Standards for Service Delivery and Case Recording VR 16.01
State and federal regulations along with agency policy require that certain information be
contained in each consumer’s record of service. The extent of the information needed varies in
relation to where the consumer is in the VR process.
The purpose of this manual section is to provide field staff with standards for case recording which meet agency standards.
Do not duplicate any information that is otherwise documented in the record of service.
Standards for Service Delivery and Case Recording VR 16.02
The case narrative allows recording of
? significant consumer/staff interaction and
? critical steps in advancing the rehabilitation process from the time of initial consumer contact through closure.
What to Include
Only significant events or developments related to the case should be recorded in a narrative. These include, but are not limited to, the following:
? consumer perceptions and expectations
? counseling efforts
? rationale for providing services in special or exceptional situations
? specific extensions of time agreed upon for the completion of determination of eligibility
? explanation of a status change
? explanation of cases in a particular status for unusual lengths of time
? discrepancies in medical or diagnostic recommendations and counselor decisions
? loss of contact with consumer and attempted efforts to contact
? significant changes in consumer situation (disability, family, financial situation, etc.)
which might affect the program
? changes in the availability of comparable services and benefits and efforts to secure these
? status changes (if not explained elsewhere, as in closures)
? employment assistance activities (including employer contacts made on behalf of the
? explanations of how services in the consumer’s IPE contributed to his/her employment
? verification of earnings for individuals who obtain competitive employment and are
compensated at or above minimum wage and that the wage and level of benefits are not
less than that customarily paid by the employer
? notation of case transfer
Standards for Service Delivery and Case Recording VR 16.03
CASE NARRATIVES (Continued)
What not to Include
Do not include in a narrative:
? statements containing medical or psychological labels describing a consumer unless
appropriate documentation is in the record of service; if there is appropriate
documentation, quote the documentation
? any judgmental statements without proper documentation
? duplicate information
Case narratives should be concise, relevant, and must address
? and, sometimes, how.
? who--I counseled Mr. Bill Jones
? when--on 7/21/98
? where--at Joe’s Print Shop
? why--to see if he and his employer were mutually satisfied
? what--Mr. Jones and I discussed his employment and he indicated he was very happy
with his job
While most contacts with consumers should be recorded, it is permissible to summarize in one
entry the information secured or action taken in the course of several contacts if this period does
not extend past two weeks. The case narrative date should be the date of the last contact.
NOTE: An important event should have its own narrative. Method of Recording
Case narratives must be written so that other staff such as supervisors, administrators, other VR
counselors, rehabilitation teachers, or RSA audit staff reading the record can get an accurate
understanding of the consumer and the development of the case.
Standards for Service Delivery and Case Recording VR 16.04
CASE NARRATIVES (Continued)
Counseling sessions are recorded in the case narratives. These may
? include a description of the purpose and the results of the counseling session,
? focus on the progress or lack of progress being made in relation to consumer's program,
? indicate any changes in attitude, if any, since the last contact, and
? describe efforts that the consumer and/or staff will take prior to the next contact.
Employment Assistance Activities
Any and all employment assistance activities must be recorded in the case narrative. These
include, but are not limited to:
? Making employer contacts on behalf of a particular consumer
? Referring a consumer to the Arkansas Employment Security Division
? Working with a consumer on resume writing or interviewing skills Employment assistance will be entitled as such.
Status 18 06-03-98: Employment Assistance Activity: On this date, counselor contacted Mr.
John Smith at Best Foods, Inc. regarding a position of computer operator for Ms. Simms. Mr.
Smith was very receptive and indicated he would like to interview Ms. Simms on 07-15-02 at
Standards for Service Delivery and Case Recording VR 16.05
CRITERIA FOR CLOSING CASES FROM STATUS 02
Criteria for terminating cases in Status 02 are:
? One or more of the basic conditions for eligibility for VR services are not met.
? Reasons other than eligibility exist. Basic Documentation
All closed cases must have documentation in the record of service describing and supporting
? the reason for the closure and
? referral action to other resources, if appropriate. Rule
Cases closed for "other reasons" must be restricted to reasons that do not appropriately fit into more definitive categories.
Standards for Service Delivery and Case Recording VR 16.06
CRITERIA FOR CLOSING CASES FROM EXTENDED EVALUATION
Criteria for closing cases in Status 08 from Extended Evaluation (06) are:
? There is no reasonable likelihood that a vocational rehabilitation objective can be
? The individual’s needs have changed.
Extended Evaluation must be terminated at the earliest time it can be determined that either of these conditions exists. (This determination may occur prior to expiration of an eighteen-month evaluation.)
No Reasonable Likelihood
Extended Evaluation must be terminated
? when it has been determined that there is no reasonable likelihood that VR services may
render the individual able to engage in a gainful occupation, or
? for reasons other than ineligibility. Needs Have Changed
When an individual’s needs change and it can be determined that Extended Evaluation can be continued without interruption, then the program is changed.
When an individual’s needs change to the extent that an interruption of services become apparent, then an assessment, using additional diagnostic studies where necessary, is made to arrive at one of the following three decisions.
Standards for Service Delivery and Case Recording VR 16.07
CRITERIA FOR CLOSING CASES FROM EXTENDED EVALUATION (Continued)
When Services are Interrupted
If the interruption is short and temporary, and
would not preclude continuation of the same or amended extended evaluation plan during the same certification period, then leave case in Status 06.
If the interruption is such that the remaining period of extended evaluation would not be sufficient to meet its objective, and closure of the case is necessary until the basic conditions for acceptability can be re-established and extended evaluation is needed to determine rehabilitation potential, then close case in Status 08.
If the interruption was caused by circumstances which clearly indicate that there is no reasonable
expectation that VR services may render the individual fit to engage in a gainful occupation, then
close case in Status 08.
Standards for Service Delivery and Case Recording VR 16.08
CRITERIA FOR CLOSING CASES AS "REHABILITATED"
Criteria for terminating services to a consumer in Status 26 and reporting the consumer as
? The program of rehabilitation services has been completed insofar as necessary or
? Substantial rehabilitation services have been provided to the consumer by DSB.
? The consumer is engaged in a suitable occupation at least 90 days, which is also in an
Note: Consumer must meet all three of these criteria.
Integrated Setting Definition
The definition of an integrated setting is:
? A setting typically found in a community in which applicants or eligible individuals
interact with non-disabled individuals other than non-disabled individuals who are
providing services to those applicants or eligible individuals, AND
? With respect to an employment outcome, means a setting typically found in the
community in which applicants or eligible individuals interact with non-disabled
individuals other than non-disabled who are providing services to those applicants or
eligible individuals to the same extent that non-disabled individuals in comparable
positions interact with other persons.
Implications of Integrated Setting Definition
Counselors should not decide that an employment situation is not an integrated setting based on
just the name of the employer. Jobs should be viewed on a case by case basis if there is question
of integration. To be integrated, the:
? individual is employed in a type of job available to the general public in the community
and is doing the same job in the company as individuals without a disability
? individual is employed under the same working conditions as others without a disability
in similar positions (e.g. rest room facilities, lunch or break arrangements, entrance/exit)
Continued on next page
Standards for Service Delivery and Case Recording VR 16.09
CRITERIA FOR CLOSING CASES AS "REHABILITATED" (Continued)
Implications of Integrated Setting Definition Continued
? individual has ongoing interaction with other workers, supervisors and the general public
to the same degree as workers without disabilities in the same or comparable occupations
? general working conditions reflect integration with other workers rather than
separation/segregation. Notification to Consumer
It is the responsibility of the counselor to inform consumers in writing when the case is closed. Accepting Employment Prior to Completion
In some cases, the consumer may identify an employment opportunity prior to completing the planned program of services. This employment may occur as a result of
? uncontrollable circumstances
? changes to more immediate goals, or
? finding acceptable employment. The consumer and counselor may jointly decide that it is necessary or appropriate for the consumer to accept this employment opportunity.
If the employment opportunity is a different type of goal, then the planned program of services should be re-evaluated to determine if there is an additional need for services. If so, the program should be amended to show this new employment goal and the additional services needed to assist the consumer to obtain or maintain this employment opportunity.
If the reassessment determines that additional services are not needed, as jointly decided by the consumer and counselor, then services may be terminated and the case closed. The consumer would be considered "rehabilitated" since all the services needed for the consumer to be successful in obtaining or retaining this job have been planned and provided.
Standards for Service Delivery and Case Recording VR 16.10
CRITERIA FOR CLOSING CASES AS "REHABILITATED" (Continued)
Substantial Rehabilitation Services
Substantial rehabilitation services is defined as any vocational rehabilitation service provided
within a counseling relationship that assists the consumer’s vocational rehabilitation.
The substantiality of the service can best be determined by its impact on the consumer’s
vocational rehabilitation, not on factors such as
? a fixed number or amount of services,
? counseling hours, or
? contacts with the consumer.
An occupation is generally considered suitable when, after a reasonable period of employment
(90 days is considered minimum), the following conditions have been met:
? The consumer and employer are mutually satisfied.
? The consumer is maintaining adequate interpersonal relationships and acceptable
behavior in the job environment.
? The occupation is consistent with the consumer’s interests, capacities, and informed
? The consumer possesses acceptable skills to perform or continue to work satisfactorily.
? The employment and working conditions will not aggravate the consumer’s disability,
and the consumer’s disability in the job situation will not jeopardize the health or safety
of the consumer.
? The wage and working conditions conform to state and federal statutory requirements.
? The employment is regular, reasonably permanent, and the consumer receives a wage
commensurate with that paid other workers for similar work. Rev. 06-03-02
Standards for Service Delivery and Case Recording VR 16.11
CRITERIA FOR CLOSING CASES AS "REHABILITATED" (Continued)
When All Conditions Are Not Met
In some situations, a case may be justifiably closed even though some of the conditions are not
Example: A consumer may desire to accept or remain on a job which, in the opinion of the
counselor, is not compatible with the consumer’s physical, mental and educational abilities, or
the job is not sufficiently permanent to assure continued self-support. Good counseling
procedure recognizes the consumer’s right to make such choices. The counselor’s obligation is to
? help the consumer understand the situation,
? give the consumer adequate information upon which to base decisions,
? encourage the consumer to pursue a more suitable plan and objective, and
? document assistance on the I P E.
When One or More Conditions Are Not Met
When a consumer accepts a job which fails to meet one or more of the criteria for suitability, the
counselor must assure that
? explanation has been given to the consumer concerning the unsuitable aspects of the job,
? the consumer has made the job choice in light of all the facts, and
? the consumer has been informed of the option to reapply for VR services if the job does
not prove suitable or the need arises for further services. NOTE: The case record must clearly indicate the justification for closing the case under these
circumstances including alternatives that were considered.
Standards for Service Delivery and Case Recording VR 16.12
Historically, there have been many problems in determining what constituted a valid homemaker
closure. This section contains descriptions and definitions that will aid the counselor in
determining what constitutes a valid homemaker closure.
A homemaker is an individual who
has the skills and abilities to maintain a home and
actively functions in that capacity.
The first important determination must be eligibility. In many cases, an individual may have a
disability and meet the first eligibility criterion.
However, when addressing the second criterion, for example, there is a distinct difference between
provision of medical care so that an individual can stay at home, and
physical restoration under a vocational rehabilitation program to aid the person in
maintaining or attaining employment (which, in this case, is homemaking). Changes in Vocational Objective
A consumer who decides to stay home may become a candidate for a homemaker closure if the following criteria are met:
the agency actually provided a substantial vocational rehabilitation service,
this service contributed significantly to the consumer’s vocational adjustment, and
the consumer meets the definition of a homemaker. Rev. 06-03-02
Standards for Service Delivery and Case Recording VR 16.13
HOMEMAKER CLOSURES (Continued)
Family status refers to the number of people in the family. When determining a homemaker closure, it is a fairly straightforward decision when an individual is responsible for the homemaking activities of an entire family.
However, for individuals who live alone, the counselor must differentiate between
home management activities.
Examples of self-care activities include:
? grooming skills
? personal hygiene
? care of hair