California Department of Aging (CDA) Senior Community Service Employment Program (SCSEP) 2012

1. Successful SCSEP Case Notes California Department of Aging (CDA) Senior Community Service Employment Program (SCSEP) 2012

2. Training Objectives: • Why document? • Documentation #1 Rule • Definition of detailed case note • SCSEP case notes

3. Training Objectives: • Elements of a detailed case note • Contents • Corrections • Good case note? • Training review

4. Why Document? • Documentation is fundamental to case management, providing proof of identity, eligibility, circumstances and activities. • Documentation is comprised of official documents – • Government issued documents – Birth Certificates, Driver Licenses, Social Security Statements, Green Cards, etc. • Business Records – Paystubs, Bank Statements, Apartment Leases, etc. • Documentation also includes detail case notes.

5. Documentation#1 Rule If it is not documented, it did not happen!

6. What Does a “Detailed” Case Note Mean? It means the case note provides enough information so that a reasonable person could make a determination as to a specific event or decision.

7. A Valid Case Note Must Include: • The date on which the information was obtained; • Provide sufficient information so that a reasonable person could make a determination as to a specific event or decision; and, • The initials or signature of the person making the case note.

8. SCSEP Case Notes • Track participant activities – host agency assignment, job search, assessments, Individual Employment Plan, unsubsidized employment placement, etc. • Provide a chronological accounting of the participant and/or the SCSEP monitor’s activities. • Support data elements when official documents are unavailable.

9. Elements of a Detailed Case Note - Contents • Telephone calls • In person conversations with participant • Results of skill testing • Letters or forms presented for verification • Supportive services provided by the SCSEP project

10. Elements of a Detailed Case Note – Contents continued • Participant’s progress in Community Service Assignment and job search • Changes in Community Service Assignment • Problems or issues associated with participant’s progress in the program • Reason for termination or exit from the program

11. Documenting Telephone Calls in Case Notes: • Include the name of the person who is the source of the information; • Include the telephone number of the source of information; and, • Include the organization and title or the relationship source of information’s organization and the relationship to the participant.

12. Chronological Order • Keep case notes in chronological order • 12/12/11 – Eligibility: Confirmed John Doe’s eligibility. Reviewed participant form (PF), calculated SCSEP includable income, and copied eligibility documents provided by applicant including; drivers license, social security card, bank statements, unemployment check stubs, and apartment lease. Called John Doe, 916-222-2222, to schedule SCSEP Orientation on 12/18/11. ps • 12/18/11 – Orientation: John Doe did not show for today’s orientation. Called applicant at 916-222-2222. Mr. Doe said he forgot the orientation appointment. Rescheduled SCSEP orientation for 12/27/11. ps

13. Correcting Case Notes • If information was excluded from a case note, add an entry as soon as possible indicating it was a late entry. • Make sure you provide a reasonable explanation, date the entry, and initial or sign.

14. Correcting Case Notes If a page of case notes is not completed, draw a diagonal line under the notes and insert initials and date. PS 12/28/11

15. Correcting Case Notes Do not use correction tape or fluid!

16. Correcting Case Notes Do Not Scratch Out Wrong or Wrong: • Participant did not attend class. Right: • Participant did not attend class. PS 12-07-11 PS 12-07-11

17. Good Case Note? 12/9/11 Ms. Lewis is a very nice lady. Assigned to host agency. 12/9/12 Termination: Mr. Wilson was terminated. PS 9/27/12 Exit: Ms. Doe starts unsubsidized employment as a customer service representative at UPS, 3415 Main Street, Bishop, CA 99444 on 10/14/12. Ms. Doe’s supervisor is James Smith (906) 888-8888. PS

18. Good Case Notes? 3/15/12 Start Date: Monitor reviewed Ms.Adam’s work history and interests to develop an IEP. Ms. Adam assigned to host agency: SPCA of Yolo County, 55 Main St., Davis, CA starting on 3/17/12. She will be training as an Office Technician. Ms. Adam’s orientation is scheduled for this afternoon. Phil Carr 8/5/12 Mr. Jones changed host agency.

19. Good Case Notes? 3/9/12 Assessment: Monitor assessed Susan Lyon today. Ms. Lyon is 60 years old. She lives with her sister, Mary Johnson, whom she does not like. Monitor reviewed the eligibility requirements and listed documents Ms. Lyon must provide to determine her eligibility. Ms. Lyon and monitor completed the Participant Form. Ms. Lyon claims no income for the last 2 years. When questioned about her income, Ms. Lyon explained that she has received intermittent assistance from the Yolo County Public Assistance Office in the amount of $300 in the last 12 months. Ms. Lyon also stated she gave blood to earn money. Her sister pays the rent and supplies food. Ms. Lyon is a Medi-Cal recipient.

20. Better Case Note? 3/9/12 Eligibility - Susan Lyon completed Participant Form. Explained to Ms. Lyon SCSEP eligibility requirements and provided her a list of documents needed to determine eligibility. Ms. Lyon lives with her sister, Mary Johnson. Her sister pays the rent and supplies food. Ms. Lyon is a Medi-Cal recipient. Ms. Lyon claims no income for the last 2 years. When questioned about income, Ms. Lyon said she in the last 12 months she received $300 from the Yolo County Public Assistance Office. In addition, she gave blood to earn money. Peggy Stadler

21. Good Case Note? 3/11/11 Eligibility: Ms. Lyon submitted the following eligibility documents: • A letter from Mary Johnson stating that she pays for the rent and groceries for herself and her sister. Letter also attested Ms. Lyon has not been employed for the last 2 years. • A letter from Mr. Smith, Ms. Johnson’s landlord, attesting that Ms. Lyon has lived with her sister for the last 2 years. • Plasma Source Inc. account statement indicating Ms. Lyon gave blood on January 14, 2010 and February 6, 2011 and received $25.00 per visit. Ms. Lyon is eligible for SCSEP. Phil Carr

22. Training Review • What did we learn? • Documentation #1 Rule • If it is not documented, it didn’t happen. • What is a detail case note? • Providing enough information so that a reasonable person could make a determination as to a specific event or decision • Three things a valid case note must have: • Date • Enough information that a reasonable person could make a determination as to a specific event or decision • Signature or initials of the person making the note

23. Training Review • What did we learn from today’s training continued: • Elements of a case note • What information should be documented • Case notes should be in chronological order • Correcting case notes • No correction tape or fluid • Don’t scratch out (cross out with a single line, date, and initial) • Examples of case notes

24. Questions?

25. Thank You!