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12.00 RECORD OF SERVICES

Introduction

State and federal regulations and NYSCB policy requires that certain information be contained in each individual's record of services. The extent of this information varies in relation to where the individual is in the VR process. The purpose of this chapter is to provide general guidelines for maintaining a record of services.

What is the Record of Services

The record of services is a compilation of reports, forms, narrative entries and other documentation related to an individual's involvement with NYSCB. The contents of the record of services may at times become public (e.g. during an appeal). It is always important to carefully consider the information written into the record of services. The record of services provides written documentation of an individual's progress through the vocational rehabilitation process. The record of services may also be used during the appeals process to provide information relevant to the appeal.

Elements of a Record of Services

The following items are considered to be part of the record of services:

1. Application for Services DSS-1002

2. Mandatory Eye Medical Report

3. Confidential Health Assessment DSS-1003

4. Survey Interview and Fact Sheet DSS-1004

5. Economic Status Report DSS-1018

6. Client Profile Form

7. Certificate of Ineligibility DSS-1024

8. Individualized Plan for Employment

Development Plan (IPEDP) DSS-3458

9. Individualized Plan for Employment (IPE) DSS-3500

10. Fiscal Information including: vouchers, bills,

receipts, etc.

11. Social Security Information

12. Training Reports

13. Medical/Psychological Reports

14. Correspondence

15. Case Notes

Organization of the Record of Services

To facilitate uniformity of format in the record of services, all folders are to include the following sections, placing the most recent items on top in each section:

1. Eligibility - the item listed first is to be placed at the bottom and subsequent items on top:

a. Application

b. Survey Interview Sheet

c. Release of Confidential Information Forms

d. Eye Report

e. Confidential Health Assessment

f. other medical and assessment information

g. reports from ongoing medical and psychological/ psychiatric treatment

h. Economic Status Report

2. Training Progress Reports

3. IPE and Annual Reviews

4. Financial - All vouchers (DSS-335's 1013's and 1016's). Note: Receipts are to be attached to the DSS-1016. Receiving reports are to be attached to the DSS-1013.

5. Case Notes

6. Correspondence and Other Information - social security information and other vocationally relevant items not included in Sections 1-5.

Case Notes

Case notes serve several purposes for the VR counselor, senior counselor and NYSCB program reviewers.

For the counselor, case notes provide:

1. a means of tracking an individual's progress by presenting a picture of what has happened, what is happening and what is being planned

2. a mechanism for organizing and integrating impressions and ideas

3. information on individuals transferred to their caseload

4. information for initial reviews, administrative reviews and administrative hearings.

For the senior counselor, case notes provide:

1. information to assess the planning process in the case

2. information to assess compliance with the vocational rehabilitation process and other NYSCB policies and procedures.

For the NYSCB program reviewers, case notes provide:

1. information to assess compliance with the vocational rehabilitation process and other NYSCB policies and procedures

2. information to document the appropriateness of expenditures.

General Guidelines for Writing Case Notes

The following guidelines apply to case documentation:

1. Case note entries should be made to document important events and developments such as movement through the rehabilitation process, medical problems, progress toward achievement of IPE goals and objectives, placement related efforts and activities and other significant events.

2. Each case note should have a marginal note stating the date of the case note, the individual's case status and a subject heading, where appropriate (e.g. eligibility, medical information).

3. Ongoing counseling should be documented in the record of services and focus upon the purpose and outcome of the counseling session and the actions to be taken by the counselor and consumer prior to the next contact.

4. Provide the rationale for providing services or equipment; don't merely record that a voucher has been mailed.

5. Record observations of the individual in behavioral statements rather than using medical or psychological labels or subjective comments.

6. Reference forms and reports (medical, training, etc.) that are in the record of services in order to reduce duplicating information that appears elsewhere in the case.

7. Record planning efforts and outcomes not only what has happened.

Verbal Authorization of Services

In circumstances where a service is to be provided and the counselor is unable to determine the cost in advance, (e.g, transportation), the counselor can document the authorization in a case note indicating the:

1. service to be provided

2. date(s) of service

3. service provider

4. estimated cost of the service or that the cost is unknown

12.01 CASE STATUS SUMMARIES

Introduction

The purpose of this section is to provide counselors with guidelines for writing case notes specifically focusing upon what information is required for each status.

The outlined information represents a minimum standard of information to be included in the case notes when available and appropriate. Other information may be added to the record of services in accordance with the guidelines on pages 12.00.02-12.00.03 and counselor needs.

When to Write a Case Status Summary

Case status summaries are to be written at the time of movement from one case status to another or when summarizing what is occurring in a case. To avoid duplication in the record of services information is to be included as a case contact only if not found elsewhere in the case. If the information is included elsewhere, a reference to its location in the case contact will be sufficient.

Status 02 - Applicant

Using the information obtained from the initial interview, the referral source, and other sources, develop a narrative profile of the applicant. The information identified below may not always be available when a case moves into Status 02. Pertinent information should be added whenever it becomes available.

1. Referral Information:

a. name and address

b. referral source and reference to any reports received from referral source

c. date of referral

d. age

e. sex

f. social security number

2. Disability/Assessment

a. indicate the nature of the primary and any secondary disabilities

b. discuss the individual's functional limitations related to his/her disability(ies)

c. discuss the impact of the individual's disability as it relates to obtaining employment.

d. discuss plans for the preliminary assessment

3. Social Information - briefly discuss pertinent information regarding the individual's family and home environment.

4. Financial Information

a. identify whether or not the individual is eligible for items contingent upon economic need

b. identify comparable benefits which are or may be available

c. identify other financial resources

5. Education and Work History

a. educational background

b. vocational training

c. previous work experience and length of employment

d. specific work skills

e. reason for not being employed

6. Describe the individual's perceptions of his/her disability(ies), needs, and problems; past work experience and future goals.

7. Describe the counselor's observations of the individual and his/her disability(ies).

8. Describe the individual's understanding of the vocational rehabilitation process including the goal of achieving an employment outcome and the individual's motivation and interest in obtaining employment

Status 06 - Extended Evaluation

1. Medical Information

a. Discuss the ophthalmological report and identify any planned follow-up.

b. Discuss medical history and the Confidential Health Assessment and any recommendations and plans for follow-up or specialty examinations

c. Where appropriate, discuss the outcome of the medical consultation

2. Extended Evaluation

a. discuss the reason(s) for the need for an extended evaluation to determine eligibility for VR services.

6. IPE

a. discuss the rationale for the IPE specifically indicating how the planned assessment services will provide information to make a decision regarding eligibility.

Status 08 - Closed from Applicant or Extended Evaluation

1. Status 02-08 - when attempts to contact the individual have been unsuccessful or the individual declines service prior to an eligibility decision:

a. indicate that prior to closure, the reason(s) for closure was discussed with applicant, his/her parent, guardian or representative or give reason for not doing so.

b. explain the reason for closure

c. indicate that the applicant was informed of the availability of assistance from the Client Assistance Project (CAP)

2. Status 02-08 - after a determination of ineligibility has been made:

a. indicate that prior to closure, the basis for the decision and the appeals process were discussed with the applicant, his/her parent, guardian or representative

b. discuss the reason(s) for the closure utilizing information gathered during the preliminary assessment

c. indicate that the applicant was informed of the availability of assistance from the Client Assistance Project (CAP)

3. Status 06-08

a. in a narrative summary, describe how the reason(s) for closure were conclusions drawn from the information obtained from the extended evaluation as planned on the IPE

b. indicate that prior to closure, the basis for the decision and the appeals process were discussed with the individual his/her parent, guardian or representative

c. indicate that the applicant was informed of the availability of assistance from the Client Assistance Project (CAP)

Status 10 - Individualized Plan for Employment (IPE) Development

1. Medical Information

a. Discuss the ophthalmological report and identify any planned follow-up.

b. Discuss medical history and the Confidential Health Assessment and any recommendations and plan for follow-up or specialty examinations

c. Where appropriate, discuss the outcome of the medical consultation

2. Eligibility

a. describe the individual's disability and how the disability presents a substantial impediment to employment

b. describe how the individual can benefit in terms of an employment outcome from vocational rehabilitation services

c. describe why the individual requires vocational rehabilitation services to prepare for, enter, engage in, or retain employment.

d. discuss the results of the preliminary assessment

3. IPE

a. discuss the results of the comprehensive assessment

b. discuss factors relevant to the development and implementation of the IPE

c. discuss the consumer's work readiness skills and identify training to be provided to improve skills if needed

Status 18 - Individualized Plan for Employment (IPE) Implementation

1. a. Discuss the services to be provided and any issues or problems related to the implementation of these services.

b. Discuss the consumer's progress towards the IPE objectives and goal.

Status 20 - Ready for Employment

1. a. Indicate that all planned services have been completed or if not, why they were not needed.

b. discuss the development of the placement plan and the strategies and activities to be taken by the consumer in implementing the placement plan

c. Discuss counselor's activities related to assisting the consumer with the job search.

Status 22 - In Employment

1. Discuss basic information regarding the consumer's employment such as: job title, employer, location, salary, and job description for those in competitive or industry based employment.

2. Discuss the consumer's progress on the job or any problems the consumer is facing and attempts at resolution.

3. Before leaving Status 22, prepare a case note for presentation to the senior counselor which describes:

a. how the services provided under the individual's IPE have contributed to the achievement of the employment outcome;

b. that the employment outcome is consistent with the individual's strengths, resources, priorities, concerns, abilities, capabilities, interests and informed choice;

c. that the employment outcome is in the most integrated setting possible, consistent with the individual's informed choice;

d. that the individual has maintained the employment for a period of at least 90 days;

e. that the individual, the employer and the counselor consider the employment outcome to be satisfactory and agree that the individual is performing well on the job.

f. any problems which might arise on the job and any need for and the nature of post-employment services.

g. that prior to closure, the basis for the decision was discussed with the consumer, his/her parent, guardian or representative and indicate the consumer's views and reactions to the services and case closure

h. when you anticipate closing the case.

Status 26 - Closed Rehabilitated

1. If not previously addressed, discuss any problems which might arise on the job and any need for and the nature of post-employment services.

2. Document that the senior counselor has approved case closure and reference the completed closure amendment.

Status 28 - Closed, Other Reasons After IPE Initiated

Status 30 - Closed, Other Reasons Before IPE Initiated

1. Document that the senior counselor has approved case closure and discuss the reasons for closure.

2. If the case was closed for lack of VR potential, provide information to support the closure action and, where appropriate, indicate the scheduling of the ineligibility review.

3. Indicate that prior to closure, the basis for the decision and the appeals process were discussed with the individual or his/her parent, guardian or representative.

4. Indicate that the individual was informed of the availability of assistance from the Client Assistance Project (CAP)

Status 32 - Receiving Post-Employment Services

1. Discuss the reasons for the individual requiring services and indicate the appropriateness of using post-employment services

2. Discuss the service needs of the individual

3. Discuss the development of the Post-Employment Services IPE

Status 34 - Post-Employment Services Completed: Employment Maintained

1. Document that actions planned and scheduled during post-employment were accomplished or give reasons why actions that were planned were subsequently not needed.

2. Discuss the reasons for closure including how post- employment services made a substantial contribution to enabling the individual to maintain or advance in employment.

3. Indicate that prior to closure, the basis for this decision and the appeals process were discussed with the individual or his/her parent, guardian or representative and indicate the individuals views of the services and case closure.

5. Indicate that the individual was informed of the availability of assistance from the Client Assistance Project (CAP).

Status 36 - Post-Employment Services Discontinued: Case Reopened

Status 38 - Post-Employment Services Discontinued: Other Reasons

1. Indicate that actions that were planned and scheduled during post-employment services were completed or give reasons why actions that were planned were subsequently not needed.

2. Discuss the reasons for closure and the rationale for reopening (Status 36) or for not reopening (Status 38) the case.

3. If the case was closed for lack of VR potential, provide information to support the closure action and indicate the scheduling of the ineligibility review.

4. Indicate that prior to closure, the basis for the decision and the appeals process were discussed with the individual, his/her parent, guardian or representative and indicate the individuals views of the services and case closure.

5. Indicate that the individual was informed of the availability of assistance from the Client Assistance Project (CAP).