Rehabilitation Counselor Training (COAST) Exam 1 Part 2

Referral and Application Process: Identification and Verification

Social Security Card, Driver's License, NC ID, REAL ID, Birth Certificate

Functional Capacity Areas and Definitions: WORK TOLERANCE

Ability to sustain the required level of work function.

Eligibility for IL

- With a Significant Disability (SD or Higher) -Whose Ability to function independently in the home or community, or whose ability to maintain employment is substantially limited -Who shall be an active Participant in his/her own IL Rehab Program, involved in making meaningful and informed choices about IL goals and objectives -Who shall be a full partner and share joint responsibility for planning and implementing his/her IL rehabilitation program AND For whom delivery of IL Services will: Improve or maintain the ability to maximize their independence in the home or community, or Enable employment, OR enable transition to VR.

VR Status Codes

00 Referral 02 Applicant 04 Pre-service listing (to be used only when the Division has implemented the Order of Selection policy) 06 Trial Work 08 Outcome from case status code 00 or 02 10 Eligible for services - IPE development 12 IPE developed and signed 18 IPE Implemented 20 Ready for Employment 22 Placed in Employment 26 Successful outcome 28 Unsuccessful outcome after services on IPE are initiated 30 Unsuccessful outcome after eligibility determination but prior to service initiation 32 Post employment services 34 Closed from Post Employment 38 Outcome from case status code 04 (to be used only when the Division has implemented the Order of Selection Policy)

Establishing Chronicity for Physical Impairements

1. Chronic Impairments - Chronic generally refers to an impairment that has a long or indefinite duration, and is marked by frequent recurrences. There are, however, impairments which have a rapid onset, but by their nature, are chronic from the outset or early stage. These types of rapid onset impairments are covered under #3 below. Other chronic impairments have a gradual or insidious onset such as multiple sclerosis. In these situations, whether an individual has an impairment with substantial impediments to employment and/or whether the individual requires a program of Division services could be determined once the chronic nature of the impairment becomes evident. However, counselors must keep in mind that some chronic diagnoses, in the early stages, do not present substantial impediments or functional loss in the individual, so in these instances eligibility cannot be established. The existence of substantial impediments to employment may not be an issue until later stages of the disease. The medical data and the case history should provide the documentation of the chronic impairment, its current status and resulting substantial impediments. Examples of chronic impairments could include: A. Multiple Sclerosis B. Crohn's Disease C. Coronary Artery Disease D. Degenerative Joint Disease E. Hemophilia F. HIV Disease G. Cerebral Palsy In terms of the age of the medical data for determining VR eligibility, this depends upon the nature of the impairment in question. For example, HIV disease tends to be unstable with exacerbations and remissions - recent medical data would be needed to determine the current status of the diagnosis. However, cerebral palsy tends to be a stable, unchanging condition with a relatively fixed set of impediments, so older medical data may actually suffice for establishing the impairment, impediments and other components of VR eligibility. 2. Acute or Temporary Medical Conditions/Injuries which Become Chronic - To a certain degree, depending upon the diagnosis, the timeframe varies for an impairment transitioning from acute to chronic. Although most of the types of diagnoses covered above under temporary/acute conditions would not become chronic, some could progress into chronic impairments and present to VR as such. Examples could include: A. Back or knee impairments presenting functional loss that have been medically documented for extended periods of time. B. Fractured bone resulting in nonunion. (This impairment is defined to have occurred if the fracture site has failed to heal by six to nine months.) Often, the question of whether an acute or temporary condition has progressed to becoming chronic with substantial impediments cannot be answered until the individual has undergone the initial set of medical interventions and had time to go beyond the acute phase in terms of recovery and healing (keeping in mind that physical therapy and other ancillary services are sometimes a part of the initial/acute interventions following surgery). However, if a diagnosis of an acute condition is documented by medical data and remains unresolved after 9 months it may be considered chronic. There may or may not have been optimal treatment interventions. The rehabilitation counselor must also establish from the medical data that the chronic impairment is presenting substantial impediments to employment. In exceptional situations, with counselor discretion, this determination may be made as early as six months from the initiation of medical intervention if the medical data definitively shows the existence of a chronic impairment. If the individual meets the other components of the VR eligibility criteria, then overall eligibility for the program may be considered. The analysis of the medical data by the counselor is of critical importance in making the determination of eligibility based upon a physical impairment. 3. Injuries or Rapid Onset Impairments which have a High Probability of Becoming Chronic - Some injuries or impairments, from the early stages, carry a high probability of becoming chronic, notwithstanding the acute level interventions that are initiated. In such cases, the distinctions between stable and unstable, acute and chronic may be unclear or academic. Also, the standards of six or nine months as indicators of chronic impairment (and stated above under number "2") may not be applicable in these cases. There may also be a high probability of substantial impediments to employment resulting from the likelihood of chronic impairment. In these circumstances, though the Division still could not sponsor emergency interventions, counselor judgment is essential in determining on an individual case basis, at what point during the recovery process a chronic impairment with substantial impediments becomes apparent and Vocational Rehabilitation services would be appropriate. Examples could be: • amputations (either traumatic or disease connected) • strokes with resulting hemi-plegia or other functional loss • diabetes • seizure disorder • reconstructive surgery • spinal cord injury • traumatic brain injury • disfigurement of one or more limbs resulting from trauma or disease • second or third degree burns Staffing with the, Quality Development Specialist and/or Unit Medical Consultant should occur whenever questions arise. ABUSE Evaluation and

Most Significant Disability

1. Who meets all aspects of the definition for significant disability BUT whose impairment seriously limits three or more functional capacities in terms of an employment outcome, AND 2. Who will require at least nine (9) or more months to complete the services on the IPE OR Will require one of the following services permanently in order to accomplish their job choice and maintain employment: • Personal assistance services • Rehabilitation Technology • Extended Services

Trial Work Experiences

A Trial Work Experience is defined as an exploration of the individual's abilities, capabilities and capacity to perform in realistic work situations. The trial work experience must be provided in the most integrated setting possible. The counselor must develop a written plan for the assessment using the VR Trial Work Plan form. Trial work experiences may include supplemental evaluations, community based assessments (CBA's), and other experiences using realistic work settings. Appropriate supports including assistive technology, job coaching, and personal assistance services necessary to accommodate the rehabilitation needs of the individual must be provided during the trial work experiences. Trial work experiences should encompass a sufficient number of work sites over a sufficient period of time to allow for an appropriate assessment and observation of the individual. If an individual cannot benefit from VR services, this decision must be supported with clear and convincing evidence gathered from the trial work experience. When a counselor questions an applicant's ability to benefit from VR services, a trial work experience for the individual must be obtained before a determination of eligibility or ineligibility is made. This does not apply to individuals who receive SSI/SSDI and are subject to Presumptive Eligibility. Presumptive eligibility includes the presumption of benefit, the presumption that an individual can benefit from VR services. The Trial Work Experience is to be carried out as part of the preliminary assessment. The VR Trial Work Plan should document the anticipated completion date of the Trial Work Experience. If the VR trial work plan is documented before the 60-day eligibility period expires and the anticipated completion date of the plan exceeds the 60-day period, an Extension of Eligibility Decision Letter is NOT needed. The signed VR trial work plan represents an agreement to delay the eligibility decision. If a VR trial work plan is being pursued but the Counselor and Client have not come to an agreement on the VR trial work plan by the 60th day, then an Extension of Eligibility Decision Letter must be completed. The counselor should render an eligibility decision upon completion of the VR Trial Work Plan. Trial work experiences may be coordinated by VR staff, or may be coordinated through Community Rehabilitation Programs. Supervisors are responsible for assisting their staff in developing resources and options for implementing this preliminary assessment function so that it is available when needed by counselors. Each trial work experience should be individualized for each applicant's unique situation. The individual should be afforded multiple opportunities to succeed. Existing Volume I policies must be followed regarding the provision of Division services, including applicability of the financial needs criteria and comparable benefits. The fact that a service(s) is being provided in a trial work experience would not alter the requirement for survey of financial needs, when applicable. Diagnostic and Assessment services are not subject to the financial needs criteria. Revised 10/1/2015

Timeliness of Eligibility Determination

A determination regarding eligibility must be made within a reasonable period of time, not to exceed sixty days from the date the individual submitted an application for services unless: 1. Exceptional and unforeseen circumstances beyond the control of the Division prevent a determination within sixty (60) days, and the Division and the individual agree to a specific extension of time. In such cases, an AGREEMENT TO EXTEND ELIGIBILITY DECISION must be completed prior to sixty (60) days from the date of application (Effective 1-1-98). The original must be sent to the individual with a copy maintained in the record of service. The exceptional and unforeseen circumstances beyond the control of the Division along with the specific and agreed upon length of the extension not to exceed 60 days must be documented. If a decision regarding eligibility is not made within the agreed upon timeline, then another AGREEMENT must be issued to the individual. If the applicant refuses to agree to extend the eligibility decision and the data is not available to make the eligibility determination, the application process should be discontinued. OR 2. The Division is exploring through TWE's the individual's abilities, capabilities, and capacity to perform in work situations including experiences in which the individual is provided appropriate supports and training.

Functional Capacity Areas and Definitions: WORK SKILLS

Ability to learn and/or perform work functions.

Functional Capacity Areas and Definitions: SELF-DIRECTION

Ability to plan and/or receive information (lack of focus, poor consequences, mental health, unable to multitask, disability related to long employment gap)

Case Service Authorizations

Case service authorizations must be issued prior to or on the effective date of the service being authorized. While it is allowable to issue a verbal authorization in times of emergency situations, written authorization must be issued within three days of the verbal authorization to cover the service. The intent is to assure the vendor and the clients are aware of the service(s) being authorized. Services not authorized should not be purchased. Any retroactive authorization exceeding seven days must be approved by the Supervisor except for required ancillary services associated with surgical procedures that are routinely authorized. All claims must be received by DVRS within 365 days of the last date of service in order to be accepted for processing and payment. Claims received after 365 days of the last date of service must be approved by the Unit Manager. Claims received after two years from the last date of service must be approved by Fiscal Services. When authorizing medical services, including durable medical equipment, comparable benefits such as private health insurance, Medicaid or Medicare must be noted, if applicable, in the section named "Less Resources." Additionally, the service description section on the authorization form can be used to provide further instructions to the vendor regarding the use of comparable benefits. When a comparable benefit has been ruled out, is no longer available or the Chief of Policy has approved waiving the usage of the comparable benefit, written documentation to explain the action is required in the case file. Definitions: Pre-Planned Authorization: An authorization issued to a vendor for services to the client in statuses 02 and 10 prior to the development of the IPE. Planned Authorization: An authorization issued to a vendor for services to the client in statuses 06, 12, 18, 20, 22, 32 upon the development of either a Trial Work Plan or the IPE. Authorization to Client: An authorization issued directly to the client in either a pre-plan or planned status, such as for transportation funds in advance of an appointment or for allowing the client to be reimbursed by the Division.

Client Signatures

Clients are required to sign many Division forms to either affirm their participation in developing the form or that they received a particular document from the counselor. Signatures may be of the individual or, if appropriate, a parent, family member, guardian, advocate, or an authorized representative of the individual. If the individual with a disability has not yet reached the eighteenth birthday and is not a legally emancipated minor, then additional signatures must be secured. If the individual is under eighteen and has been adjudicated a ward of the State, then an adult who is involved with the individual must sign required documents. Specific requirements are noted in appropriate polices. In the electronic case management system, dating a signature for the individual signifies that the individual has signed a hard copy of the document. A signature should not be dated in the electronic case management system until the individual has signed the particular document.

Determination of Psychological/Psychiatric Impairment

Evaluation and diagnosis by the appropriate specialist is required to establish the existence of a mental, emotional, or substance abuse impairment.* Family Nurse Practitioners (FNP) and Physician's Assistants (PA) may diagnose impairments that are within the purview of the medical specialty that employs them. Appropriate specialists include: Attention Deficit Disorder** • Psychologist • Licensed Psychological Associate • Psychiatrist • Neuropsychologist • Neuropsychiatrist • Neurologist • Pediatrician Autism/Pervasive Developmental Disorder • Psychologist • Licensed Psychological Associate • Psychiatrist • Neuropsychologist • School Psychologist (w/copy of IEP Team Report) • Neurologist • Neuropsychiatrist • Pediatrician Borderline Intellectual Functioning** • Licensed Psychological Associate • Psychologist Intellectual Disability, Learning Disability** • School Psychologist (w/copy of IEP Team Report) • Psychologist • Licensed Psychological Associate Other Mental Health Disorders • Licensed Professional Counselor • Licensed Clinical Addictions Specialist • Licensed Marriage and Family Therapist • Licensed Clinical Social Worker • Licensed Psychological Associate • Psychologist • Psychiatrist • Physician associated with Treatment Facility • ABAM (American Board of Addiction Medicine) Certified Physician Substance Use Disorder** • Psychologist • Psychiatrist • Physician associated with a treatment facility • ABAM (American Board of Addiction Medicine) certified physician • Licensed Clinical Addictions Specialist • Licensed Psychological Associate • Certified Clinical Supervisor (CCS) *Division staff having any of the above credentials are prohibited from diagnosing and providing treatment to individuals served by the Division of Vocational Rehabilitation Services. For questions about secondary employment contact the Human Resources Section of NC DVR. **Refer to the corresponding entry in the appendix for further documentation requirements for establishing the impairment and impediments. If the individual falls within a target population group for publicly funded mental health services, the Counselor should use these resources for diagnostic and treatment purposes as long as access to and utilization of these services do not present substantial delays in or difficulty with accessing VR services. Diagnoses noted as being "by history" are not accepted due to lack of current impediments to employment. Diagnoses with the qualifier "in full sustained remission" should be assessed on an individual case basis and may or may not present current impediments to employment. For those individuals in school, intellectual disabilities, learning disabilities and autism spectrum disorder must be documented by obtaining a copy of the school psychological and a copy of the IEP (Individualized Education Plan) Team report. Psychological evaluations from the school systems may be used for the identification of learning disability and may be considered along with data specified in the LD policy (Appendix). School psychological evaluations may also be used for the identification of an intellectual disability provided the individual is being served by the school system as intellectually disabled as evidenced on the IEP team documentation. In situations when the school psychologist and the IEP Team do not concur regarding placement for one of these three conditions, the counselor must use the disabling condition that corresponds to the IEP team placement as evidenced on the IEP team report. Other diagnoses, such as emotional or behavioral disorders, require a valid DSM diagnosis (Diagnostic and Statistical Manual of Mental Disorders). For individuals with intellectual disabilities, it is important that diagnostic information contain comprehensive adaptive behavior test results in the three domain areas: conceptual, social, and practical. Subdomain scores from each core domain should be reported in addition to intelligence test scores to assure that the diagnosis is not only meeting DSM 5 standards, but also to assure cross-agency acceptance of VR-funded psychological evaluations for referral purposes. This is critical to prevent disruption of services such as long term support or other supportive services as funded through LME/MCOs that may be critical to the client's success. If the LME/MCO requires updated adaptive behavior testing or other updated partial/full testing in order to access long term supports it is permissible to sponsor such testing. Evaluations from other sources such as educational institutions, government agencies, or institutions such as prisons, hospitals, or mental health clinics are considered valid sources of data as long as the evaluation is performed by or under the direction of one or more of the specialists

Use of Existing Information

Existing medical documentation or other specialist data shall be used for determining eligibility and rehabilitation needs. Counselor discretion is required to determine whether existing information is relevant and sufficient to determine eligibility for services. If the existing data is not sufficient to describe the current functioning of the individual, then additional assessments must be obtained. The information must be sufficient to document the existence of a chronic physical, mental, or emotional impairment(s) for VR or in the case of IL, the information must document a significant impairment. Second opinions may be secured when a question arises regarding a diagnosis or treatment plan. In addition to medical data, counselor observations, school records, information provided by the applicant or the applicant's family, information used by the Social Security Administration, and determinations made by officials of other agencies may be used to identify impediments to employment.

Functional Capacity Areas/Impediments to Employment

Functional capacity areas are the areas of ability which are impacted by an individual's disability and are used to determine impediments to employment. The counselor must be able to specify and document how the impediments interfere with employment. There must be a direct relationship between the impairment and impediment and the individual's current employment status. While it is understood that all eligible individuals have substantial impediments to employment, there are varying degrees of impact on vocational limitations, ranging from non-serious to seriously limiting. Functional Capacity Areas are defined below along with examples of serious and non-serious impediments to employment. This list is not all-inclusive. NOTE: An IPE objective generally defines how the plan intends to address the client's rehabilitation needs. Therefore, the objectives on the IPE will be determined by the selection of functional capacity area limitations and impediments to employment. These objectives will automatically transfer from the functional capacity area limitations selected on the VR Certificate of Eligibility/Ineligibility. Additional objectives may be added. Services must be selected on the IPE that correlate with the objectives stated on the plan.

Sponsorship of Medical Diagnostic Services for Physical Impairments

Generally, the Division should not sponsor diagnostic medical evaluations of new onset impairments for purposes of determining eligibility for services. The Division will not sponsor emergency hospitalization, diagnostics or treatment needed at the time of referral relating to an acute impairment, injury or suspected impairment. The appropriate point for VR involvement is generally the rehabilitation phase of chronic impairments. However, the Division may sponsor diagnostic examinations/assessments associated with stable or slowly progressive conditions for use in eligibility determination if available existing data containing a chronic diagnosis is insufficient in establishing a current impairment with impediments, or if an updated evaluation is advisable given the nature of the impairment. Examples could include situations in which the existing data obtained by the counselor is dated and insufficient in providing a current picture of client's condition or impediments; or, in which the condition may be unstable in nature, characterized by exacerbations and remissions, and an updated assessment is advisable to address the individual's current status and to clarify current impediments to employment. An individual may present at referral with compelling indications of a chronic disabling condition even though there may be a lack of existing data. In this situation, in order to determine the existence of a disabling condition, the Supervisor may approve an exception and authorize a diagnostic specialty evaluation. The Quality Development Specialist and/or Chief of Policy and Casework Operations should be consulted whenever questions exist. The counselor's knowledge base and professional discretion are critical factors in identifying the indicators of chronic versus acute, temporary or remediable conditions.

Sponsorship of Medical Diagnostic Services for Psychological/Psychiatric Impairments

Generally, the Division should not sponsor diagnostic psychological/psychiatric evaluations of previously undocumented impairments for purposes of determining eligibility for services. When no previous assessments are available, the counselor should conduct a structured interview to determine whether there is a history of or indicators of impediments to employment and whether the individual requires a program of rehabilitation services. Diagnostic testing may be provided based on counselor judgment when there are indicators of a psychological/psychiatric impairment and no previous documentation exists. Psychological/psychiatric conditions must be chronic and current. Some individuals with mental health impairments may require evaluation by more than one specialist depending on the complexity of their impairment (e.g. a person with schizophrenia diagnosed by one of the nonmedical specialists may need referral to a psychiatrist for medical management). Counselor discretion is imperative in determining whether existing assessments are sufficient in describing the nature and severity of the individual's impairment. As always, if existing assessments are not sufficiently comprehensive to describe the individual's impairment and current functioning, additional assessments may be obtained.

Eligibility for VR: Presumption of Eligibility

If an individual has been determined, pursuant to title II or title XVI of the Social Security Act, to be a person with a disability, the individual is presumed to be eligible to receive services if the individual intends to achieve an employment outcome. These individuals are also presumed to benefit from VR services. Presumption of eligibility and presumption of benefit do not imply that the counselor should forego a thorough comprehensive assessment for individuals receiving SSI/SSDI, nor does it imply entitlement to any specific VR service. The counselor and individual presumed eligible must be able to identify an employment outcome and related rehabilitative services which are consistent with the unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice of the individual. Medical records are not required to document presumption of eligibility; however, the counselor must obtain documentation from the Social Security Administration confirming the current benefit status and nature of the award.

Determination of Impediments

Impediments are defined as the vocational deficits that result from the functional capacity limitations created by the impairment(s). Once the impairment(s) are established, the counselor must determine if and to what extent the diagnosed impairment(s) create substantial impediments in terms of an employment outcome.

Presumption of Benefit in terms of Eligibility

In making a determination regarding an individual's eligibility, there is a presumption that the individual can benefit from vocational rehabilitation services in terms of an employment outcome. Essentially, this means that the Counselor must interpret assessment data within the context of this presumption, i.e., the applicant has the capability to work as the result of the provision of vocational rehabilitation services. Should the Counselor have reason to question this presumption due to the severity of the disability, it is required that the counselor provide, to the extent necessary, appropriate assessment activities to obtain necessary additional data to demonstrate by clear and convincing evidence that the individual is incapable of benefiting in terms of an employment outcome from vocational rehabilitation services. Under no circumstances should the applicant be determined ineligible for services due to the severity of the disability without first conducting additional assessments including, when appropriate, trial work experiences with appropriate supports provided by the Division. Individuals who are presumed eligible because they receive SSI or SSDI (see subsection 4-2-1: Comprehensive Assessment and Presumption of Eligibility) are also presumed to benefit from VR services regardless of the severity of their disabling condition.

Referrals and Application Process: Timeliness of the Application Process

In order to assure that individuals with disabilities receive services in a timely and equitable manner, the Division shall initiate the application process as soon as possible for each referral. Vocational Rehabilitation must initiate contact immediately and begin the application process within no more than 21 calendar days after receiving a referral. Options for initiating the application process are as follows: • Scheduling an individual intake and counseling session in the office • Scheduling an individual intake and counseling session at the individual's residence at the time of referral • Providing a referral packet to an individual who comes to the office and requests services • A documented telephone call explaining VR services followed by mailing an application packet for the individual to return • A letter or email with an application and information packet included • Receiving parental consent on the VR Application/Agreement of Understanding for a transition-aged student followed by scheduling an intake at the office or the student's school (NOTE: The date of receipt of the signed parental consent represents the referral date. Attempts to schedule a subsequent intake appointment with the student or the student and the student's representative satisfy the 21day requirement for initiating the application process.) • Receiving guardian consent on the VR Application/Agreement of Understanding for an individual with a guardian followed by scheduling an intake at the office or other location. (NOTE: The date of receipt of the signed guardian consent represents the referral date. Attempts to schedule a subsequent intake appointment with the individual or the individual and the guardian satisfy the 21-day requirement for initiating the application process.) • A group orientation in which applications and information packets are distributed

Eligibility for VR: Eligibility Requirements (MEMORIZE THIS CARD)

In order to be eligible for vocational rehabilitation services the individual must: Be an individual with a disability. This is defined to mean: 1. the individual has a physical or mental impairment which for such individual constitutes or results in a substantial impediment to employment; 2. the individual can benefit from vocational rehabilitation services in terms of an employment outcome; AND 3. requires vocational rehabilitation services to prepare for, secure, retain, advance in or regain employment consistent with the individual's strengths, resources, priorities, concerns, abilities, capabilities, informed choice and economic self-sufficiency. Notes: a) The term "substantial impediments" should be interpreted in its broadest context and will not be limited by the specific vocational goal that is being considered. b) An extensive employment or educational history cannot be used as factors to determine an individual ineligible for services.

Referral and application process: Availability for Services

In order to become an applicant for services or continue in services, the individual must be available to participate in necessary assessments for purposes of determining eligibility, rehabilitation needs and services. When a criminal records check indicates that the individual is a fugitive from justice (i.e. criminal background check contains instructions to contact law enforcement authorities immediately), the individual will not be considered available for services. Individuals in the following circumstances may not be considered available for participation in services: 1. Have current charges with pending court dates or sentencing that would prevent the individual from participating in a program of vocational rehabilitation services (these situations must be staffed with the Supervisor) 2. Cannot/or are unwilling to attend appointments and evaluations 3. Are unwilling to participate in essential disability related treatment that will enable an individual to benefit from Division services in terms of an employment outcome As a division of North Carolina state government, Vocational Rehabilitation is required to comply with any orders on file with the NC Department of Criminal Justice for reporting individuals having outstanding warrants to the appropriate authorities.

Invoice Processing

In order to meet Federal requirements regarding authorization for services, rates of payments, and determination of comparable benefits, the Division requires the submission of an invoice for any service provided to a client that is consistent with the corresponding authorization for services. Invoices must be submitted on forms specified in this policy and found on the automated case management system along with required supportive information. Other required information includes client name, inclusive dates of service, complete description of service, vendor name, vendor address, and the counselor's approval in BEAM.

Order of Selection: Category 5

Individuals with a non-significant and permanent disability that will need multiple vocational rehabilitation services to attain a suitable employment outcome

Order of Selection: Category 4

Individuals with a significant disability (SD) that are seriously limited in one functional capacity area

Order of Selection: Category 3

Individuals with significant disabilities (SD) that are seriously limited in two functional capacity areas

Order of Selection: Category 1

Individuals with the most significant disabilities (MSD) that are seriously limited in four functional capacity areas

Order of Selection: Category 2

Individuals with the most significant disabilities (MSD) that are seriously limited in three functional capacity areas

Eligibility for VR: Determination of a Physical Impairment

Physical impairments must be diagnosed by the appropriate medical specialist and should be chronic in nature. Family Nurse Practitioners (FNP) and Physician's Assistants (PA) may diagnose impairments that are within the purview of the medical specialty that employs them (e.g. a PA in an orthopedic practice may diagnose orthopedic impairments). "Chronic" would refer to those conditions that are of long duration. "Acute" conditions are generally of short duration, of sudden onset, and should not present residual problems following treatment. If all that an individual requires is payment/sponsorship of a medical service, then the individual is not eligible for VR services. The counselor must always question whether the individual meets VR eligibility in requiring a program of VR services (meaning, are the skills, resources, and supportive counseling provided by a qualified VR counselor needed?). This does not apply to individuals who because of the nature of their disabilities require permanent equipment, rehabilitation technology, or ongoing on-the-job supports (examples - hearing aid, wheelchair, home or worksite modifications, etc.).

Referral and Application Process: Referrals

Referrals may be made by any individual, agency, professional, relative or friend; or individuals may self-refer. Once an individual states an interest in VR services, the individual must be provided with sufficient information to aid the individual's decision on further pursuit of services. This will include informing the individual that the Division conducts criminal background checks on all interested individuals including those who are minors. A criminal background check must be completed in order for the individual to be scheduled for a group orientation session or referred for VR services. In addition, the Division's confidentiality policy should be explained, including circumstances in which information will be shared with or without the client's consent. Upon completion of the referral, the individual may be scheduled for an appointment for purposes of taking a VR application. The following information will be documented at the time of the referral: • Name • Date of referral • Address • Date of birth • Telephone number • Stated impediment to employment and requested services • The date the application intake is scheduled or applicant packet mailed or given to the individual • If the application is not completed within 21 calendar days, the circumstances for delay must be documented • At least two efforts to contact the individual must be documented on the referral form if an application is not completed • Completion of Criminal Background Check Circumstances that result in a delay in the application process must be documented on a case note. The date of referral must be entered into the database. Counselors will work closely with referral sources to establish criteria for appropriate referrals. It is also the counselor's responsibility to educate the referral source that the individual must consent to a referral to VR to be considered a referral. Individuals who have been referred as a part of a large list of potential referrals will not be considered an official referral. Once the individual has been contacted by a counselor or other designated staff, and a referral has been completed, the application process must be initiated within 21 days.

Order of Selection for Services- Definitions

Successful implementation of the Order of Selection plan and the flexibility to serve the maximum number of individuals possible with existing resources is contingent upon the Counselor's accurate and fair decisions in assigning the categories. 3-7-1: Definitions The following definitions apply to the Order of Selection process: 1. Established - The Order of Selection process is established upon approval by the Rehabilitation Services Administration (RSA) of the State Plan. 2. Implemented - The Order of Selection process is implemented when a category or categories are closed (not being served) due to insufficient resources to accept all clients eligible for service. 3. Acceptance - The Division is serving the category to which the individual is assigned and the individual will receive services. An individual may be eligible and accepted for services or may be eligible and not accepted for services. Each individual who is eligible and not accepted for services will be placed on a waiting list. 4. Pre-Service List - (Waiting List) - List of eligible clients that establishes the order in which individuals will be provided services once resources are available. Clients are placed on the list after eligibility for services has been determined by their priority category and date of application.

Temporary Medical Conditions which are not eligible

Temporary conditions which are easily addressed and remedied with acute level treatment do not fall within the definition of impairment for eligibility purposes. Division funds should not be viewed and used strictly to supplant health insurance, or the lack thereof. There are medical conditions and services that many individuals face at some point in their lives that do not result in substantial impediments to employment. Examples of these types of conditions could include but are not limited to: • Appendicitis • Fractures • Recent Onset Knee Injury • Recent Onset Back Injury • Recent Onset Hernia • Recent Onset Gynecological Conditions • Lipoma • Cholecystitis (Gall Stones) • Renal Calculus (Kidney Stone)

Certificate of Eligibility/Ineligibility

The Certification of Eligibility must be completed on all individuals determined eligible for services. Completion of the form documents and substantiates that the applicant meets all eligibility criteria for the VR program and includes information regarding the SD/MSD/non-SD category and client rights. A completed form must be maintained in the case record and a copy of the Eligibility Letter must be given to the client. NOTE: It is not necessary to re-state impediments on the Written Rehabilitation Analysis Page (WRAP) that have been addressed on the Certification of Eligibility. However, if additional impediments are determined as a result of the comprehensive assessment, they should be documented on the WRAP.

Order of Selection Description

The Division Director will make a determination prior to the start of each Federal fiscal year or whenever circumstances change during the year whether to implement an Order of Selection for services. If resources are sufficient to accept all individuals determined eligible for services, the Division will not implement the Order of Selection. If resources are not sufficient to serve all individuals determined eligible, the Director will implement the Order of Selection. Individuals not accepted for services will be placed in a pre-service listing (case status code 04) by their priority category until resources become available. The counselor will provide written notification to all applicants at the time of application of (1) the existing Order of Selection and (2) that restrictions will be imposed on who may be accepted for services. At the time of eligibility determination, the counselor will assign the appropriate highest Order of Selection Category for each individual and provide written notification of the category to the individual. If due to a change in the client's circumstances it is deemed necessary to change the individual's Order of Selection Category, the counselor will notify the client in writing of the change. The client may appeal the Order of Selection category. An Order of Selection has no impact on the Division's obligation for case finding and referrals. The Division has a continuing responsibility to make the public and referral sources aware of the services it has to offer individuals with disabilities, especially those with the most significant disabilities. Furthermore, the Division shall ensure its funding arrangement for providing services, including third party arrangements and establishment grants, is consistent with the Order of Selection. Each individual who is determined to be eligible is assigned a category based on the significance of the individual's disability. Priority is placed on individuals assigned to the categories that represent the Most Significant Disabilities.

Special Conditions for Eligibility

The Division has established criteria to assist counselors in making decisions regarding the existence of an impairment that for some individuals may cause substantial impediments to employment. Service delivery staff should be very familiar with these conditions in order to assure that individuals with disabilities are evaluated consistently and fairly. The appendix contains policy entries addressing criteria the Division has established for the following impairments: Attention Deficit Disorder, Blind and Visually Impaired, Borderline Intellectual Functioning, Chronic Fatigue Syndrome, Chronic Pain, Cochlear Implants (Hearing Impairment), Dental Impairment, Hearing Disabilities, Human Immunodeficiency Virus (HIV Disease), Learning Disability, Intellectual Disability, Substance Abuse.

Referral and Application Process: Procedures to Enter Applicant Status

The Division must inform each individual of the application requirements and identify the information that must be gathered to process the application. Referral packets mailed or given to the individual to complete must minimally include the following information: • A cover letter explaining application requirements and advising the individual that their provision of existing information could assist with making a more timely eligibility determination • An application for services and related intake documents • Information regarding client rights, appeals process and CAP • Information Release Forms • An explanation of the income verification process and required documents • Requirement for a Social Security number • Parent consent on the VR Application/Agreement of Understanding if the individual is under 18 Guardian consent on the VR Application/Agreement of Understanding if the individual has a guardian The preliminary assessment begins at the time of application for Division services and terminates at the time an eligibility decision is made. An individual is officially an applicant once the application form is appropriately completed and signed by the individual and/or, as appropriate, the individual's parent, guardian, advocate, or representative. Individuals who are under age eighteen and are not legally emancipated minors or who have a guardian cannot apply for services until the counselor has received signed parental/guardian permission on the VR Application/Agreement of Understanding. If the minor applicant is referred by the school system, then the parent/guardian's signature on the VR Application/Agreement of Understanding gives consent for the student to provide intake information and participate in the initial interview with or without the parent's presence (as indicated on the form). The same is true for a guardian signature. All signatures must also be obtained on the VR Application/Agreement of Understanding in order for the student/ward to enter applicant status, The VR Application/Agreement of Understanding may be signed by the parent/guardian prior to the intake appointment. The VR Representative should sign the application on the date that the counselor collects the required intake information from the student/ward. The date of the last required signature shall be the date that the client enters applicant status. For VR purposes, the counselor must notify each applicant that an order of selection for services would be implemented if it is determined the Division has insufficient resources to serve all individuals determined eligible for services. If an applicant is not fluent in English, does not understand verbal or written information, or communicates by sign language, the VR representative must arrange for the most appropriate method of communication. Each applicant must be given a copy of the Client Assistance Program brochure. All required signatures must

Medical Consultation

The North Carolina Division of Vocational Rehabilitation Services employs a Medical Consultant/physician to provide medical consultation services to all unit offices. Consultation is often necessary to interpret, clarify, expedite, and make decisions regarding medical aspects of the case. It remains the counselor's responsibility to determine eligibility, provide/arrange for all appropriate services and set employment objectives. All counselors must have access to medical consultation to aid them in proper decision-making and to keep informed concerning current diagnostic and treatment methods. The responsibilities of the Medical Consultant are as follows: 1. Interpret medical terms and medical information on clients; 2. Clarify and explain physicians' reports in terms of client disability; 3. Assess the adequacy of medical information and advise on the need for specialist consultation or further medical evaluation; 4. Advise on nature and extent of functional impediments and improvement from proposed interventions; 5. Advise on likelihood of residual impediments after treatment; 6. Assess medical prognosis related to rehabilitation potential; 7. Provide staff education regarding disease or injury and current methods of treatment; and 8. Serve as liaison with colleagues in the medical community. Medical situations which must be staffed with the Medical Consultant include those in which: • A second opinion regarding chronic pain or chronic fatigue syndrome is considered desirable; • Differentiation of an acute versus chronic condition is difficult; • Unusual studies or treatment are involved; • Severe disabilities render an eligibility determination difficult to establish, e.g. head injury, spinal cord injury, stroke, and chronic progressive conditions such as MD and MS; • An elective hospital admission under VR sponsorship is requested when preadmission certification has been denied for a Medicaid recipient; • There is question as to the appropriate level of care or reasonable length of stay for specific procedures or conditions; • Require more than 7 days diagnostic hospitalization; or questions arise regarding inpatient -vs. - outpatient services or treatment.

Functional Capacity Areas and Definitions: INTERPERSONAL SKILLS

The ability to establish and/or maintain appropriate Interactions with others.

Functional Capacity Areas and Definitions: MOBILITY

The ability to move from place to place.

Functional Capacity Areas and Definitions: SELF-CARE

The ability to plan and/or perform daily activities

Functional Capacity Areas and Definitions: COMMUNICATION

The ability to use, give, and/or receive information.

Shelf Life

The age validity or "shelf life" of an evaluation is dependent upon the impairment and counselor discretion. For the comprehensive assessment, up to date evaluations may be needed to show the current functioning or status of the individual's impairment; however, if the evaluation is for eligibility purposes in establishing the impairment, then the following guidelines for age validity apply: 1. For individuals currently in treatment there is no age requirement on existing data as long as the treatment has been provided by one or more of the specialists listed under 3-6-5, and has been uninterrupted. This would include individuals in correctional facilities who have been in treatment for the duration of their incarceration. 2. For individuals not currently in treatment, if a condition is defined by the DSM- 5 as a cognitive disorder, psychotic disorder, or mood disorder, individuals should be reevaluated if the information is more than five years from the date of application for services. Anxiety disorders, personality disorders, and mental and emotional disorders not elsewhere classified, require a reevaluation if the report is older than two years from the date of application for services. 3. For individuals not currently in treatment, if an intellectual disability or another pervasive developmental disorder (i.e. autism) has been previously diagnosed and there has been no dramatic change in the client's environment or physical well-being, then there is no age requirement on existing data. 4. For the diagnosis of Borderline Intellectual Functioning (BIF), a psychological evaluation may be considered as current for up to five years from the date of application for services. 5. For individuals not currently in treatment, reports providing the diagnosis of Attention Deficit/Hyperactivity Disorder have a shelf life of three years from the date of application for services. 6. If a learning disability (LD) has been previously diagnosed in a secondary education setting and the individual has been served under an IEP within the past two years, a school psychological evaluation with the IEP team report may be regarded as current for up to five years from the date of application for services. Other provisions specified in the LD policy (Appendix) apply. For psychological reports providing the DSM diagnosis of learning disability, the five year shelf life also applies. 7. For individuals not currently in treatment, for purposes of the preliminary assessment, reports providing the diagnosis of substance abuse or dependence can be considered as current within one year of the date of application for services.

Requires VR services

The counselor must document why the applicant requires a program of rehabilitation services in order to reach a successful employment outcome. The specific services necessary to reach the employment outcome need not be known or documented. To affirmatively address this part of the eligibility determination, the counselor must have a thorough understanding of the applicant's impairment(s) and substantial impediments to employment. For example, an individual with an easily ameliorated impairment which can be totally resolved without residual impediments to employment would not require a program of rehabilitation services.

Significant Disability

The determination of SD/MSD/non-SD is derived from the selection and classification of the impediments to employment as either seriously or non-seriously limiting. This decision is an inherent component of the eligibility determination. Counselor judgment is essential in determining the perceived degree of difficulty presented by the individualized nature of the disability. An individual with a significant disability is a person: 1. Who has a significant physical or mental impairment that seriously limits one or more functional capacities (such as communication, interpersonal skills, mobility, self-care, self-direction, work skills, work tolerance) in terms of an employment outcome. "Seriously limits" means that the lack of functional capacity requires accommodations and/or interventions that cannot be easily achieved and that will be required permanently in order for the individual to obtain and maintain successful employment. AND 2. Who requires multiple services over an extended period of time in order to complete vocational rehabilitation; Definitions Multiple Services: Two or more different CORE services. All other services are supportive. This in no way limits the services provided to the client in the supportive category, but limits the definition of multiple services to the five (5) vocational rehabilitation core services. Multiple Services refer to the number of different core services that will be required on the IPE. Extended period of time: The individual will require at least nine (9) months to complete the services on the IPE. This does not include the standard amount of time required to complete a postsecondary training curriculum, but does include extra time required to complete the curriculum due to disability related reasons, OR 3. Will require one of the following services permanently in order to accomplish their job choice and maintain employment: Personal assistance services: Personal assistance services may include personal attendant services, interpreting services for individuals with hearing disabilities, and reader services. Rehabilitation Technology: Rehabilitation technology may include wheelchairs, prostheses, hearing aids and orthotics prescribed due to seriously limited functional capacity areas. Extended Services: Extended services are defined as ongoing support services for Supported Employment that may include natural and community support. In locations where there is no provider for Supported Employment, Extended Services may also be used to meet the extended period of time criteria for individuals who have completed Work Adjustment Job Coaching. Refer to the definition of Extended Services and ongoing support services in subsection 2-20-13 Supported Employment. AND 4. Who has one or more physical or mental impairments resulting from amputation, arthritis, autism, blindness, burn injury, cancer, cerebral palsy, cystic fibrosis, deafness, head injury, heart disease, hemiplegia, hemophilia, respiratory or pulmonary dysfunction, intellectual disability, mental illness, multiple sclerosis, muscular dystrophy, musculo-skeletal disorders, neurological disorders (including stroke and epilepsy), paraplegia, quadriplegia and other spinal cord conditions, sickle-cell anemia, specific learning disabilities, end-stage renal disease, or another disability or combination of disabilities determined, on the basis of an assessment for determining eligibility and vocational rehabilitation needs, to cause comparable substantial functional limitations. In order to be classified significantly disabled, the individual must have a disability and meet all three requirements stated above. Individuals who are receiving SSI or SSDI (with supporting verification in the case record) are considered to be significantly disabled.

Referral Process and Application Process: Procedures to Exit Applicant Status

To exit the applicant process, the individual's record of service must: 1. Be closed for reasons other than ineligibility; 2. Be closed due to ineligibility; or 3. Be determined eligible for rehabilitation services. Applicant records for VR services cannot be closed because an individual is ineligible due to the severity of the disability/unfavorable medical prognosis (reason code 02) without first exploring the capacity to perform in work situations through trial work periods. (1998 Amendments to the Rehabilitation Act of 1973; Eff. 8-7-98)

Implementation of Order of Selection

When implementing an Order of Selection, the Division shall: • Implement it on a statewide basis; • Notify all eligible individuals in writing of the priority categories and their categorical assignment. Notify all eligible individuals in writing of their right to appeal the decision; • Continue to provide all needed services to individuals who began receiving services under an IPE prior to implementing the Order of Selection; • Continue to serve individuals who are receiving services under an IPE for post employment; and • Ensure that eligible individuals who are placed on a pre-service list (case status code 04) are provided the following information and referral services: o Accurate Vocational Rehabilitation information and guidance (which may include counseling and referral for job placement) to assist them in preparing for, securing, retaining, or regaining employment; o Use of appropriate modes of communication to assist them in the referral and guidance process; o Referral to other appropriate Federal and State programs, including other components of the statewide workforce investment system best suited to address the specific employment needs of an individual with a disability; o Notice that the referral has been made to the agency carrying out the program; o Information identifying a specific point of contact within the agency to which the individual is being referred; and o Information and advice regarding the most suitable services to assist the individual to prepare for, secure, retain, or regain employment. When a restricted category is opened for services, the Division will notify individuals in that category in writing that they can now be accepted for services or that they will continue to be on the waiting list until further notice.