Record of Services

Synopsis of Federal Regulation

Rehabilitation Services (RS) shall maintain for each applicant or eligible individual a record of services that includes, to the extent pertinent, the following documentation:

1. If an applicant has been determined to be an eligible individual, documentation supporting that determination.
   
2. If an applicant or individual receiving services under an Individualized Plan for Employment (IPE) has been determined to be ineligible, documentation supporting that determination.
   
3. Documentation that describes the justification for closing an applicant’s or eligible individual’s record of services if that closure is based on reasons other than ineligibility, including closure prior to eligibility determination.
   
4. Documentation supporting the determination that an individual has a significant disability or a most significant disability.
   
5. If an individual with a significant disability requires an exploration of abilities, capabilities, and capacity to perform in realistic work situations through trial work experiences or extended evaluations in order to determine whether the individual is an eligible individual, documentation supporting the need for and the plan for the trial work experience or extended evaluation, documentation supporting the periodic assessments conducted during the trial work experiences or extended evaluations, and the written plan developed during the trial work experience or extended evaluation.
   
6. The IPE and any amendments to the IPE.
   Documentation describing the extent to which the applicant or eligible individual exercised informed choice regarding the provision of assessment services and the extent to which the eligible individual exercised informed choice in the development of the IPE with respect to the selection of the specific employment outcome, the specific VR services needed to achieve the employment outcome, the entity to provide the services, the employment setting, the settings in which the services will be provided, and the methods to procure the services.
   
7. In the event that an individual obtains competitive employment, verification that the individual is compensated at or above the minimum wage and that the individual’s wage and level of benefits are not less than that customarily paid by the employer for the same or similar work performed by non-disabled individuals.
   
8. Documentation concerning any action and decision resulting from a request by an individual for review of a rehabilitation counselor determination.
   
9. In the event that an applicant or eligible individual requests that documentation in the record of services be amended and the documentation is not amended, documentation of the request.
   
10. Documentation regarding referrals made by RS.
    
11. In the event an individual’s record of service is closed as a successful rehabilitation, documentation that demonstrates the services provided under the individual’s IPE contributed to the achievement of the employment outcome. In addition, documentation must show that all of the following requirements have been met:
    • The individual has achieved the employment outcome that is described in the individual’s IPE and is consistent with the individual’s strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice.
      
    • The individual has maintained the employment outcome for an appropriate period of time, but not less than 90 days, necessary to ensure the stability of the employment outcome, and the individual no longer needs VR services.
      
    • At the end of the appropriate period, the individual and the qualified rehabilitation counselor employed by RS consider the employment outcome to be satisfactory and agree that the individual is performing well in the employment.
      
    • The individual is informed through appropriate modes of communication of the availability of post-employment services.
      
12. In the event that an individual’s IPE provides for VR services in a non-integrated setting, a justification to support the need for the non-integrated setting.
    
13. In the event an individual achieves an employment outcome in which the individual is compensated in accordance with the Fair Labor Standards Act or RS closes the record of services of an individual in an extended employment on the basis that the individual is unable to achieve an employment outcome or that an eligible individual through informed choice chooses to remain in extended employment, documentation of the results of the annual reviews required, of the individual’s input into these reviews, and of the individual’s (or representative’s) acknowledgement that these reviews were conducted. (Note: Such closures would not meet the requirements for a Status 26 closure.)

RS Policy

Documentation is intended to meet, but not exceed, the federal requirements for records of service. RS staff will exercise professional judgment and discretion in determining the nature, scope and extent of relevant information to be included in the record. Information should be limited to that which is necessary and sufficient to show the basis and justification for eligibility decisions, order of selection designations, service decisions and the expenditure of public funds. The IPE should be written with sufficient detail to avoid any misunderstanding about the goal, services and responsibilities. Duplicate and extraneous materials do not need to be kept in the record. Documentation of a decision should be sufficient to show that the decision is reasonable, based on adequate fact and information, correctly applies policy, and that the client participated in the decision.

Generally, narratives should address:

• What occurred: (decision made, client reported progress, counseling and guidance occurred, information requested, etc.)
• An explanation of what occurred, if needed.
• A description of the client’s involvement in what occurred.
• A brief notation of the next step.

  Narratives are necessary only for information that cannot be found in other records.

  Beyond the minimum documentation requirements, staff should focus time and effort on value-added activities, including counseling and guidance, which lead to quality employment outcomes.
  

  If requested or otherwise necessary, a record of services will be transferred based upon the residence of the individual, the nature of the individual's disability, the availability of services, and the individual's choice. See Section 1 / Part 13.

Effective Date: October 1, 2001