SAMPLE POLICY WORK

b. Scope

This record keeping policy applies to every Simpl Care Services LLC staff member, regardless of position, and covers all categories of records, including:

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Individual Client Files: These files contain assessments, individual support plans, progress notes, incident reports, consent forms, and all other clinical and service-related documentation for each client. Service Documentation: Documentation of the services provided is recorded in daily service logs, progress notes, incident reports, and other forms that reflect the delivery of direct care. Financial Records: All financial transactions such as billing, payroll, expense reports, and budget documentation are maintained with accuracy and transparency. Personnel Records: Files for all employees, including job applications, background checks, performance evaluations, training records, and certification documents.

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• Operational and Administrative Documents:

Includes internal policies, procedures, meeting minutes, memos, and other documents that support the overall management and governance of the organization. Every document created or maintained by the agency must be handled strictly in accordance with the protocols delineated in this policy, ensuring that records remain accurate, secure, and readily available for authorized audits and regulatory reviews.

c. Detailed Policies and Procedures

Individual Client Files Individual client files are the cornerstone of our service delivery system. These records compile all relevant data about a client, forming the basis for individualized care plans and ensuring the continuity of service.

Required Contents of Client Files Each client file must include, at a minimum, the following:

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Assessment Reports: Initial assessments, subsequent re ‑ assessments, functional skills evaluations, psychological evaluations, and any other clinical testing results.