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Administrative Management



Believe Therapies, LLC has a governing body that assumes full legal responsibility for the conduct of the rehabilitation clinic, regarding the management and operation of the clinic. The governing body will designate an administrator who is responsible for being familiar with all aspects of operation of the clinic such as the scope of services provided, budgetary and fiscal matters, personnel, and other areas necessary to effectively direct operational activities.


These policies are reviewed annually by the managing member and update as necessary.


To demonstrate compliance with the regulation the following items will be available for review at all times in the jump drive in the master binder.

  • Certificate of formation and company agreement

  • Organizational Board showing administrative Framework




Believe Therapies, LLC will have a governing body that assumes full legal responsibility for establishing and implementing policies regarding the management and operation of the clinic.


The administrator should be familiar with all scopes of services provided, budgetary and fiscal matters, personnel and other areas necessary to effectively direct operational activities. The administrator is also responsible for the coordinating staff education. In this regard the administrator should see that each employee has the opportunity to increase the skills and knowledge necessary to promote effective and efficient client care, review program content, type and date of instruction and attendees. This policy will be reviewed annually by the managing members and update this as necessary.



To ensure that all policies and procedures of Believe Therapies, LLC are implemented in a consistent manner, and will meet both the state and federal rules and regulations. The provision of adequate and effective services requires that the rehabilitation clinic must be responsible to internal and external needs and demands, which may necessitate changes in program operation. Additionally, policies and procedures will reflect both internal and external matters.



The governing body will provide guidance and direction specifying

  1. The governing body is made up of the managing members.

  2. The governing body will meet, at least annually, to review policies, procedures and finances. A financial planner may be in attendance in the annual meeting.






The administrator must have a bachelor degree and have experience or specialized training in the administration of health institutions; or has experience in one of the professional health disciplines.



The administrator will be familiar with aspects of the rehabilitation clinic such as the scope of services provided, budgetary and fiscal matters, personnel and other areas necessary to effectively direct operational activities. The administrator is also responsible for staff education, clinical coordination and business management in developing a monthly/annual calendar for training to comply with policies and their updates.




STANDARD SUBSECTION (C): Personnel Policies and Professional Personnel Qualifications



Personnel policies address the relationship between the administration and staff. The administrator will govern the conduct and performance of its employees and its responsibility to the staff. All employees are required to adhere to personnel practices as well as written personnel policies, the Employee Handbook and Standard Operating Procedure Manual. The administrator will conduct annual performance reviews on the staff. The personnel policies will comply with state and federal laws. Believe Therapies, LLC will conduct a new hire screen for employment that is fair and equitable as per the procedures stated below.



The following policy and procedure will be available for review to assess compliance with this policy. Upon hire, the candidate is given their employment contract, along with their job description. A Job Description Acknowledgement Form is completed and all documents are uploaded into the electronic HR system. 

  1. Job Descriptions:

  • Administrators – Business Administrator & Clinical Administrator

  • Division 1 – Establishment Manager

  • Division 2 – Client Services Manager

    • Authorizations

    • Intake Coordinator

    • Receptionist

  • Division 3 – Finance Manager

    • Billing Specialist

    • Collections Specialist

  • Division 4 – Therapy Services Manager

    • Occupational Therapist

    • Occupational Therapist Assistant

    • Physical Therapist

    • Physical Therapist Assistant

    • Speech Language Pathologist

    • Speech Language Pathologist Assistant

    • Therapy Technician

  • Division 5 – Quality Manager

  • Division 6 – Marketing Manager


   2. Employee Handbook


   3. Standard Operating Procedure Manual


   4. Selecting Qualified Personnel

  1. It is the responsibility of each applicant to demonstrate that s/he meets the requirements of the position.  A minimum of two and a maximum of six applicants will be interviewed for any one position.

  2. Applicants will receive an acknowledgement of receipt of their application.

  3. Each interview team will consist of a minimum of two persons.  The composition of this team will depend on the position being filled.  For a management position the interview team will be chosen by the Regional Administrator.  For the Executive Director position, the interview team will be chosen by the Managing members. 

  4. Applicants who meet the basic requirements of the position will be invited to an interview where they will be evaluated on their response to a preset list of topics and educational and experiential criteria. 

  5. Second interviews will be held when several candidates demonstrate equal abilities. 

  6. Once a final candidate has been determined and prior to any offer of employment, approval must be obtained from the Regional Administrator, except if the position being filled is that of the Executive Director, in which case the managing members must give approval. 

  7. Following receipt of approval to hire, a verbal offer can be made to the candidate.


   5. Documenting Verification of Current Licensure

  1. During the Pre-employment stage, the HR personnel will request a copy of the therapists’ original license and renewal certificate.  The HR representative will then use the license number to verify online through the therapists’ state Board website. 

  2.  The original license, license renewal and online license verification will be stored in the therapists’ employee file.  When the renewal becomes expired, the HR Representative will archive the expired renewal and ensure the current renewal has been uploaded into the employee file.

  3. Upon hire, all full-time therapies staff will be required to present their original license to the company in order to display license at the therapist’s primary site.


   6. System for Assessing Competency of Personnel Providing services

  1. Upon new hire the applicant is required to provide Believe Therapies with a minimum of 2 references from previous employers to contact.

  2. During the interview process, the candidate is asked a list of questions that have been generated by Believe Therapies to ensure the selection of qualified personnel. 

  3. Once hired, the employee is assigned a mentor from Believe Therapies for up to 90 days for direct supervision. The mentor will provide full training on documentation requirements, assessment materials and their location and one-on-one support during therapy sessions if needed. Mentor will also review new hire’s documentation until the quality standards of Believe Therapies have been met. If additional time is needed, the mentor will address his/her concerns with the clinical administrator to ensure proper training has taken place. 

  4. The candidate’s licensure, experience, interview responses, background check, and reference check are analyzed and compared to the job description for the potential position to ensure all qualifications have been met to fulfill the position.

  5. All therapist assistants will receive the same mentorship in addition to a required co-signature by their mentor on all notes completed until the mentor feels it is no longer necessary.  


   7. Continuing Education Requirements

All employees must have prior approval to attend a continuing education workshop. Approval is obtained in the following manner:

  1. Employees must complete the continuing education form and submit it to human resources for online approval.

  2. The employee must pay for the workshop prior to attending it.

  3. Once the workshop has been authorized by human resources and attended by the employee, the employee must complete the online reimbursement form to be reimbursed for incurred expenses and submit the reimbursement form with copies of receipts and the course completion form or certificate. Once all documents submitted are approved by HR, the employee will be reimbursed at their next bi-weekly check.


   8. Hiring/Firing Practices

In order to maintain an efficient and productive work environment, Believe Therapies has established an employee disciplinary program listed below, in the following order:



The administrator may give employees an informal verbal warning to help the worker correct an issue. The informal warning is given when the worker may not be aware of a problem or has a personal issue that is affecting his/her work. Documenting an informal verbal warning can provide a paper trail in the event the worker fails to correct a problem. For a first warning, the documentation is in simple, informal manner to include: Date and Time Who was present during the discussion A summary of the topic discussed The memo does not go to the Human Resources department or the personnel file, but stays with Administrator. The administrator must keep a record of all counseling sessions with any employee.



The administrator can include a formal verbal warning in an employee's personnel file for future reference. The informal warning may be enough to correct a performance problem, but in cases when the worker continues the behavior/issue, the formal warning may be necessary. In most circumstances it follows an informal verbal warning, but this may not be the case, based upon the seriousness of the situation. When giving a formal verbal warning to an employee, it is important to discuss the issue in private. Write down the behavior or performance issues the worker is exhibiting to provide him/her with specific details about the problem. For example, if the worker is chronically late, give him/her the dates and the number of times he/she has been late. Give the employee an opportunity to discuss the issue and address any of his/her concerns. The formal verbal warning is an opportunity to clear up the problem and set the employee on the right track. The administrator should document the meeting in memo format including the following information:  Title: Formal Verbal Warning, Date and Time, who was present during the discussion, a summary of the topic discussed, and the employee’s comments Both. the administrator and employee sign the memo and the employee is given a copy after the memo is complete and both parties have signed the document.



If an employee does not clear up an issue after a formal verbal warning, the administrator must create written warning. When giving a written warning to an employee, it is important to discuss the issue in private. The administrator should document the meeting in letter format including the following information: Title: Formal Written Warning, Date and Time, Who was present during the discussion, Write down the behavior or performance issues the worker is exhibiting to provide him/her with specific details about the problem, including recent issues and previous discussions, such as an informal or formal verbal warning. Give the employee an opportunity to discuss the issue(s) and address the areas of his/her concerns. Include this discussion in the written documentation. Create a specific written plan of action to address each area of concern and include a follow up date of correction. The follow up date is for review purposes and must give the employee opportunity to correct the issue. Disciplinary actions should be outlined in the plan of action, in the event the employee does not correct the issue(s). Both, the administrator and employee sign the completed form. The written warning is kept in the employee’s personnel file and a copy is given to the employee.


If the corrective action steps are unsuccessful in improving the behavior or performance in question, further disciplinary action may be appropriate, such as probation, suspension without pay, demotion, reduction in pay, termination of employment, or other measures depending on the specific circumstances. The Company retains the right to determine if an unacceptable behavior or a violation in policy, law or safety guideline should result in termination without following the actions listed above. Employment at Believe Therapies at-will and may be terminated at any time for any reason. Believe Therapies may not terminate employees for unlawful reasons, including any reason related directly to race, religion, color, creed, national origin, citizenship, sex (including pregnancy), sexual orientation, gender identity or expression, age, disability, genetic information, veteran status or any other characteristic protected by applicable law.


   9. Annual Performance Reviews

The annual performance review process provides a means for discussing, planning, and reviewing the performance of each employee. Performance reviews influence salaries, promotions and transfers and it is critical that supervisors are objective in conducting performance reviews and in assigning overall performance ratings. Annual reviews are conducted and scheduled based on the employees’ position in the organizational board and may include one or a combination of the following individuals: the direct supervisor, the division manager, and/or the administrator over said division.



  • Provide objective criteria for a Personnel Performance Evaluation on a standard basis within Believe Therapies, LLC.

  • Compel an examination of all individual traits affecting employee performance.

  • Help to support conclusions and recommendations for positions and compensation improvements.

  • Produce a fair evaluation of an employee.

  • Identify opportunities for development and set goals for individuals and professional growth.

  • Allow the company to gather feedback from its employees on company operations, management performance, communication, growth and goals.



  1. Staff evaluations are assessed annually for all employees at Believe Therapies.  The annual staff evaluation allows administrative and/or management staff to provide feedback to the employee on all areas of their job performance. 

  2. 360° Review will be completed.  Following individuals will complete a performance review on each employee:

  • Peer selected by the individual receiving the review.

  • Peer selected by the Division Manager and the

  • Division Manager.

The above process for selecting reviewers will be used for all division managers by their direct administrator. 

The above process for selecting reviewers will be used for all administrators by the Board of Directors. 

The above process for selecting reviewers will be used for Chief Executive Officer (CEO) by the Board of Directors, unless the CEO is also on the Board of Directors, then no review will take place. Board of Directors (aka Managing Members or owners) will not receive an annual review.

3. Decide for each of the following traits, which have been identified for job success, the level at which the employee has performed for this evaluation period.  Write the corresponding value in the rating column.  Once all areas have been rated, add the numbers in the rating column to obtain a total score.

4. Once all performance reviews have been completed scores will be compiled in order to calculate the performance rating.

5. A face to face review is scheduled with the employee by their direct supervisor in order to review performance findings.  This review allows the supervisor to comment on the employee’s strengths as well as areas for further improvement.  Goals will be set to reflect areas where growth has been identified.

6. Finally, document the employee’s reaction to this evaluation and make additional recommendations for changes, such as rate of pay.

7. All information documented on the performance review and discussed during the review meeting will, and should, be handled with the upmost privacy.  Human Recourses will ensure all portions of the performance review and meeting will become a permanent attachment in the employee’s electronic personnel file.

Performance Review Forms:​

  • Therapy Staff

  • Clerical Staff

  • Business Administrator

  • Clinic Administrator


   10. Salary Advances

Each year the Executive Team will determine the pool of merit increase funds available.  Both the objectives of the compensation program and financial resources available will be considered in the decision-making process.

Merit pay is used to reward successful performance.  Larger merit increases will be awarded to employees who consistently exceed performance standards.  Increases will not be granted to employees whose performance has been rated as unsatisfactory/needs improvement overall.


To be eligible for a merit increase, an employee must be employed with at least twelve months of continuous service before the merit award date.

An employee whose pay is at the maximum of the salary range may not be granted an increase that would cause the base salary to exceed the maximum of the range for that position. 

Determination of Merit Increase

In accordance with Believe Therapies, LLC guidelines, your manager and/or administrator will recommend: a) whether an employee should receive any merit increase based on his or her annual performance review and b) the amount of increase appropriate for the performance results.

The following factors are the basis for awarding merit pay to employees:

  • The employee’s performance as reported I the annual performance review.

  • The employee’s statistical performance for the past 12 months.

  • The appropriate pay level within the range for the employee considering the employee’s performance and performance of others in the range.

  • Pay increase funds available.

  • Recommendations of managers and/or administrator, as approved by executive officers.


Performance Reviews

Employee performance is to be formally reviewed at least once each year.  The focus of the review is to discuss the employee’s performance for the rating period, review standards, including statistics, for the position, communicate the amount of the employee’s purposed merit increase and set goals for the next rating period.



Review of Merit Increase

Merit increases require the recommendation of the employee’s immediate manager and/or administrator and the approval of the Human Resource Manager.  Employees are to be notified of their merit increase as soon as possible after employee merit increases for the year have been approved.



    11. Documentation Placed in Personnel Records 

All personnel records will be confidential, accessed on a “need to know” basis, and remained comprehensive and current in status.

  • An employee’s personnel file may contain documents used by Believe Therapies to determine the employee’s employment, promotion, compensation, transfer, termination, performance and disciplinary or other personnel actions.

  • Personnel files are maintained on a confidential basis to protect the company and employee privacy.  Access to personnel files is limited to a “need to know” basis.

  • Believe will house all employment records and payroll records within their electronic HR and payroll program for a minimum of 6 years once an employee has separated from the company.  Separated employees will continue to have access to these records during this time, provided their information is current, with a personal email, in Believe’s electronic HR and payroll program.



STANDARD SUBSECTION (D): Client Care Policies



Client care policies are established by the professional staff of the rehabilitation clinic and outside professional staff when appropriate. Designated professional staff will participate in the for the purpose of policy development and review. Minutes of meetings will be maintained and located in the minute meeting binder. The policies of the clinic will be current and responsive to the needs of clients. The Client Care Committee will be composted of the following personnel:

  • Administrator

  • Occupational Therapist

  • Physical Therapist

  • Speech Language Pathologist

The following procedure will be reviewed annually by the managing members and the professional staff as part of the Client Care Committee.




The following procedure is a list of the most common services offered by the clinic which were developed by the Client Care Committee and reviewed, annually, by the managing members. The clinic maintains written plans of care through its employees and those arranged for the following services:



Activities of Daily Living

Augmentative Communication

Bilingual Speech Language/English Speech Language

Oral Motor/Feeding



Upper Extremity and Hand Function

Manual Muscle Test



Range of Motion

Sensory Processing

Standardized Testing

Wheelchair and Special Equipment





Activities of Daily Living

Developmental Training (Fine and Gross Motor, Cognitive & Visual/Perceptual)

Education Services

Oral Motor/Feeding Therapy

Gait Training

Functional/Therapeutic Activities


Joint Mobilizations

NDT Treatment

Neuromuscular Re-education

Orthotics Training/Adjustments

Sensory Integration Treatment



Fluency Therapy

Speech/Language Therapy



Cold (cold packs)

Heat (hot packs)

Electricity (e-stim)

Water (foot bath whirlpool)


Client Rights and Responsibilities:

All staff members will attend an orientation and in services that address client rights and responsibilities. The client’s medical record will verify that the client and/or family were informed of the client rights. The client will be provided with the following client rights policy during the intake process.



Notice of Information Practices and Privacy Statement

Believe Therapies, LLC and its employees collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails and from the submission of applications that is either required by law or necessary to process applications or other requests for assistance through our organization.

Information about client’s financial situations, medical conditions and care that is provided to the company in writing, via email, on the phone (including information left on voicemails), contained in or attached to application to applications or directly or indirectly given to Believe Therapies, LLC is held in strictest confidence. Believe Therapies, LLC does not give out, exchange, barter, rent, sell, lend or disseminate any information about the clients who apply for or actually receive services that is considered client confidential, is restricted by law, or has been specifically restricted by a signed HIPPA consent form.

Information is only used as is reasonably necessary to process applications or to provide therapy services which may require communication between Believe Therapies, LLC and health care providers, medical products or services providers, insurance companies, and other providers necessary to: verify your medical information is accurate; determine the type of medical supplies or any health care services needed including, but not limited to; or to obtain or purchase any devices.

If the client provided information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, non-medical information can be given to legal authorities including police, investigators, courts and/or attorneys or other legal professionals, as well as any other information as permitted by law.

Believe Therapies, LLC does not collect information about site visitors. Believe Therapies, LLC does use some affiliate links that may or may not capture traffic date through our site. To avoid potential data capture that you visited a website, simply do not click on any of our outside affiliate links.

Any pictures, stories, letters, correspondence, or thank you notes sent to Believe Therapies, LLC becomes the exclusive property of Believe Therapies, LLC. Believe Therapies, LLC reserves the right to use non-identifying information about our clients for promotional purposes that directly relates to the company’s mission.

Client’s may specifically request that NO information be used whatsoever for promotional purposes, but the client or guardian must identify any requested restrictions in writing. Believe Therapies, LLC respects the right to privacy and assures clients that no identifying information or photos will ever be used.  

Clients have a right to inspect their medical information. Clients also have a right to request restrictions on the use of their information and how it is disclosed. Believe Therapies, LLC will use protected health information for treatment, payment and other health care operations unless the client objects. If there is an objection to this normal business practice, please notify the staff to request this in writing.  

CREATED:  04-01-2012

REVISED:  10-01-2020

REGUALATION:  Form CMS-1893 (12/08):  42 CFR §485.709

AAAASF OPT STANDARD:  AAAASF Standard 3.0, Section 15, Sub-section C

Believe Therapies

521 I-45 Suite 4,

Huntsville, TX 77340

phone: 936.293.8800


fax: 936.715.3721


Monday - Friday

8:00AM - 7:00PM

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Believe Therapies

2305 Longmire Dr Suite 300

College Station, TX 77845

phone: 936.293.8800


fax: 936.715.3721


Monday - Friday

8:00AM - 7:00PM

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