered(Required)
Match Closure Task Completed in SDP(Required)
Should include: - documentated reason for match closure - recommendations for appropriateness for rematch - recommendations for re-engagement of the parent/guardian, child/youth, and/or volunteer.
Notice of Match Closure(Required)
Mentor closure letter should be sent/delivered within two weeks of match closure. Must be sent by registered mail if match closed due to safety concerns.

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?
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 Reviewer's Signature(Required)
MM slash DD slash YYYY