Section 22: the Participant's Service Record
SECTION 22: THE PARTICIPANT'S SERVICE RECORD
The Rehabilitation Division will establish and maintain a service record for each applicant and/or recipient of vocational rehabilitation services, which, to the extent pertinent, will contain:
Required Documentation:
· Documentation concerning:
a. The assessment and certification of eligibility/extended evaluation;
b. The need for extending the time for evaluation of eligibility determination as applicable; and,
c. The assessment of vocational rehabilitation needs leading to the nature and scope of services to be provided.
· Documentation regarding the reasons for an ineligibility determination, if the participant
is found to be incapable of achieving an employment outcome. A notation of a review of the determination conducted no later than 12 months after such determination was made, unless the medical condition is rapidly progressive or terminal;
· Documentation supporting the determination of a significant or most significant
disability, which may include verification of SSDI or SSI allowance;
· Documentation of periodic assessment of the participant’s functioning during a period of
trial work experience or an extended evaluation;
· An IPE or time-limited written extended evaluation plan and any modifications;
· If physical restoration services are provided, documentation that the clinical
status of the participant is stable or slowly progressive;
· Documentation supporting any decision to provide services to family members;
· Documentation relating to the participant's participation in the cost of services;
· Documentation relating to the eligibility of the participant for comparable services and
benefits and their use;
· Documentation the participant has been advised of the confidentiality of all case
information and the release of such information;
· Documentation of the reason for closing a participant's case including the individual’s
employment status and the basis upon which the employment was determined to be suitable;
· Documentation via the IPE or IPE modifications of any plans to provide post
employment services after the employment outcome has been achieved, the basis upon which these plans were developed, a description of the services provided and the outcomes achieved;
· Documentation concerning any action and decision involving the request by the
participant for review of a Rehabilitation Counselor’s determination and Fair Hearing or Mediation;
· Documentation of appropriate reviews where a participant has been provided services
under an IPE but who has been determined to be no longer capable of benefiting from vocational rehabilitation services.
· An assessment of vocational rehabilitation needs must be done at the time the IPE is
written.
· A Progress Review Summary every 90 days if no current progress review notes (PRN)
exist within this time frame.
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureau of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 92
Required Contact: Additional Required Applicant/Participant Contact And Documentation:
· All progress review notes must be entered into RAISON.
· Application Status: The Rehabilitation Technician, designated support staff (Administrative Assistants) and the Rehabilitation Counselor have responsibility for applicant contact, occurring no less than monthly. Results of contact will be documented by the Rehabilitation Technician or designated support staff in a case note within 48 hours of the contact.
· Eligibility through Planned Service: The Rehabilitation Counselor and the Rehabilitation Technician have the primary responsibility for participant contact at least every 90 days, in addition to those contacts occurring at decision points (defined in definition of terms) during the rehabilitation process. Decision point contact and/or actions will be documented by the Rehabilitation Counselor in a progress review note within 48 hours of the contact and will include an assessment of the event(s) and plan of action.
· Job Ready (Service J) through Employment: The Rehabilitation Counselor and the Rehabilitation Technician have the primary responsibility for participant contact during this phase of the rehabilitation process and will occur no less than every 60 days. Contact will be documented by the Rehabilitation Counselor in a progress review note within 48 hours of the contact and will include an assessment of the event(s) and plan of action.
· Employed Status is a case note requiring 30, 60 and 90 days to document contact and follow along.
· A Transfer Summary will be completed in all case files prior to the file being transferred to another Rehabilitation Counselor. This summary will include a status update of all planned services and identify any new, ongoing or potential issues, and support systems in place. Personalized letters to participants must be sent 10 working days prior to transfer by the current Rehabilitation Counselor advising of case transfer. Personalized introductory contact letters to the participants by the receiving Rehabilitation Counselor must also be sent within 10 working days to the participant.
· A Closure Summary will be completed which includes detailed closure information and reason for application, substantial services provided, and explanation of the closure reason for all closures.
· An Employment Outcome Closure Statement which includes a detailed summary of the reason for application, vocational goal, job at closure, employment start date, wages, employment stability, statement of how the job meets the identified vocational needs and a statement that the Rehabilitation Counselor or and participant agree on the case closure are required for all employment outcome closures.
· The Rehabilitation Technician is responsible to ensure electronic progress review notes and other narrative documentation is placed in the hard copy case file every 7 days. The Rehabilitation Counselor to inform the Rehabilitation Technician to print and file new records in the hard copy file.
Case File Organization
· For all BVR and BSBVI case files. All sections will be labeled with the appropriate descriptive heading.
· All duplicate copies of fiscal paperwork (authorizations, P.O.’s etc.) and related invoices, RD09’s, 87’s, and any other documents for each specific transaction are to be stapled together and placed in date order (latest on top).
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureau of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 93
SECTION I: Accounting
1. All Fiscal Information.
2. Check Receipt.
3. Authorizations.
4. RD09-Cash Payment Request Form.
5. RD87-Verification of Receipt of Goods & Services.
6. Paratransit Ticket Issue Sheets.
SECTION II: Application/ IPE/PRN’s/Related Documents
1. Application
a. Intake.
b. Certificate of Eligibility.
c. IPE.
2. Progress Review Notes (in chronological order).
3. Ineligibility/Closure Statement.
4. Supervisory Review Documents.
5. Case File Review Documents.
6. RAISON Job Ready Forms
SECTION III: Medical and Psychological
1. Health Survey (Last two pages of application).
2. Medical/Dental/Psychological Consultation.
3. Psychological Testing and Reports.
4. Medical Records (most recent, according to date received, always at the top).
5. Medical release returned with no information on participant.
6. Workers’ Compensation Medical/Psychological Information.
7. Referral Letters for Medical/ Psychological Exams/Evaluations.
8. Letters from Physicians/Medical Staff regarding participant’s Medial/Psychological condition.
and/or Medical Reports in Letter Format.
9. NA & AA Progress Reports.
SECTION IV: Case Documentation
1. SSA Data (tabbed) if applicable (SSI - SSDI Section), Ticket to Work information.
2. Patient’s Bill of Rights.
3. Vocational & Testing Requests & Reports.
4. OJT Contracts & Reports, CBA & Other Training Progress Reports (Labeled “Training Reports”).
5. Transcripts/Grade Reports/ GED Certification (HS Diploma, Cert. of Completion).
6. Community Based Assessment Agreements.
7. Financial Aid Report, Award letter.
8. WOTC, Schedule A & B/700 Hour.
9. Food Stamp Information.
10. General Assistance (yellow copy).
11. Paratransit Application.
12. Rehabilitation Engineering reports referral, etc.
13. Job Placement Programs Reports (Labeled Job Placement Reports).
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureau of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 94
14. Recreational Therapy Reports.
15. Participants Resumes and Applications.
16. Rap sheets from Parole and Probation.
17. Job Analysis.
18. Letters of Reference.
19. Non-medical Workers Compensation Information.
20. Certificates.
21. Labor Market Survey
22. E-mail from school vendors, the vocational evaluation unit and job developers.
SECTION V: Participant Background Data
1. Financial Participation Assessment Form (proof of wages &/or IRS tax returns)
2. Releases (all) and copies of letters requesting medical records
3. Subpoena Protocol
4. Military Information
5. Judgment reports from court - Parole Certificate
6. Civil papers from Judge - Court - Attorney
SECTION VI: Correspondence & E-mail
1. Correspondence (including letters from participants and thank you cards)
2. Referral Letters/Memos
3. Memos, Paratransit Letters, Intro. Letters, etc
4. Letters of Reference for Participant
5. E-mail from participants and other Rehabilitation Counselor
6. CAP Reports, Releases & Letters
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureau of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 95