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TranscriptCSR Documentation: Consumer Service RecordsPage 1WelcomeWelcome to RapidCourses, a self-paced learning option, available 24/7, designed to provide you with essential, fundamental knowledge of the independent living field. Here are a few tips for easy navigation. Click the BACK and NEXT buttons at the bottom right portion of the page to move backward or forward through the module. Found on the left side, the Menu, Tools, Glossary, and Help buttons can provide you with additional information throughout the course. Menu – displays course content, available anytime except during a Knowledge Review or Final Quiz.Tools – contains downloadable tools and forms.Glossary – displays pre-defined terms used in this course.Help – provides help with navigation and control bar items, exam question types, page links.Click the EXIT button at the bottom left portion of the page to exit the module at any time. If you do not complete the module, your progress will be saved. We hope you enjoy RapidCourses and return regularly as we add to the course catalog. All of us with the IL-NET are committed to supporting you with tools, training, and technical assistance as you carry out your important mission of helping others achieve their goals for independent living.Page 2Module ObjectivesWhen you complete this module, you will– 1. Know what a consumer service record (CSR) is.2. Know what an independent living plan (ILP) is.3. Understand the fundamental federal expectations for record keeping and reporting.4. Understand the importance of CSRs in meeting the reporting requirements for the federal program performance report (704 Report) of services and activities that all CILs must complete annually.5. Be aware of useful practices for gathering consumer information, developing Independent Living Plans, and maintaining complete and accurate records.Page 3IntroductionCenters for Independent Living (CILs) provide vital services that impact individuals, communities and systems. CILs challenge society's assumptions about disability and make it possible for individuals with disabilities to gain or maintain independence. They strengthen support systems and increase the accessibility of communities. CILs also shape local, state, and national disability policies.To accomplish their mission, CILs must employ effective records management and reporting practices that provide a sound foundation of accountability to their consumers, their communities, and their funding sources.This module was designed to help CILs meet these requirements. Just as important, the module will help CIL staffs to have efficient and effective ways of creating and maintaining service records that will, in turn, support high quality services to CIL constituents.The guidance in this tutorial is based on these sources. 1) Regulatory requirements: Title VII of the Rehabilitation Act of 1973 (as amended) (“the Act”) 2) 45 CFR 1329 Independent Living Regulations. 2) Useful Practices that are recommended because centers have found them worthwhile and practical. 3) Requirements of the annual required program performance report (704 Report). 4) What we believe are expectations of the Administration for Community Living, Independent Living Administration (federal oversight agency) that have not yet been captured in written regulations or guidance.Page 4A Note on TermsMany CILs were founded at the same time that consumer awareness was becoming important to a variety of advocates in our country. Leaders in the Independent Living Movement sought a term that would describe how empowered people would participate fully and completely in the decisions that affected their lives. The term “consumer” was seen as meaning personal control and awareness. It is used in the regulations, and defined there as, "Consumer control means, with respect to a Center or eligible agency, that the Center or eligible agency vests power and authority in individuals with disabilities, including individuals who are or have been recipients of IL services, in terms of the management, staffing, decision making, operation, and provision of services. Consumer control, with respect to an individual, means that the individual with a disability asserts control over his or her personal life choices, and in addition, has control over his or her Independent Living Plan (ILP), making informed choices about content, goals and implementation."The term, Consumer Service Record, refers to the record maintained for each individual receiving services (other than information and referral) from an independent living service provider, including CILs. Many CILs use the job title “IL Specialist” to designate staff members with the primary responsibility of providing services, including initiating and maintaining the CSR. Throughout this module, the term IL Specialist is also used to mean the designated CIL staff member. Your center may use the term IL Specialist, IL Coordinator, IL Generalist or another similar term.Page 5Complete and Accurate CSRs Foster High Quality ServicesComplete, accurate service records help you, the IL Specialist, to document that you offer consumers services of the highest quality.Accurate record keeping, including maintenance of CSRs that include thorough documentation, enhances accountability of the CIL’s operations and provides a basis for sound reporting.Good records foster an organized approach to providing and documenting services and help you show that the services are effective. A structured interview, guided by well thought out forms, will help the consumer and the IL Specialist identify needs, goals, and barriers.A structured process supported with effective forms and well maintained records will foster consumer control. It ensures the consumer has complete information to make sound decisions about his or her future.The consumer will have a plan that will allow him or her to track and follow results.Up-to-date records promote continuity of services, even with staff absences and staff changes.The consumer will learn planning skills by participating in goal setting that will be useful in many areas of life.Page 6Complete and Accurate CSRs Support Systems Advocacy, Program Planning, and ReportingReports drawn from CSRs may help your CILTrack systems barriers encountered by multiple consumers and provide documentation for policy change, legislative advocacy, and systems change actions. Collect data that facilitates long-term planning and resource allocation. Secure data that support funding applications and grant proposals. Show how you are meeting requirements of the law, regulations, standards, assurances, and (when they become available) compliance indicators. Provide accurate data for federally required reports and for onsite compliance reviews and audits. Demonstrate satisfactory progress to qualify for CIL continuation award funding and increase accountability at the state and federal level. (Any information in the CSRs and/or reported on the 704 Report is subject to verification by the Administration for Community Living (ACL), for example through on-site reviews.)Page 7Information and Referral to IntakeFor many individuals with disabilities, an initial contact to the CIL with a request for information may be the beginning of a longer-term relationship with the CIL. Information and referral (I&R) inquiries may lead to an individual opening a CSR, but I&R may be provided without the requesting individuals having a CSR. CILs are required to provide I&R services to any individual who requests it, whether or not he or she has a significant disability.When a request for information is received – Provide complete information in response to the request or make a referral to a useful resource.Record the contact. Show the time and date of the contact and the information requested. Some CILs also record the name of the caller and their contact information so that follow-up calls may be made if additional information or a new resource should become available. Follow-up calls can also be used to verify whether the information provided helped the consumer to obtain access to previously unavailable transportation, health care, and assistive technology, as required in the annual federal program performance report.If the request requires more than a straightforward referral or the individual expresses multiple concerns,Ask if the individual would like an appointment with an IL Specialist who could spend more time to discuss needs in greater depth. If the individual is interested in doing so, schedule the appointment.Secure basic contact information and document the needs that were identified by the individual. This will enable the IL Specialist to concentrate on forming a relationship and determining needs without requesting information that has already been obtained.Page 8Determining Eligibility for ServicesAt the first meeting with the individual, determine whether he or she is eligible for services through the CIL.An individual is eligible when –He/she has a significant disability. Significant disability means the individual has a severe physical, mental, cognitive, or sensory impairment that substantially limits or interferes with their ability to function independently in the family, home, or community, or to obtain, maintain, or advance in employment and for whom the delivery of IL services will improve the ability to function, continue functioning, or move toward functioning independently in the family or community or to continue in employment; andThe individual with a significant disability requests services.Eligibility must not be limited to individuals with a certain type of disability or circumstance. The CIL must serve people with any disability, and can't restrict services to only individuals who are deaf, for example.The eligibility determination must be documented in the Consumer Service Record. Centers do not require medical documentation for IL services, but simply a declaration by the consumer that they have a significant disability.The eligibility determination may be maintained on the intake form or as a separate eligibility determination form.The documentation must be dated and signed by the consumer and an appropriate IL Specialist.Page 9Ineligibility for ServicesIf an applicant for IL services is determined not to be an individual with a significant disability, the CIL must provide documentation of the ineligibility determination.Documentation must be dated and signed by a designated IL Specialist.When an individual has been determined ineligible for IL services, the CIL must notify the individual in writing of this determination and inform the individual, or the individual’s representative, of their rights to appeal the action taken.The CIL must also provide an explanation of the availability and purpose of the Client Assistance Program, including the information on how to contact the CAP.If the person requests services that the CIL does not provide, an appropriate referral can be made and documented in the applicant’s file. The referral should include information on where needed assistance is available, how it may be accessed, and any specific eligibility criteria, cost, or restrictions. Page 10Review of IneligibilityIf an applicant for IL services has been found ineligible, it is good practice for the CIL to review the applicant’s ineligibility at least once within 12 months after the ineligibility determination has been made or whenever there is a material change in the applicant’s status.The review date and any changes to the applicant’s eligibility status should be documented and signed by the designated IL Specialist. Typically, this determination requires a phone call or other contact with the individual to ask "Did you resolve your concern? Have there been any changes that may change what you need from us?”The review need not be conducted if the applicant has refused the review, the applicant is no longer present in the state, or if the applicant’s whereabouts are unknown.If a review is not conducted, the reason should be documented in the applicant’s CSR. Page 11Gathering Essential Information: CSR Intake FormMuch of the basic information that will aid you in providing high quality services to the consumer is best gathered during an initial intake interview. CILs are encouraged to develop a standard set of forms to be used by all staff. It may be useful to develop your forms around the information needed in your program performance report. You will find a set of example forms used by other CILs on the ILRU website by clicking forms are provided only as examples and have not been approved by ACL/ILA.Before you start to fill out the forms and gather needed information, make sure that the application process and the reasons for asking personal questions are fully explained to the consumer.Recording information about the consumer on a well-organized initial interview or intake form will help you maintain and locate important information about the consumer. It is likely that you will refer to this intake form often as you assist the consumer, and as you follow up with them to see how effective the services were.Page 12Standard Information to Include in Each Consumer Service RecordBasic Consumer InformationFull nameMailing address, county of residence*, e-mail, or telephone numbers (and if the person’s phone or mailing address are not reliable you may want to ask for secondary contact information through a friend, family, or other agency.Age*Gender*Race/ethnicity*Type of Disability.* A consumer may describe several disabilities or conditions. If there are two or more disabilities/conditions that are barriers to living in the community, list each one.Documentation of Eligibility/Ineligibility. The eligibility determination must be dated and signed by the IL Specialist and the consumer. It may be as simple as a yes/no question on an intake checklist that asks, "Do you have a significant disability?"Services requested by the consumer. When an eligible individual requests services from a CIL, other than the simple provision of information or making a referral, a CSR is created.Either the Independent Living Plan (ILP) developed with the consumer or a waiver signed by the consumer stating that an ILP is unnecessary.*Identifies items required for the program performance report.Page 13Standard Information to Include in Each Consumer Service Record, cont'd.IL goals established with the consumer written in an ILP or separately in the CSR if the consumer has waived the plan. Whenever possible you should record the actual words used by the consumer to describe their goals.IL goals achieved by the consumer documented in an ILP or separately if the consumer has waived the plan.A service narrative record containing complete yet succinct notes documenting each in-person contact, telephone call, or other communication that describes actions taken, results, and other pertinent details relative to the development and achievement of IL goals by the consumer.The CSR narrative should demonstrate that the IL Specialist is facilitating the development and achievement of the consumer's IL goals.The CSR may be maintained either electronically or in written form.Page 14Standard Information to Include in Each Consumer Service Record, cont'd.Participant Rights and Responsibility Statement. The CIL is required to inform each individual of his or her rights. A Participant Rights and Responsibility Statement may be included in the CSR, including a statement signed by the applicant documenting that he or she has received a written description of his or her rights and responsibilities. The statement may include information detailing the ways to give feedback to the CIL about the service experience. Copies of the form or forms may be retained in the CSR.Signed release of information to share information. A basic principle of consumer-direction is that consumers have a right to confidentiality and control over information that is collected and shared about them. If there are other individuals with whom the consumer wishes you to share information, a signed release of information with the person /entity that receives information must be included in the CSR. These signed documents can be scanned in or you can keep them in a paper file in addition to the electronic record.Signed release of information to obtain information. A release of information form must be completed and signed by the consumer (or his/ her representative) prior to the CIL accessing specific information that will assist CIL staff in providing more effective services to the individual. Obtaining blanket releases that give permission for CIL staff to access information from multiple sources over an extended period of time is not encouraged. It is best to have a separate release of information form signed for each organization from which information will be requested or to which information will be provided. The information should be essential to the consumer’s goals. Each release form should be completed at the time that the information is needed.HIPAA Rights Documentation. If your CIL is providing health related services, you may need to include documentation that you informed the consumer about his/her rights under the Health Insurance Portability and Accountability Act (HIPAA). You can learn about HIPAA requirements through the programs associated with the health related services you provide.The consumer's right to appeal and review. CILs are required to establish policies and procedures that an individual may use to obtain review of decisions made by the service provider concerning the individual's request for IL services or the provision of IL services to the individual. These policies and procedures must use formats that are accessible to inform each individual who seeks or is receiving IL services from the service provider.Page 15Documentation of Receipt of Client Assistance Program (CAP) Information All CILs must notify each individual seeking or receiving its services about the availability of the Client Assistance Program, the purposes of the services provided by the CAP, and how to contact the CAP.The CIL may choose to include documentation of this notification as part of the CSR. However, it is not a required component of the CSR and may be documented by other means. Page 16Quality ControlAccurate and timely record keeping is critical to a well-functioning CIL.Some CILs designate a staff member (often a program manager) to conduct quality control by regularly reviewing CSRs to ensure they are complete and accurate.Some CILs review all records; others review a random sample. Reviews can include several components:Completeness of the record. Do you have a checklist that helps you assure completeness?Quality of the goals and plan. Are the goals measureable? Do they state a desired outcome? Do the narrative and other entries demonstrate how services were provided and their effectiveness?Page 17Developing an Independent Living Plan (ILP) After the individual has been determined eligible, the IL Specialist should offer him or her the opportunity to develop an ILP or a consumer may choose to waive the right to develop a plan. If the right to develop an ILP is knowingly and voluntarily waived, the consumer must sign a waiver stating that an ILP is unnecessary.The ILP or the waiver must be maintained in written form.The ILP must be signed by the IL Specialist and the consumer.As is true for all materials provided to or used with applicants and consumers, the plan or waiver must be provided in a format accessible to the individual with a significant disability. Or, if consistent with State law and if it’s what the individual chooses, it may be provided to his/her guardian, parent, or other legally authorized representative.An ILP can assist both the consumer and the IL staff to be clear about what the consumer’s goals are and which steps are necessary to reach them.A written plan is an excellent way to help the individual set a course of action and stay focused, as well as review and document progress.Plans are not burdensome paperwork if they are used-—not just filed!To view sample Independent Living Plans on the ILRU website click 18Developing Goals Goals are a critical and required part of IL services, whether or not the individual waives a written plan. Goals can best be identified by spending time with the consumer to explore his/her needs.Goals generally relate to significant life areas and/or to gaining access to previously unavailable transportation, appropriate health care, and assistive technology.After goals are identified in partnership with the consumer, the IL Specialist and consumer will develop action steps with projected timelines. These should be achievable and realistic. Set time frames for when actions will be taken and when milestones should be reached.Often IL services will be a means used to achieve the goal, not the goal itself. The IL service is, in reality, a means to an end. Consumers should be encouraged to think beyond a service to the ultimate goal or significant life area to be achieved. Be sure to set the projected duration of each of the services. Document goals and action steps for any consumer who has IL goals they want to achieve, even for those who do not wish to develop a formal plan (but who have signed a waiver).Provide a copy of the ILP in a format that’s accessible to the consumer when it is created or changed.Page 19Documenting ProgressGood documentation ensures continuity and consistency of services, regardless of which CIL staff member provides services. This is especially important if there are staff changes or when a staff member is on leave or away from the center for other reasons.Document progress when each contact is made.Record brief notes (narrative entries) in the CSR for each contact.Examine all forms and information in the CSR to ensure information is still accurate when you meet with the consumer to review his or her ILP. Then, make appropriate changes and updates.The CSR and ILP should be reviewed regularly and frequently toEnsure the ILP is still addressing the person’s needs;Determine if new goals should be added; andDetermine whether goals continue to be a priority for the consumer.Page 20Documenting Progress, cont'd.Plans must be reviewed as often as necessary, but a review at least annually is required to see if services should be continued, modified, or discontinued, or whether the consumer should be referred to a program of VR services or to any other program of assistance. CILs often review plans at different intervals: monthly, quarterly, or semi-annually to maintain both engagement with the consumer and ensure that the ILP is moving forward. It is considered a useful practice for the consumer and the designated IL Specialist to sign and date changes, updates, and reviews of the CSR and ILP.In assessing the quality of CSR narratives, CILs should evaluate whether the narratives demonstrate the IL Specialists’ role in facilitating the development and achievement of the consumer's IL goals.Page 21Closing the CSRThe CSR represents an active partnership between the consumer and the CIL. The CSR should not remain open if joint activities are not occurring. As a Useful Practice guideline, a CSR should be promptly closed when:The consumer has achieved goals and does not want to set new goals at the time.The consumer asks to discontinue services.The consumer relocates with no forwarding contact information.The consumer is deceased.The consumer does not return calls, attend meetings, or demonstrate interest in working on the goals in the ILP.There has been no activity for a significant period of time, such as 90 days. Remember, the CIL may not impose any duration limits on IL services. Sometimes a consumer may become discouraged and will not want to keep working on the goals he or she established. If this occurs, the IL Specialist can encourage the consumer to continue by suggesting other approaches or even a change in goals. However, if the consumer still does not want to continue, the CSR should be closed. Closing the CSR includes notifying the consumer in writing of the action taken, the availability of CAP services, and referrals to other agencies as appropriate.Remember that closing the CSR does not mean ending the relationship with the consumer. Hopefully the consumer will continue to be engaged with the disability community through peer opportunities, system advocacy, or serving on the board, to name a few activities that may not require a CSR but does engage the individual with the community.A CIL can open a new CSR for an individual if the previous CSR has been closed for a period of time. CSRs may be reopened if the individual’s circumstances have changed and/or an additional service is requested. Page 22Documentation of ClosureIn closing a CSR, the staff member should do the following:Notify the consumer in writing that his or her CSR will be closed, but can be re-opened if the consumer requests that it be reopened within 10 days. Place a signed and dated copy of the closure letter in the CSR.Move the file to an inactive status. In many CILs, this means physically moving the file to a separate file cabinet or area of the CIL office. Page 23Summary of Required SignaturesEligibility. There must be a written statement maintained in the CSR that documents that the person is eligible, that is that they state or confirm that they have a significant disability. This statement may be separate from the intake form, but must be signed and dated by the IL staff member.If the applicant is determined not to be an individual with a significant disability, the CIL must provide documentation in the applicant’s file of the ineligibility determination. This may be an intake form signed by the consumer and the IL Specialist.Independent Living Plan or Waiver. The consumer and the IL Specialist must sign the ILP. The consumer must sign a waiver of the ILP, should they choose to waive that written plan document.CSR Closure. A copy of the closure letter may be placed in the CSR. It must be signed by the IL Specialist and dated.Page 24Summary of Signatures and Documentation – Useful PracticesParticipant Rights and Responsibility Statement. Each record may include a statement signed by the applicant documenting that he or she has received a written description of his or her rights and responsibilities as a consumer of the CIL, the right to confidentiality, the internal CIL appeals process, and information detailing the available ways to give feedback to the CIL about their service experience.Client Assistance Program information. The CIL must notify individuals about the availability of CAP. This can be documented in multiple ways, for example, through the CSR or an intake checklist, so long as there is documentation and that documentation is included in the file.Release of information. This form is completed and signed only if needed for accessing specific information required to facilitate provision of services to the individual. It is best to have a separate Release of Information form signed for each organization from which the information will be requested. Each release form should be completed at the time that the information is needed. Blanket or incomplete forms should never be presented to the consumer.Page 25Recording Information from the CSR in an Information SystemMany CILs record data in an information system so that information about services requested or provided and goals set or achieved can be summarized for planning and presented in reports to funders. These systems may be as simple as an electronic spreadsheet or as sophisticated as a customized system developed especially for a single CIL. A few CILs record information using card files or paper registers.When using an electronic system, it is still necessary to obtain consumer and IL Specialist signatures and provide the consumer with a copy of the plan. Signed documents may be kept in a paper CSR that complements the electronic record, or may be scanned and attached to the electronic record.Although each of these systems operates differently and may use different forms for data collection, in most cases the CIL staff member will record the following in the system:Information from the initial interview form, for example name, address, age, gender, disability type.Dates of application, opening a CSR, and closing a CSR.Whether the person chose to develop an ILP or waived the ILP.Goals set and goals rmation about each contact with the consumer.Services requested and provided.Regardless of the system used, it is crucial that data be entered accurately, regularly and frequently. Backlogs in entering data lead to errors and associated problems in reporting. To ensure consistency and accuracy in maintaining CSRs, the CIL should designate responsibility for overseeing the maintenance of CSRs. One useful practice would be to develop a quality assurance process for periodically reviewing a sample of CSRs maintained by each IL staff. The results of the review could be used to identify training needs of the IL staff and also used in staff performance evaluations.Page 26Accessibility of Materials and CommunicationsCommunication is at the heart of an effective CIL and supports consumer participation and empowerment from basic information and referral functions, through intake, to the CSR and the ILP. Communication includes oral communication, written materials, and materials for consumers whose primary language is not English.Help for Those Whose Primary Language is Not English:Providing an interpreter for an applicant or consumer who does not speak English or whose language skills are limited will help the individual to fully understand all aspects of applying for and receiving services from your CIL. Persons who are unable to communicate in English or who rely on alternative modes of communication must be provided an explanation of service provider policies and procedures affecting personal information through methods that can be adequately understood by them.Regardless of the type of activity or service, all communication must be in a format or mode readily useable and accessible to those requesting or receiving services from the CIL such as:Sign language or oral interpreters for interviews and meetingsTTY, videophone or relay services for phone communicationAlternate formats for those who do not read print, including large print, electronic files, Braille, and material made available through accessible Web pagesPage 27Readability of MaterialsAll materials provided to consumers should be written clearly in plain language. Use simple, direct language. Material should be written at the 6th – 8th grade reading level. This is the reading level used by newspapers for the general public. Most word processors have a feature that allows you to check the readability and reading level of a document. Page 28Summary of Points to Remember Regarding Documentation and CSRsDocument eligibility or ineligibility determination.Ensure that a consumer has a written plan or signs a waiver of the plan.Document services requested and provided for those consumers with plans as well as those seeking services who have waived the plan.Review and update the CSR and ILP regularly and often.Close the CSR with a signed and dated closure letter when services are no longer provided or the consumer cannot be contacted.It is important to remember that any information in the CSRs and/or reported on the program performance report is subject to verification by ACL/ILA, for example through requests for electronic records or during on-site reviews.Page 29Program Performance ReportingThe information collected for the CSR should correspond to the information requested on the 704 Report. As changes occur in the report, you may want to revisit your data collection system to assure you are tracking all the necessary information through the year. ................
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