Section 1 / Part 12
Effective Date: April 26, 2005

Documentation Guide

This Documentation guide contains the following sections:

General Requirements
Case File Organization
Referral
Application
Initial Interview
Eligibility
Order of Selection
Comprehensive Assessment
Individualized Plan for Employment
Substantial Counseling and Guidance
Progress Notes
Frequency of Contact
Employment Outcomes (Rehabilitated)
Supported Employment Outcomes
Other Outcomes
Records Retention

IMPORTANT NOTE REGARDING THIS DOCUMENTATION GUIDE

The provision of certain services often requires specific information to be researched and analyzed. The provision of certain services, or services which exceed standard cost caps, may also require exceptions to be approved by the RS Program Administrator for your Region, or by the Central Office. Policy and procedure on such issues are maintained in the RS Manual, which should be used as a reference by counselors in determining specific documentation requirements for such circumstances.

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General Requirements

When viewed as a whole, the case file (record of services) should reflect:

• The quality and substantiality of the services provided by VR.
• Evidence of counseling and guidance provided to promote the client's full involvement and participation in the rehabilitation process, to guide the client in exploration of options, to support and assist with problem solving, to refer to other appropriate services, and to coordinate services.
• Maintenance of appropriate and timely contact with the client, with no undue or unwarranted delays. (See Section 9 / Part 9.)
• Timeliness of services provided with no undue or unwarranted delays. The case file should show evidence that RS Staff responded to individuals in a timely way at each stage of the VR process and that services were delivered as expeditiously as possible.
• Evidence that the Client exercised informed choice throughout every aspect of the VR case. Examples include:
• Summaries of initial interviews which identify how the client expects to be helped through the provision of VR services and the client's ideas related to employment options.
• Narratives identifying options for vocational objectives, services, or service providers explored in a collaborative partnership between the counselor and the client. Narratives which reflect that the counselor provided information on these subjects and/or that the client conducted his or her own research on these subjects.
• Narratives that reflect information provided or research conducted on the labor market.
• Completion of the "Customer/Client Guide to Developing the IPE," which is Section 9/Part 4 of the RS Manual.
• Completion of KMIS screens related to extension of the timeframe for determining eligibility or developing the IPE. (The KMIS printout must be filed in the service record.)
• Narratives reflecting counseling and guidance provided to help the client consider options and make choices.
• Narratives which provide the counselor's rationale for supporting or denying the client's choice.
• Narratives which document conversations in which the counselor explained state policies related to the parameters of services that can be provided.
• Closure narratives that reflect the client's satisfaction with the job achieved and agreement that additional services are not needed.

See Section 1/Part 8 of the RS Manual for more information on informed choice.

• That the overall case shows an emphasis on helping the client achieve a high quality employment outcome.

Any information used to evaluate or support casework decisions needs to be in the service record. Information must be sufficient to show that decisions were reasonable, were based on adequate fact, were considerate of the individual's circumstances, and correctly applied policy. Unless specified otherwise, documentation may be in the form of narratives, various reports, correspondence, copies of e-mail communications, KMIS printouts, completion of forms, and other sources of information. You must get the client's permission to file TTY printouts.

When necessary to organize and clarify multiple or vague sources of information, the counselor should use the narrative to provide an analysis of the information and a rationale which supports the decisions made. The counselor must provide an explanation of apparent discrepancies. (For example, medical information indicates that the client has difficulty walking across the room without getting out-of-breath. The VO is day care provider. This is an apparent discrepancy in that it is difficult to understand how a person with such a limitation would be able to work as a day care provider. Another example of discrepancies occurs when there are conflicting medical records or when medical and school records are not consistent.)

Narratives are necessary for information that cannot be found or not clearly shown in other records. Narratives are essential to recording the counselor's rationale for actions taken. Generally narratives should address: what occurred; the client's involvement; decisions made; client progress; counseling and guidance; information requested; each client contact; attempted client contacts: other party contacts, such as guardians, agencies, providers, employers; and suggested next steps.

Narrative entries should be dated with the current case status, and include the counselor's initials. If other staff add to the narrative, they should sign their full names.

Care should be taken to assure that other client names aren’t inadvertently placed in a service record. For example, if multiple client names appear on an e-mail message to be filed in the service record, black out all names/information that do not relate to the specific client.

Progress notes from vendors (contractors/service providers) need to clearly identify the vendor as the source.

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Case File Organization

The information filed in the service record should be organized as follows:

Counselors have the flexibility to divide each section described above into two parts for ease of handling of lengthy case files.

Information in the case file should be in chronological order, with the most recent information on top.

Reports of contact should be maintained with the related information. For example, a definitive medical report would be placed with medical information. A specific question answered by a psychologist would be placed with the other psychological information.

Every effort should be taken to keep the file folder free of duplicate and unnecessary information. For example, if there are multiple accounts of the same medical information, only one copy is needed. Records received that are not pertinent to the VR case can be destroyed. The counselor should note in the narrative what records are being destroyed and why.

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Referral

• For third party referrals, the record of services needs to provide evidence that the counselor responded as soon as possible but not more than 30 days after receiving the referral; evidence that the response included information about VR services and how to apply; copy of response letter in case file; narrative regarding responses if by phone or in person.
• For direct inquiries, the record must provide evidence that the VR staff provided immediate information about how to apply for VR services; evidence that an appointment was scheduled in a timely manner.

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Application

• Application is signed and dated by the individual (or if appropriate, by the individual's representative), or the individual has otherwise requested services and provided necessary information.
• Application is date stamped when received in the VR office.
• Application is entered on KMIS.
• Evidence that the individual has received the Handbook of Services, as shown by the signed application form.

See Section 2 / Part 1.

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Initial Interview

In addition to the Rehabilitation Services application form, the following information, to the extent it will impact the VR process or employment, must be collected as part of the application process and recorded in the record of services.

• Applicant's description of the disability and how it impacts the ability to work and to complete daily activities.
• Employment history, such as work performed at home; paid work (employers, dates, wages, duties, job title, reason no longer working there); job duties the applicant can no longer perform; type of work the applicant wants to do; accommodations that may be required.
• Residential, domestic and family information (such as number in family, dependents, typical routine, support available through family, friends and social groups.)
• Medical history, such as names of hospitals, doctors, psychologists, social workers.
• Current medications.
• Transportation available? Driver's license? Ability to use public transportation, if available.
• Corrections history, including names of probation or parole officers.
• Child care arrangements.
• Media of choice.
• Does the client have a Ticket-to-Work? Is it available for assignment? Or, if the client has assigned it to another Employment Network (EN), identify the EN.
• How can VR help? What is the applicant's reason for applying?

Documentation must identify the name of the person who conducted the initial interview, if that person was someone other than the VR counselor.

See Section 2 / Part 1.

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Eligibility

The determination of an applican's eligibility for VR services must be based only on the following requirements:

• A determination by qualified personnel that the applicant has a physical or mental impairment.
• A determine by qualified personnel that the applicant's physical or mental impairment constitutes or results in a substantial impediment to employment for that specific individual applicant.
• A determination by the RS VR counselor that the applicant requires VR services to prepare for, secure, retain, or regain employment consistent with the applicant's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice.

It is presumed that the applicant can benefit in terms of an employment outcome from the provision of VR services unless there is clear and convincing evidence to the contrary.

An individual's financial status or economic need may not be used to determine eligibility. Economic need is used during the IPE development and process and throughout service delivery to determine whether the eligible individual will be asked to contribute financial to the cost of his/her rehabilitation plan.

Any applicant who has been determined eligible for SSI or SSDI is presumed eligible for VR services, and is considered to be an individual with a significant disability. (This means that these individuals are in at least Category 2 in the Kansas Order of Selection.)

Extended evaluation is not allowed for individuals eligible for SSI or SSDI since they are presumed eligible for VR.

Related to eligibility, the case file must address the following factors:

• Description of the applicant's primary and secondary impairments. [A physical or mental impairment means: any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological, musculo-skeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine; or any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.]
• Descriptions of impairments are usually found in medical or psychological records, and may be enhanced by information in vocational assessments and/or the counselor's narrative description.
• If the individual has a disability that can be verified by counselor observation or by information provided by the individual or family, they meet this first part of the eligibility criteria. In such cases, Part 1 of eligibility should not be delayed while medical or psychological information is gathered. Such information, however, may be necessary to develop an appropriate plan of services.
• If the individual is not receiving SSI/SSDI and does not have an impairment that can be verified by counselor observation or information from the individual or family, then request medical information. The case must show that such requests were made in a timely manner. Delays must be explained in the narrative.
• Documentation must show that existing information was used to the extent available, timely and adequate for eligibility determination. Information used must show the current functioning of the individual.
• A description written by the counselor that explains how the applicant's impairment constitutes or results in a substantial impediment to employment for that specific individual. The description should specify the impediment, how it results from the impairment, how it hinders employment, and why it is substantial for the individual. [Substantial impediment to employment means that a physical or mental impairment (in light of attendant medical, psychological, vocational, education and other related factors) hinders an individual from preparing for, entering into, engaging in, or retaining employment consistent with the individual's abilities and capabilities.]
• Documentation from the counselor that explains why the applicant requires VR services to prepare for, secure, retain or regain employment consistent with the applicant's unique strengths, resources, priorities, concerns, abilities, capabilities, interests and informed choice. (The counselor must presume that a person who has a disability which has been determined to constitute an impediment to employment can benefit from VR services in terms of an employment outcome unless there is clear and convincing evidence to the contrary.)
• Evidence that an applicant who has already been determined eligible for SSI or SSDI, or who has a Ticket-to-Work, is presumed to be eligible for VR. Notation of how this status was verified is required. Verification of this status may include a Ticket, an SSA award letter, a current check stub, the KMIS interface, or other verifiable evidence. Eligibility should be completed as soon as receipt of benefits is verified.
• Evidence that the eligibility determination was made as soon as possible, but no later than 60 days from the date of application (date stamped date). If the determination was not made within 60 days, there must be documentation of the reason for the delay, and evidence that the applicant agreed to a specific time extension. The KMIS time extension screens must be completed and the KMIS printout filed in the service record. Evidence of the individual's agreement may include a completed and signed form, or a counselor's narrative of a conversation. The extension must be completed, including the applicant's agreement, prior to expiration of the original 60 days.

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Order of Selection

• Completion of the functional limitations worksheet, including the counselor's rationale for identifying each limitation selected. List services that will address the limitations in terms of employment.
• Appropriate documentation supporting that the individual has a significant or most significant disability.
• Evidence that the individual was informed of their category designation. This may be conveyed in person or by phone, followed up with the appropriate brief narrative entry. This information may also be conveyed in writing, with a copy placed in the service record.
• Evidence that individuals receiving SSI/SSDI, or individuals with a Ticket, are automatically in at least Category 2.
• Documentation of referrals made on behalf of individuals who are placed on a waiting list. This may be conveyed in person or by phone, followed up with the appropriate brief narrative entry. This information may also be conveyed in writing, with a copy placed in the service record.

See Section 2 / Part 5.

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Comprehensive Assessment

• Documentation of any additional impairments and associated substantial impediments to employment that were not described during determination of eligibility and Order of Selection category.
• Information from a strengths-perspective which describes the assets (skills and abilities, interest in working, etc.), and resources the individual brings to the employment arena.

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Individualized Plan for Employment

• The IPE and amendments have been signed and dated by the individual (or if appropriate, by the individual's representative) and the counselor. A copy of the original IPE and any amendments have been given to the individual.
• Evidence that the plan was developed as soon as possible, but no later than 120 days from the date of eligibility (Status 10). If the IPE was not signed within 120 days,, there must be documentation of the reason for the delay, and evidence that the applicant agreed to a specific time extension. The KMIS time extension screens must be completed and the KMIS printout filed in the service record. Evidence of the individual's agreement may include a completed and signed form, or a counselor's narrative of a conversation. The extension must be completed, including the applicant's agreement, prior to expiration of the original 120 days.
• Narratives which clearly document how the consumer was involved in developing the IPE. Notes that describe the consumer's interests and employment goals. Evidence that the individual had informed choice in selecting the vocational objective. Information regarding availability of employment related to the VO. Evidence that the individual had sufficient information regarding alternatives to make informed choices about services and providers.
• The service record must support that the vocational objective is consistent with the assessment of the individual and his/her primary employment factors.
• A narrative discussion of how the services on the IPE address the individual's needs and relate to the individual's vocational objective. (This should result in evidence that all services listed on the IPE are necessary to achieve the employment goal.)
• Identification of the criteria that will be used to evaluate progress.
• Evidence that comparable benefits were considered and used as appropriate.
• IPE amendments are completed whenever a service was added or deleted. IPE amendments are also required whenever the vocational objective is changed. However, no amendment would be required if the individual accepts a job during the placement phase that is different than the job listed on the IPE. Such a change should be documented specifically in the closure letter. The letter must be labeled “IPE Amendment.”
• Documentation of economic need. Policy requires counselors to obtain verification of information, such as income tax returns or current pay stubs.
• Were annual reviews of the IPE conducted? Is there evidence that the individual took part in such reviews? Was economic need updated annually?
• Documentation that the individual's progress is regularly updated/reviewed, and that sufficient contact is maintained with the client according to the individual circumstances of the case.
• Documentation of the Ticket-to-Work assignment process and outcome.
• For students receiving special education services, notation that the IPE is consistent with the transition portion of the student's Individualized Education Plan (IEP).

• For supported employment cases, the record of services must include:
• Description of the time limited services, not to exceed 18 months, to be provided by VR.
• Description of the ongoing services needed by the individual and identification of the provider of ongoing support. In the event that identification of the source of ongoing services is not possible at the time the IPE is written, a statement explaining the basis for concluding that there is a reasonable expectation that such ongoing services will become available.
• A provision for periodic monitoring to ensure satisfactory progress toward meeting the work goals by the time of transition to extended ongoing services.
• The client's goal for the number of hours to work.
• The criteria for job stabilization. Job stabilization shall be individually determined for each client. This criteria should describe the methodology that will be used to determine when VR funding should cease and ongoing support should take over.
• Projection of the number of hours of job coaching needed for the client to reach stabilization and case closure.

See Section 3 / Part 14.

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Substantial Counseling and Guidance

Documentation of substantial counseling and guidance (Service Code 370) must address specific, substantial counseling services provided directly by the VR counselor. These services must be vocational in nature and specifically designed to assist the individual in participating in the rehabilitation process or in reaching an employment outcome. Documentation must show multiple sessions, and show that issues such as the following were addressed:
* Vocational exploration.
* Career decision-making.
* Establishment of a career path, including short- and long-term goals.
* Self-advocacy in the work place.
* Development of problem-solving skills.
* Use of community resources related to employment.

Documentation should address outcomes achieved as a result of such counseling and guidance.

See Section 3 / Part 4.

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Progress Notes

Documentation must include identification of client's progress, and interventions or action plans used to address issues or concerns, if any.Progress notes may be found in counselor narratives or in reports from service providers.

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Frequency of Contact

Frequency of contact should be determined by individual circumstances and at critical points in the rehabilitation process. As a general rule, contact on a monthly basis is appropriate. More frequent contact should typically happen during assessment for eligibility, IPE development, initiation of services, and when employment begins. Less frequent contact might reasonably occur after the client has stabilized in longer term services, such as when an individual has established good performance in a training program.

If services are interrupted or there is a loss of contact, the reasons must be entered in case narrative. The narrative should also reflect what is being done to resume the rehabilitation process.

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Employment Outcomes (Rehabilitated)

Documentation must address the following questions and issues:

• Did the services provided contribute significantly to achieving the employment outcome? (What substantial services were provided? Did the services provided by the agency make it possible for the person to be employed or achieve the specific job they have?)
• Was the employment outcome consistent with the individual's primary employment factors (strengths, resources, priorities, concerns, abilities, capabilities, interests and informed choice)?
• Did the individual maintain the employment outcome for an appropriate period of time, but not less than 90 days, necessary to ensure the stability of the employment outcome? (The date when employment began must be clearly identified.)
• Is there evidence that the individual no longer needs VR services?
• Was the employment in the most integrated setting possible, consistent with the individual's informed choice?
• Did the individual and the counselor agree that the employment outcome was satisfactory and the individual was performing well on the job?
• Discussion of the need for post-employment services.
• Evidence of the individual's wage, that the wages/benefits were comparable, that the work was in an integrated setting, and the work was the choice of the consumer.
• Closure letter is titled IPE Amendment, and specifically states the services provided, individual's dates of employment, wage, benefits, place of employment, views regarding closing the case, appeal rights including Client Assistance Program (CAP) services.
• When closing a case as a homemaker, the service record must document the appropriateness of the outcome based on the individual's needs and circumstances. In order for homemaking to be considered as an employment outcome, the essential functions of the homemaker duties must be performed by the individual with or without a reasonable accommodation. There must have been benefits derived from VR services which contribute to the client's ability to function as a homemaker. This includes the individual for whom a change in the vocational objective to homemaker is determined to be most suitable given that services have contributed substantially to an improvement in homemaker abilities and client independence. Counselors and clients will work together to define the specific homemaker duties for each individual case, and these duties must be identified in the service record.

See Section 5 / Part 1 and Section 8 / Part 42.

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Supported Employment Outcomes

In addition to the employment closure requirements described previously, such closures should be based upon the following factors:

• The client was provided appropriate and substantial services in accordance with the IPE.
• The client is in paid employment.
• The client has made substantial progress toward working the number of hours per week specified in the IPE.
• The client's workplace offers opportunities for integration with non-disabled persons (not paid service providers) who may be supervisors, co-workers or customers.
• The community service system has assumed the responsibility for funding and providing the extended ongoing support services necessary to maintain employment.
• The client's performance meets the criteria for job stabilization defined in the IPE. Stabilization must be based on the following factors:
• The client has reached a maximum level of work performance.
• The agreed upon hourly work goal has been reached.
• Job coaching and related support services have decreased to a level necessary to maintain the individual in employment through ongoing support.
• If the individual is stabilized in employment at a level of hourly work that is less than the goal established on the IPE, the client and counselor agree that the situation may be considered substantial and suitable employment.
• Placement is maintained for at least 90 days after making the transition to extended ongoing services. The ongoing supports being provided are adequate to meet the client's needs with respect to maintaining employment.

See Section 5 / Part 1 and Section 8 / Part 41.

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Other Outcomes

• The counselor has provided a rationale for closing the record of services.
• Rationale for ineligibility decisions. If ineligibility was based on severity of disability, was there clear and convincing evidence (based on more than assessments or testing) that the individual is incapable of benefiting from VR services in terms of an employment outcome.
• The consumer was given a written notice of case closure, which included reference to appeal rights and CAP services.
• The consumer has been referred to other appropriate services which then are documented in the case narrative.

See Section 5 / Part 2 and Section 5 / Part 3.

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Records Retention

Service records will be retained for five years after the closure of the case. Service records containing HIPAA information will be retained for six years.

At the end of each month and each calendar year, the Central Office will send the Field Office Records Retention Officers a list of cases closed during that period. These lists should be retained for future reference in determining which files can be destroyed.

At the end of each calendar year, the Field Office Records Retention Officers should prepare a list of records they intend to destroy. This list will be sent to the RS Central Office Records Retention Officer for approval prior to destroying any records.