GUIDELINES:

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 in the next 90 days.  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

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.

REQUIRED CASE RECORD DOCUMENTATION BY ACTIVITY:  

REFERRAL: See Referral Process

Task note: Note decisions, activities, progress, next steps, no shows, etc. any relevant information needed for Orientation. Include date, reason for referral, scheduling considerations, appointment time, if accommodations are needed, others (authorized representative, parent, agency) involved to include in the meeting, etc.

File: Referral form, if used.

QE2: Enter referral data into QE2. Automated task note generated for referral status and identifies previously closed cases.

ORIENTATION: See Application and Transfer to the Employment Program

Task note: Note decisions, next steps, late, no shows, attempted contacts, etc. 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. 

File: Orientation Confirmation Letter/Notice in case file. 

QE2: Enter VR Orientation in the Assessment Services Screen,

INITIAL MEETING: The Initial Meeting may take more than one session to complete. A Task Note summary is required for each Initial Meeting session. Document if the individual decides not to apply for services. Note: no shows, tardiness, attempted contacts, decisions, next steps, etc. See Initial Meeting

Task note: Note decisions, next steps, late, no shows, attempted contacts, etc. 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. 

QE2: Automated task note "Application completion"

ELIGIBILITY DETERMINATION: Documentation supporting determination of priority for services, impairment, impediment, ability to benefit and achieve an employment outcome.  See VRIS Eligibility/Eligibility Extension or Ineligible/No Longer Eligible 

Task note: Discussion with the individual of the summary of Eligibility/Ineligibility discussion and when a priority group is upgraded. Documentation needs to include next steps, future plans, who the individual was referred to on the Information and Referral to Other Programs form to allow for follow-up activities and any other relevant information. The automated eligibility task note alone is not adequate, as it does not capture the entire discussion. 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.

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. 

QE2: Complete the Eligibility, Ineligibility or Eligibility Extension Determination screen, as required for each determination.

QE2 Narrative Guidance:

• Eligibility and Priority Group: 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.
• Eligibility Extension: 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.
• Ineligible: Complete the Eligibility screen with an Ineligible determination. Provide the clear and convincing evidence for the basis of this justification.

Automated task note for "Eligibility Approved," "Eligibility Extension Approval," and "Eligibility/Waiting List letter sent"

Automated email will be generated to the Director of VR and the Specialist's Office Director for review of the rare case exceeding 120 days.

CAREER PLANNING: Services shall be 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. See VRIS Career Planning

Task note: 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.

QE2: Enter assessment as a service. When in an Order of Selection, automated task note for "Removed from the waiting list" (90 day timeline for planning starts once removed).

BENEFITS 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

Task note: Title by the type of service provided or authorized (Benefits Assessment, Benefits Planning, Benefits Management, PASS Plan). 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. 

QE2: Enter Benefits Orientation as an assessment service and client's benefits on Benefits and Services screen (correct information, if no longer accurate), authorize for benefits services.

IPE APPROVALS, AMENDMENTS, EXTENSIONS and ANNUAL REVIEWS: See VRIS Individualized Plan for Employment

Task note: Automated task note alone is not adequate, as documentation needs 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, the specific rehabilitation services needed to achieve the employment outcome, the entity providing the services, the employment setting, the settings in which services will be provided and the method to procure the service. 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. 

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

QE2: Complete required IPE, Extension or Annual Review screens, as appropriate which in turn creates an automated task note for IPE Extension, IPE Approval, IPE Amendment and Annual Reviews which includes equipment issuance items. 

IPE Narrative Guidance:

• 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? 

EMPLOYMENT SERVICES: See Employment Services 

Task note:  Note decisions, activities, progress, next steps, no shows, etc. Utilize QE2 Placement screen. 

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.

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

QE2: Placement Services referral, Placement Services ended, Job Search Agreement completion, 

EMPLOYMENT FOLLOW UP: See Employment Services

Task note: Client Contact. During each client contact assess progress on the job, any retention 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 preformed by non-disabled individuals. 

• Documentation of congratulatory letter sent.
• First 30 days - 2 contacts with the client 
• 60 day - prior to the 60th day of employment 
• 90 day - a minimum of 90 day on the job to discuss stabilization and any need of further services
• Copy of Congratulatory Letter in case file

Employer Contact. 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.

File: Targeted Jobs Tax Credit, if used

QE2: Add job to employment history and click the follow up button when the individual has stabilized on the job.

AUTHORIZATIONS: See VRIS Authorization Policy, 

Task note: Justification for the purchase, ensuring the item or service is required to obtain or maintain the IPE Employment Outcome.

Include:

• Justification for ALL purchases
• Outcome of search for comparable services and benefits, to include personal and health insurance and/or employment benefits, if appropriate.
• Client contribution or inability to contribute
• 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

QE2: Compete authorization in QE2. Obtain any needed approvals. Automated task note for all authorizations, extensions, approvals and exceptions.

CORRECTIVE ACTION - See Client Accountability,

Task note: Document the specific issue and the plan to correct it.

Include:

• 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 

QE2: "Corrective Action" will be identified in the QE2 casefile header and search feature

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

Task note: Document the client's and VR's perspective of the situation and the evidence supporting it. 

File: Office Director Letter

QE2: NA

REQUEST TO AMEND CASE FILE RECORD - Client or authorized representative request documentation change to case file record - See Records, Confidentiality and Information Release and Client Appeals, Rights and Procedures

Task note: A client, recipient, applicant (or their representative) may request to review the case file and also receive a copy of requested documents. This request must be in writing. Document date of request and file the written request in the casefile. 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

QE2: NA

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

Task note: Document 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

QE2: Answer questions asked during the Application, Annual review or “Address Line 1” changes:

CASE  CLOSURE: Client and if appropriate, authorized representative consultation is required to close a case. Automated task note alone is not adequate. 

Task note for successful closure: 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.

Task note for 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 chapter. 

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.)

QE2: Complete case closure screen. Automated task notes for case closed and Ineligible 12 month follow-up completion.

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. 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.
4. 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. See attached examples.
5. 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.
6. Narratives should be concise and include only pertinent information.
7. 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.
8. Entries should indicate the method of contact or attempted contact - in person, face to face, by phone, e-mail, letter, etc.
9. Any team member can enter task notes. If making an entry for someone else, identify who originated the information.  
10. 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. 
11. Existing task entries are not to be altered by staff who did not make the entry.
12. 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.

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.

All major decisions need documented in the QE2 Task Notes, with the rationale used.

Client contact is required every 30 days, at a minimum for active VR cases. Refer to Supported Employment chapters for guidelines on contact with the Provider and client.

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 (successful/unsuccessful) or at any time the client disagrees with a VR final decision.

Key VR Timeframes