Federal Regulations require that the North Carolina Division of Services for the Blind maintain a record for each consumer. The record will contain pertinent information about the consumer and the services he/she receives. All information as to personal facts given or made available to the agency in the course of administration of the Independent Living Services Program will be held confidential. Refer to Manual Section 300, VII B.2.b. p.20 for additional information on confidentiality policies.
If the SWB needs to obtain an eye report or other health information, it is necessary for the DHHS-1000 Authorization to Disclose Health Information to be completed and signed by the consumer. A copy of this form must remain in the case record. See Section 500 for a copy of the form and the instructions for it’s use.
The case record provides the only source of sequential information regarding the consumer's situation. All workers will maintain individual case records on each consumer for whom they have service delivery responsibility. Each record will contain a paper copy of all work done even when the SWB has done forms, narratives, etc. electronically. Social Workers for the Blind will also maintain central or composite files of all applicants found ineligible for independent living services. Also, Resource Specialists will maintain central or composite files for all referrals they reject for specialized services.
A. Contents of Case Records
The North Carolina Division of Services for the Blind maintains a case record on each person receiving independent living services. Depending upon the workers’ office location, these records are housed either in the district office of the Division of Services for the Blind or in the county department of social services. Each record will contain basic data regarding the consumer's individual situation, eligibility documentation and service information necessary for case management and service delivery.
1. For Social Workers for the Blind, each of the following documents must be maintained in the consumer's case record at all times:
a. DSB-7001: Application
b. DSB-7103: Independent Living Services Assessment and Plan
c. Eye Examination Report
(1) This report must describe the consumer's current visual acuity as validation of his/her eligibility for Independent Living Services on the basis of vision;
(2) Must be dated and signed by a medical or eye care professional;
(3) May be in the form of DSB-2202: Report of Eye Examination or a written statement as outlined in Section 250 of ILS Manual
d. On-going quarterly case recording, including Case Closure Summary when case is closed
e. Copy of Resource Specialist Service Plan, if applicable
f. Current quarterly case progress reports from each Resource Specialist who has accepted the consumer for specialized services and skills training
g. Copies of all applicable reporting formats and attachments that worker is responsible for preparing
h. All other correspondence, documentation, etc. necessary for a thorough knowledge of the consumer's individual situation and for effective case management and service delivery.
2. For Resource Specialists, each of the following documents must be maintained in the consumer's case record at all times:
a. Copy of DSB-7103: Independent Living Services Assessment and Plan from worker who made referral
b. Copy of Eye Examination Report from worker who made referral
c. Orientation and Mobility Service Plan (DSB-7103B or Independent Living Rehabilitation Counselor Service Plan (DSB-7103C)
d. On-going quarterly case recordings, including Case Closure Summary when case is closed
e. Current quarterly case progress reports from Social Worker for the Blind who is ILS Case Manager for consumer
f. Copies of applicable reporting formats and attachments that worker is responsible for preparing
g. All other correspondence, documentation, etc. necessary for knowledge of the consumer's individual situation and for effective case management and service delivery.
B. Retention of Case Records
All case records must be retained for a minimum of three years after the case is closed. Records for closed cases may be in the form of the original record itself or microfilmed format. Social Workers for the Blind who are housed at the local Department of Social Services must follow the respective agency’s policy of a purge date and the procedures for purging records.
Social Workers for the Blind, Independent Living Rehabilitation Counselors and Orientation and Mobility Specialists are responsible for maintaining case recording for all consumers in the Independent Living Services Program for whom they have case management and/or service delivery responsibility.
Case recording entries must be made by all workers at least quarterly. A summary of several contacts made during the report quarter may be recorded in one quarterly entry, if desired. All case recording is maintained in the consumer's case record.
A. Purposes of Case Recording
1. To serve as a source of information about the consumer and the agency’s contact with him/her.
2. To identify services provided to consumer.
3. To show effectiveness of service delivery and consumer's movement toward goal achievement
4. To identify gaps in service or lack of resources in a given situation.
B. Guidelines for Case Recording
Case recording will include data on:
a. Identify type of contact, such as home visits, telephone, collateral, office visits, etc.
b. Date of contact
c. Purpose of contact
2. Case activity
a. What service(s) was provided and the eligibility verification for it? Identify service by name, not just reporting code?
b. Who provided the service(s)?
c. What progress did consumer make toward achievement of goal?
d. What was the outcome of intervention or service provision?
e. What activities will worker and consumer work on during the next 90 days?
f. Include specific service provision activities which you, the worker, have completed with the consumer and/or family members.
g. Use key words such as "trained", "taught", "arranged for", "provided", etc. Avoid such phrases as "talked with", "assisted", "showed the consumer how to", etc.
3. Changes that have taken place that will facilitate or inhibit goal achievement, such as:
a. Change(s) in consumer's needs or attitudes
b. Change(s) in family or individual functioning or potential
4. Worker's observations and conclusions based on the above factors.
5. Case Closure Summary (see sample on page 44)
a. Prepare at time of case closure. Retain in case record
b. Forward copy to each Social Worker for the Blind and Resource Specialist involved with the case
C. Closing and Transferring Cases Moving Out of County
Service cases in which the consumer is actively receiving services at the time he/she moves to a second county in North Carolina must be closed or transferred immediately after the date the consumer moves from the first county. A closing summary, such as illustrated on the following page, must be prepared.
EXAMPLE of Case Recording and Closing Summary
When consumer was referred to this agency, she had lost the ability to function independently due to her poor vision and depression. Counseling services enabled consumer to cope with the depression and anxiety which were a result of to her vision loss. This counseling helped the consumer's understanding and enabled her to develop a positive attitude about herself and to function independently in her home and community.
Independent Living skills training and adaptive equipment enabled consumer to better compensate for her visual loss. The consumer can now prepare meals, use her stove safely, clean and organize her house, thread a needle, dial the phone and identify money. Orientation and mobility training has enabled consumer to travel up and down stairs, cross streets safely and travel independently around her community.
If the consumer indicates he/she wishes to continue receiving services from the agency in the county to which he/she is moving, the Social Worker for the Blind will transfer the case record with a closing summary. One copy of the closing summary is to remain in the first county. The original is to be sent to the second county with a copy of the current eye report.
D. Service Responsibility to Out-of-County Residents
For cases in which consumers temporarily
reside in another county such as for licensed boarding home placements, rehabilitation
purposes, etc., it is the responsibility of the Social Worker for the Blind
in the county of temporary residence to contact the consumer within thirty
days; determine his/her need for services; and follow through (including
maintenance of records) as may be appropriate.
E. Interstate Correspondence on Service Cases
All request for forwarding of information to another State agency must be received in writing and must be accompanied by an appropriate release of information form signed by the consumer.
For questions or clarification on any of the policy contained in these
manuals, please contact the local district office.