Guidelines

Nebraska VR is committed to promoting each client’s satisfaction and engagement in his or her 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.

By regularly contacting the client at least once every 30 days during the VR process, such contacts keep the client informed of what is transpiring with his or her case, allows his or her questions to be promptly asked and answered, allows for timely self-report on progress and/or issues impacting his or her progress, and promotes the client feeling connected to and supported by the VR program throughout the whole process. On occasion and if agreed upon by the client and counselor, an alternative timeframe can be arranged when necessary but needs to be documented in the file with the agreed upon time for contact. 

Periodically, the client and specialist should mutually agree upon what type of contact is to be made by considering the client’s current milestone, activity and circumstance. A documented monthly contact may be any one of the following.

• Face to face
• Phone
• iChat, FaceTime, etc.
• Text
• Email
• Letter
• MyVR

The standard of what is an 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 mutually agreed upon next action to keep the case moving. All major decisions need to be documented in the task notes.(See attached for specific time lines for services)

Required documentation in a Task Note:

• Decisions (including discussion and rationale)
• Progress information
• Pertinent information (facts to support conclusions/opinions)
• Next steps
• Exception Rationale
• Office Director or Program Director Approval or Disapproval of exceptions
• Justification for ALL purchases
• Verification that items purchased by ‘cash advance’ were obtained and method of verification

Task Note Requirements Case Record documentation by activity:

REFERRAL process - include 

Enter referral data into QE2. Include date, reason for referral, appointment time, any accommodations needed, others (guardian, parent, agency) to include in the meeting, etc.

File copy of referral form and individual’s Confirmation Letter/Notice in case file, if completed. Complete VR Orientation in the Assessment Services Screen; or if not complete, enter a task note  title: Orientation

QE2 will automatically create a TASK note of previously closed cases. VR staff need to explore and note the reasons for previous unsuccessful termination(s) Task note titled: Decision on Referral of Previously Terminated Unsuccessful Cases

• 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. 

INITIAL MEETING to include the following:​​​​​​ The Initial Meeting may take more than one session to complete. If using the Summary of Initial Meeting form, only one form is needed to summarize all the sessions. A Task Note summary is required for each Initial Meeting session. File the copy of the VR Application and Release of Information and any other forms completed into the case file.

• 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

Document if the individual decides not to apply for services.

ELIGIBILITY DETERMINATION- File copies of any documentation used to arrive at eligibility decision in case file

Eligible - Complete QE2 Eligibility Determination of impairment(s) and assign priority group 

Eligibility Extension - Complete QE2 Eligibility Extension screen. See Eligibility & Eligibility Extensions

Ineligible -  Complete QE2 Eligibility Determination screen and file the copy of Office Directors Letter in case file. See Ineligible, No Longer Eligible

Summary of 30 DAY CLIENT CONTACT (in person, by phone, email, text or letters) Every 30 days, there should be contact with the client documented in the QE2 record or case file.
What is a Contact? A contact is an actual interaction with the client (face-to-face, phone call, e-mail with reply, or letter with reply). The contact must provide an indication of what is/has 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 in the next 90 days.Note unsuccessful attempted client contacts and no shows; when a client or staff member does not show for an appointment

CAREER PLANNING

Vocational Evaluation; the date the client is referred, scheduled and completed.

Completion of Vocational Evaluation task noted with and summary of results Vocational Evaluation Report to include strengths, barriers, interests, impairment(s), VR & community service recommendations and summary.

Justification for any CWA, OJE or WBLE and summarize the goals of the experience. Outcome/result of activity.

Justification for providing post-secondary training as an assessment service. Outcome/result of activity.

BENEFIT SERVICES (See below)

IPE Approvals, Amendments and Annual Reviews Complete QE2 screens.

Exception Rationale (moved up top)

Office Director or Program Director Approval or Disapproval

Justification for ALL purchases

Verification that items purchased by ‘cash advance’ were obtained and method of verification

TRAINING Document completion or termination of academic and/or worksite training with a summary of the results. Obtain grades and/or progress reports for case file. 

EMPLOYMENT SERVICES: utilize QE2 Placement screen. Employment Services.

Document in task notes:

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.

Employment Follow up:

Document follow up contacts with the client will be made at least twice within the first 30 days of employment, and at 60 and 90 days. For any job maintenance issues identified, describe what strategies will be implemented.

A follow up contact with the employer will be made within the first 30 days of employment, if VR advocated on behalf of the client with the employer. Assess the employer’s impression of the client’s progress on the job. For any job retention issues identified, describe what strategies will be implemented.

Case Closure Documentation: Task note summary of closure reason/case outcome.

Successful Outcome

Termination

For Voter Registration:  Enter a task note stating 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. Follow the steps outlined in the Program Manual Chapter: Assisting Individuals with Disabilities to Register to Vote.

For Benefits Services:

1.  Document that a referral for Benefits services is made to client’s chosen provider. Note type of service—Benefits Orientation, Benefits Assessment, Benefits Planning, Benefits Management, or PASS Development.

2.  Following the completion of any type of Benefits Service, document the outcome of the service in a task note titled to match the service provided (Benefits Orientation, Benefits Assessment, Benefits Planning, PASS development, and Benefits Management.)

• The Benefits Planning task note must include the following details for use in job placement and as the person continues to work:
  • List of work incentives available to the person and those chosen by the person as part of their strategy to return to work
  • Projected impact of chosen work incentives on benefits
  • Maximum number of hours the client can work and maximum earnings he or she can make in order to implement the outlined plan (work incentives, identification of projected impact on benefits, etc.)
  • Identification of who will be responsible for reporting income and other information, to which entity (SSA, DHHS, HUD, and any other entity applicable), as well as how the information will be reported
  • List of any record-keeping tool to be used by the client or others, any training that is needed, and who will provide the training
• Other task notes must include sufficient detail to identify the findings of the service provided and any next steps or activities that must be completed, such as reporting or follow-up.
• If the client refuses Benefits Services a TASK note will need to be completed and titled, "Benefits Service Refusal" and the narrative will include the reason for the refusal along with the refusal form.

TASK Note content:

1. 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.

2. 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)’.
3. When an agreement has been made between the Specialist and the client on contact outside of the 30-day contact practice, a task note should be entered to state the agreed upon contact.  Please refer to Supported Employment chapters for guidelines on contact with the Provider and client.
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. Do not copy whole 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. See attached examples.

• 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.

6. Conversations with NDE Legal Council 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.
7. Narratives should be concise and include only pertinent information.
8. 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.
9. Entries should indicate the method of contact or attempted contact - in person, face to face, by phone, e-mail, letter, etc.
10. Any team member can enter task notes. If making an entry for someone else, identify who originated the information.  
11. 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.
12. Existing task entries are not to be altered by staff who did not make the entry.
13. 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.

 

All major decisions need documented.

Client contact documentation is required every 30 days, at a minimum for active VR cases. 

Key VR Time Frames