Nebraska VR is committed to promoting each client’s satisfaction and engagement in their rehabilitation plan and services. Research indicates that one of the reasons for client disengagement from the VR program is how long it takes to move through the system. We need to keep our clients actively engaged in the VR process.

Complete narrative for All Major Decisions in the QE2 Task Notes, with the rationale used.

Document all Team Services from the Case Home screen at the time the service is provided

30 Day Client Contact. This is a minimum standard for active VR cases. During career planning more regular contact is recommended and during job search weekly contact is required.  

Nebraska VR must provide the Client Assistance Program (CAP) information to clients during the application process, when developing the individualized plan for employment, case closure or at any time the client disagrees with a VR final decision.

GUIDELINES:

Client contact is required every 30 days, at a minimum for active VR cases. By regularly contacting the client at least once every 30 days during the VR process, the recipient or client is informed of what is transpiring, provided the opportunity to ask questions, receive timely self-report on progress and/or issues impacting progress, and promotes the client feeling connected to and supported by the VR program throughout the whole process.

Recommend client contact based on the status of the case. The 30 day contact is a minimum standard. During career planning more regular contact is recommended and during job search weekly contact is required. Periodically, the client and specialist should review the individual's contact needs and mutually agree upon the occurrence and type of contact to be made by considering the client’s current milestone, activity and circumstance. On occasion and if agreed upon by the client and counselor, an alternative timeframe to the above can be arranged when necessary, but needs to be documented in the file with the agreed upon time for contact.

Standard of effective contact is one that accomplishes or addresses any presenting activity/task, purpose, need, concern or issue of the client or the specialist with a next action to keep the case moving. A contact is an actual interaction with the client (face-to-face, electronic face time; phone call; e-mail, text and letters with replies). The contact must provide an indication of what occurred in the case within the previous 30 days as far as planning/initiating services, progress/lack of progress in a service, and/or completion/termination of a service. If there has been a disruption, delay or lack of participation in services, the contact documentation should identify the corrective action to be taken.  All major decisions need to be documented in the task notes. Task note unsuccessful attempted client contacts and no shows; when a client or staff member does not show for an appointment. 

Automated task notes and form letters do not meet the 30 day standard of client contact, unless there is also a response from the client.

Include in client contacts and task notes: 

• Pertinent information (facts to support conclusions/opinions)
• Progress information
• Major decisions (including rationale decision was based upon)
• Next steps
• See Supported Employment chapters for guidelines on contact with the provider and client

REQUIRED CASE RECORD DOCUMENTATION BY ACTIVITY:  

• Document all Team Services from the Case Home screen at the time the service is provided
• Complete QE2 Task Note narrative for All Major Decisions and the rationale used.
• Note: no shows, tardiness, attempted contacts, next steps, etc.

REFERRAL: See Referral Process

QE2: Enter referral data into QE2. Automated task note generated for referral status and identifies previously closed cases. Summarize contact and include in the narrative any relevant information needed for Orientation. Include date, reason for referral, scheduling considerations, appointment time, if accommodations are needed, next steps, no shows, etc. others (authorized representative, parent, agency) involved to include in the meeting, etc.

File: Referral form, if used.

ORIENTATION: See Application and Transfer to the Employment Program

QE2:  VR Orientation Service is auto-generated by QE2. Document Team Service of VR Orientation and summarize contact. Note decisions, next steps, late, no shows, attempted contacts, etc. Note the reasons for previous unsuccessful termination(s) Address:

• Actions the previous client has taken to resolve previous issues.
• Services VR could offer that might help resolve issues and result in successful employment of the individual
• Task note titled: Decision on Referral of Previously Terminated Case - conclusion on whether to proceed or not with the case. 

File: Orientation Confirmation Letter/Notice in case file. 

INITIAL MEETING: See Initial Meeting

QE2: Automated task note "Application completion". Complete task note narrative summarizing contact. Document if the individual decides not to apply for services.

Address the following topics:

• Why the individual came to VR
• Presenting impairment
• How the impairment causes vocational issues
• General work history
• General educational history
• Family situation
• Legal situation
• Other agencies involved
• Economic situation
• Impressions
• Next steps

File:  VR Application, Release(s), Information and Referral to Other Programs, ABI if used and any other relevant documentation provided. Only one form is needed (Summary of Initial Meeting or Next Steps), to summarize all the sessions. 

ELIGIBILITY DETERMINATION:  See VRIS Eligibility or Ineligible/No Longer Eligible 

QE2: To authorize for Assessment Supports needed to determine eligibility, enter Assessment Service - Eligibility and then select the Assessment Support needed. Complete the Eligibility/Ineligibility Determination screen, as required for each determination. This will generate an automated task note "Eligibility completion". The automated eligibility task note alone is not adequate documentation, as it does not capture the entire discussion. Document in the task note narrative the discussion with the individual of the Eligibility/Ineligibility determination and when a priority group is upgraded. If a Trial Work Experience is utilized, include documentation supporting the need for, and the plan relating to, and documentation regarding periodic assessments carried out during the TWE. See VRIS Trial Work Experience.

Narrative Screen Guidance:

• Complete Eligibility and Priority Group screens: Document the case specific evidence and information for the justification of the selected functional limitations and assigned severity, based on the individual's impairment(s). This needs to include how the impairment has resulted in individualized vocational limitations. Utilize the individual's work history and experiences to document your case specific evidence.
• Ineligible: Complete the Eligibility screen with an Ineligible determination. Provide the clear and convincing evidence for the basis of this justification.

File: Eligibility, Ineligible and Upgrade of Priority Group Letters, Information and Referral to Other Programs form, medical records and other documents used for the eligibility or ineligibility determination. 

ELIGIBILITY EXTENSION: See VRIS Eligibility Extension

QE2: Complete the Eligibility Extension screen prior to the 60 days expiring, as required. Narrative Screen Guidance:

• Complete Eligibility Extension screen: Document in the comments section what exceptional and unforeseen circumstances precluded making the eligibility determination within 60 days. Provide specific rationale why the extension is needed and what steps will be taken to complete this determination as soon as possible.

If the eligibility is not completed by the agreed upon Extension date, an automated email will be generated to VR Contact, who is required to provide an explanation within 3 days to the Director of VR and the Specialist's Office Director.

In the rare case an Eligilbity Extension isn't completed at all, an automated email will be generated to VR Contact, who is required to provide an explanation within 3 days to the Director of VR and the Specialist's Office Director.

CAREER PLANNING: See VRIS Career Planning

QE2: Click Document Team Service button and enter Career Planning as an Assessment Service - Assessment Support." When in an Order of Selection, an automated task note for "Removed from the waiting list" will start the 90 days for planning. Document client contact to show they are completed in a manner that affords clients the opportunity to exercise informed choice in selecting an employment goal which is consistent with the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and labor market information. Address the above pertinent topics and specific information used to make decisions. Describe the extent to which the recipient exercised informed choice regarding the provision of assessment services with respect to the selection of the entity providing the services, the setting in which services will be provided and the method to procure the service. Note: no shows, tardiness, attempted contacts, decisions, activities, progress, next steps, etc. 

For specific services include:

• Vocational Evaluation: the date the client is referred, scheduled and completed. See VRIS Vocational Evaluation for further information.
• Vocational Evaluation Report: to include strengths, barriers, interests, impairment(s), VR & community service recommendations and summary.
• OJE or WBLE: Justification and purpose of the experience. Any issues and how addressed. Outcome/result of activity. See VRIS On-the-Job-Evaluation and Work Based Learning
• Post-Secondary as an assessment: Justification and purpose for service. Any issues and how addressed. Outcome/result of activity. See VRIS Post-Secondary as an Assessment
• Supported Employment: Rationale for this method of service delivery.  

File: Reports, Progress reports, transcripts/grade reports, VR Profile, assessments and documents used for planning.

BENEFITS ORIENTATION AND SERVICES: Benefits information is vital for the client to have in making an informed decision about working, and provides foundational information prior to referral for Benefits Analysis Services. See Benefits Orientation and Benefits Analysis Services

QE2: QE2 will auto create a record on the Existing Benefits screen based on the benefits reported at application, and, if applicable, auto generate the Benefits Orientation service. Complete information on the Existing Benefits records and make a Benefits Referral. Document Team Service of Benefits Orientation at the time it is provided and summarize client contact. Authorization of Benefits Assessment, Benefits Planning, Benefits Management, PASS Plan show the service was provided. Summarize client contact in task note. Document the findings of the service with details sufficient to identify work incentives, who will report income, any training and next steps.

File: BPQY, reports for each benefit service provided. 

IPE APPROVALS, AMENDMENTS, EXTENSIONS and ANNUAL REVIEWS: See VRIS Individualized Plan for Employment, IPE Extension, IPE Annual Review, IPE Amendment

QE2: Complete required IPE, Amendment, Extension or Annual Review screen, as appropriate. This will create an automated task note for IPE Extension, IPE Approval, IPE Amendment and Annual Reviews which includes equipment issuance items. The automated task note of IPE Approval alone is not adequate. The task note narrative needs to include the summary of the discussion with the client, to include the extent to which the applicant or eligible individual exercised informed choice regarding the provision of assessment services and in the development of the IPE with respect to the selection of the specific employment outcome. In the event an individual's IPE provides for vocational rehabilitation services in a non-integrated setting, a justification to support the need for this setting. For Supported Employment cases document the rationale for Supported Employment being the method of service delivery and the provider that will deliver the services. Document why this individual, based on their disability, requires this service. NOTE: Amendments to Terminate Services cannot be completed in QE2. Use IPE -  Termination of Service form.

IPE Narrative Screens:

• IPE Extension - Document in the comments section what exceptional and unforeseen circumstances precluded making the eligibility determination within 90 days. Provide specific rationale why the extension is needed and what steps will be taken to complete this determination as soon as possible.
• IPE Approval & Amendment "Explain why the proposed IPE and/or Amendments will result in employment in the stated job goal" - Include case specific information to address how the employment goal is consistent with the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and labor market information. Ensure the disability and limitations are consistent with the employment goal and if not, how they will be compensated or accommodated. Address the labor market demands - Is the job locally available or is the client willing to relocate? What skills are required to do this job and why is it an appropriate job goal for this specific individual? 

File: IPE and all amendments, documents used in developing the IPE and IPE Amendments

JOB SEARCH ASSISTANCE: See VRIS  Placement Services

QE2:  Complete a Placement Services Screen referral when a client is starting Job Search Assistance; end Placement Services referral when Job Search Assistance is being stopped for an extended period of time; document Job Search Agreement completion; document Job Seeking Skills completion.

Document Team Service of Job Search Assistance and summarize client contact each time it is provided:

• Referral to JSS & Job Placement
• Completion of a Job Search Agreement form and place copy in case file.
• Weekly contacts
• Completion of a 90-Day Review of Job Search Agreement. Place copy in case file.
• Results of background Screening results, if needed.

File: Job Search Agreement form(s), resume, cover letter, etc. 

EMPLOYMENT FOLLOW UP:  See VRIS Placement Services

QE2: Add VR supported job to employment history and click the follow up button. During each client contact assess progress on the job address any issues. For any job maintenance issues identified, describe what strategies will be implemented. When competitive employment is obtained, include verification that the individual is compensated at or above the minimum wage and the individual's wage and level of benefits are not less that the customarily paid by the employer for the same or similiar work performed by individuals without a disability. 

Document Team Service button of Employment Follow Up and summarize client contact each time it is provided.

• Documentation of congratulatory letter sent.
• Follow up contacts with the client will be made at least twice within the first 30 days of employment, and at minimum once a month thereafter, until case is closed or the client has completed the transition to extended services.
• Employer Contact. With client's permission, a follow up contact with the employer will be made within the first 30 days of employment. Assess the employer’s impression of the client’s progress on the job. For any job issues identified, describe what strategies will be implemented.

File: Copy of Congratulatory Letter. Targeted Jobs Tax Credit, if used.

AUTHORIZATIONS: See VRIS Authorization Policy

QE2: Compete authorization in QE2. Obtain any needed approvals. Automated task note for all authorizations, approvals and exceptions will be generated. Complete task note summarizing client contact to include:

• Justification of  purchase
• Outcome of search for comparable services and existing benefits, to include personal and health insurance and/or employment benefits, if appropriate.
• Needed bids
• Verification that items purchased by ‘cash advance’ were obtained and method of verification. 
• Exception Rationale
• Office Director or Program Director Approval or Disapproval of exceptions

File: authorization, comparable bids, ATP Report, AgrAbility Report

CORRECTIVE ACTION - See Client Accountability,

QE2: "Corrective Action" will be identified in the QE2 casefile header and search feature.  Summarize in the task note narrative the client discussion.

Include:

• Specific issue and the plan to correct it.
• What is the lack of progress or issue to be corrected in question? 
• What are the specific steps for the corrective action plan developed with the client?
• What supports for the corrective action are available?
• How will the corrective action plan be monitored and measured?

File: Signed Correction Action Plan 

SERVICE DISSATISFACTION AND APPEALS -  Case cannot be closed in the middle of an appeal. See Client Appeals, Rights and Procedures

QE2: Document a summary in the task note narrative, the client's and VR's perspective of the situation and the evidence supporting it. 

File: Office Director Letter

REQUEST TO AMEND CASE FILE RECORD - See Records, Confidentiality and Information Release and Client Appeals, Rights and Procedures

QE2: Document in the task note narrative when an applicant, client  (or their representative) request to review the case file and/or receive a copy of requested documents. This request must be in writing. Document date of request. If there is a requested correction, include the specific concerns any action or decision resulting from the request to change case documentation. If there is not agreement, inform the individual of their rights and appeals procedures,. 

File: Written request to see file

VOTER REGISTRATION - See Assisting Individuals with Disabilities to Register to Vote.

QE2: Answer questions on the Application and Annual review screens or when an individual's address changes. Document in the task note narrative, the date the Voter Registration form was mailed/submitted to the election commissioner or county clerk and include if at the time of application, annual review or a change of address. 

File: Nebraska Voter Registration Application

CASE  CLOSURE:

QE2: Complete case closure screen. An automated task note will be generated for case closures. The automated task note alone is not adequate documentation as the individual needs to have a full consultation. Include a task note summarizing the client discussion and agreement. Include the authorized representative, as applicable. 

• Successful Ooutcome: Discussion with individual and summary of the justification the services provided under the IPE contributed to the achievement of the employment outcome. Ensure case meets ALL requirements for Successful Outcome.
• Termination: Discussion with the individual and justification for closing an applicant's or eligible individual's record of service. Ensure all relevant case information has been documented. See VRIS Termination 

File: All documentation used to arrive at the determination to close the case (reports, Contact Letter, 15 Day Letter, Termination Letter, Office Director Letter, medical, etc.)

TASK NOTE CONTENT:

1. Any team member can enter task notes. If making an entry for someone else, identify who originated the information.  
2. Existing task entries are not to be altered by staff who did not make the entry. 
3. TASK entries can be deleted by Office Directors and Administrative staff only. TASK notes should not be deleted while there is an active CAP case.
4. Every entry must have a header. QE2 will have standard headers that can be used for task entries. Staff may create their own header when the standard headers do not fit. Do not use the header to start the narrative. The header is a "title" of the narrative content. Select "Customized Task Title" when the other headers do not apply.
5. Use professionalism when composing task notes as consumers and others may request a copy of the file, or the file may be entered into evidence in an appeal or legal proceeding. 
6. Narratives should be objective and should state facts versus the opinion of staff.  Noting observations/impressions and including the basis/evidence for the impression, while remaining objective is acceptable practice.
7. Entries should indicate the method of contact or attempted contact - in person, face to face, by phone, e-mail, letter, etc.
8. If using a person’s name, other than the client, include a descriptor so other staff can identify who the person is. An example would be ‘John (client’s father)’.
9. Narratives should be concise and include only pertinent information.
10. Do not copy entire emails into the task notes. If there is data from an email that you need to document in a task note copy just that part of the email or paraphrase the information. Do not include the email addresses within the task note, unless relevant to the correspondence. See attached examples.
11. Words should be complete. Text language and shorthand are not allowed. 
    • Acronyms are allowable, if the word is spelled out at least once in the task note. For example, you could use CA after first using Community Alliance (CA).
    • Statewide commonly understood acronyms that are not specific to one office or community are acceptable without spelling out. Examples are VR, ATP, SSDI and SSI.
12. Conversations with NDE Legal Counsel documented in a Task Note should be limited to any decision rendered, direction provided, or requested action. The summary should not include any detailed rational or commentary.
    • Note: The results of client background checks can be copied into the QE2 task notes or paper record.
    • Copies of any other emails from NDE Legal Counsel should never be copied to the QE2 record or filed in a client's paper case file.
    • Any summary of an email from NDE Legal Counsel shall be limited to any decision noted in the email. The summary should not include any detailed rational or commentary.

Key VR Time Frames