WIPA Case File Management
VCU-NTC
February 9, 2011
Learning Objectives
• Review record keeping guidelines
• Review minimum components for WIPA case
files
• Review confidentiality and disclosure concerns
• Review guidelines for writing case notes
Record Keeping Guidelines in the WIPA
program
• Record keeping in the WIPA program refers to
more than just the management of the beneficiary
case file
• Record keeping in the WIPA program entails
knowledge of proper procedural and
documentation requirements
– This is especially important when working with
representative payees or other stakeholders
Record Keeping Guidelines in the WIPA
program
• Confidentiality in the WIPA program
– If WIPA is housed in a larger agency, case files are
separate from all other agency records and are only
accessible by CWICs
– Access to locked files is limited to certified WIPA
staff who have completed the federal security
clearance required by SSA
– Should generally NOT include forms or information
related to other services the beneficiary has, or is
receiving from the same provider agency under a
different program
Record Keeping Guidelines in the WIPA
program
• Confidentiality Requirements (continued)
– All beneficiary information is confidential and is not
to be shared without explicit consent from the
beneficiary using signed releases of information
– Files must be kept under lock and key unless in the
CWIC’s physical possession; this includes keeping
files in locked cases while traveling
– When working from home, files must NOT be visible
to others in the household
– Computers should have the best of security features
including password protections
Case File Components
• Case files should be consistent throughout the
WIPA project!
• Any eligible individual served by the WIPA project
should have a case file
– This includes beneficiaries who receive only I&R
services
Case File Components
1. Intake sheet
2. Case notes
3. Release of information forms
4. Correspondence used to verify ALL benefits (BPQY and
any verification about other benefits received)
5. Verification that the beneficiary understands WIPA
project policies and procedures
6. Copies of BS&As, WIPs, etc.
7. Copies of correspondence to and from other agencies
8. Copies of work incentives information
9. Cover sheet
Case File Components
1. Intake sheet
– Should include contact information and
demographic data
– No required form, but should include all the
information SSA requires per the WIPA RFA
– Tip: you can enter intake data directly into ETO
and print out the completed form to include as
the intake for the case file
Case File Components
2. Case notes
- Case notes should describe services rendered,
issues discussed, actions taken
- Address how you assisted the beneficiary
and/or the beneficiary’s family in the access and
coordination of benefits
- Take note of any goals that were addressed
- Case notes should appear in chronological order
- Case notes should include any other clinically
relevant information
- Case notes should be dated and signed
Case File Components
3. Copies of Release of Information Forms used to access
benefits information from SSA or other federal, state, or
local agencies
- You MUST use the form SSA-3288 to access
information about a beneficiary from the SSA
- Other release of Information forms used by the
agency must always indicate what information is
being sought, be signed by the beneficiary and
have an expiration date
- For a list of all required components, see the
following POMS:
https://secure.ssa.gov/apps10/poms.nsf/lnx/020330500
1!opendocument#b2
Case File Components
4. Copies of Benefits Planning Queries (BPQYs), statement of
benefits, and any correspondence verifying public
benefits, food stamps, housing subsidies, TANF, Veterans
benefits, Unemployment Insurance, Worker’s
Compensation or any other public disability benefit current
benefits status, payment amounts, or work incentives used
- Release of Information must be on file for each item
- Verification of Medicaid (i.e. Medicaid waivers,
spenddown, 1619(b) etc.)
- Verification of Medicare Savings Programs (i.e. QMB,
SLMB); verification of Part D LIS
Case File Components
5. Verification that the beneficiary has read and understands the
WIPA project policies and procedures
- Could consist of a signature sheet signed by the
beneficiary, or the legal guardian and the CWIC
- Minimally, these policies should cover the following:
- Scope of services to be provided (including limitations)
- Beneficiary responsibilities
- WIPA service eligibility criteria
- Confidentiality policy
- Grievance/complaint procedure, or appeals process
(including information on the PABSS program)
- Any other beneficiary rights or disclaimers
Case File Components
6. Copies of any Benefits Summaries and Analyses (BSA)
reports, Work Incentives Plan (WIP) and summaries of
other advisement provided or related correspondence
- Includes SSI calculation sheets and Title II disability
benefits charts or timelines
- Monthly Budget/expenses
- Monthly Hours worksheet
- Earnings Record Grid
- Referral Forms
- Closure Summary (if applicable)
Case File Components
7. Copies of any correspondence to and from other
agencies
- Letters to SSA or state Medicaid Department
8. Copies of work incentives information
- PASS/IRWE/BWE documentation
- Copies of pay stubs
- SSA correspondence (i.e. Notice of change in
benefits)
Case Files Components
9. Cover sheet
- use a checklist of included above items as a face
sheet in files, to quickly assess any missing
information that needs to be included, and to allow
an efficient review of the case file.
Case File Components
• Optional Components
– Surveys
– Grievance and response forms (if applicable)
– Miscellaneous
•Fact sheets
•List of information sent to client
•ETO issues
Case File Components
• What WIPA case files should NOT include
– No diagnostic, medical, or disability information,
unless it is directly related to the WIPA services
provided
– No forms or information related to other
services the beneficiary has or is receiving from
the same provider agency under a different
program
– Value judgments or opinions
Case File Quality Review
• Do case notes document “just the facts” of services
provided?
• Are items identified in the initial intake form and on the
BPQY covered in the BSA?
• Are the recommendations in the BSA appropriate to the
stated goal?
• Does the information in the BSA flow in a logical manner?
• Are appropriate calculation charts included?
• Does the WIP reflect appropriate action steps as identified
in the BSA?
Case File Quality Review
• Is there any missing information in either the BSA or
the WIP?
• Are appropriate updates to the BSA and WIP
included?
• Are all earnings reports and work incentives
documentation current?
• Is the file information presented in a clear and
organized manner so that another CWIC could step
in if necessary?
• Are contacts with SSA and other relevant agencies
noted and tracked?
SSA case file reviews
• To ensure proper data is maintained, SSA will review case files for
the following components:
– Initial Intake
– Releases of Information
– BPQY
– Benefit Summary & Analysis
– Work Incentive Plan
– Contact Log
– Wage Reports (if applicable)
– Referral forms (if applicable)
– Quality and Completeness
– Other (as needed)
• They will also ensure that benefits were verified as needed
Confidentiality and Disclosure
• When do I ask about a beneficiary’s disability?
• What can I ask about a beneficiary’s disability?
• What if the beneficiary does not disclose that he or she has
a disability?
• Right to privacy is also known as confidentiality
• Respect the beneficiary’s right to control personal
information and have access to it
• Ask yourself: Why do I need to know? Is the disability
relevant to the beneficiary’s employment goal?
Case Notes
• Case notes are a narrative description of activity
conducted for, with, about, or on behalf of a
beneficiary
• Case notes are a required component of WIPA project
record keeping!
• Case notes are relevant to the development of the
WIP and should always support the beneficiary’s
employment plan
Case Notes
• Purpose of case notes
– Provide a chronological description of services rendered to
help CWIC stay organized
– Document services rendered and progress made to
funding and regulatory agencies
– Allow multiple professionals working with the beneficiary
to stay informed and up to date
– Provide a historical record to insure continuity of services
during staffing changes
– Provide a way for project managers to assess quality of
services
– Serve as a legal document if a case record is subpoenaed
Case Notes
• Case Notes Dos
– Do describe services rendered and results achieved
– Do record progress (or lack thereof)
– Be clear, concise and accurate
– Use direct quotes (when appropriate)
– Write notes for each contact
– D.A.T.E. : Do At Time of Event
– Sign and Date every entry (signatures must be
original)
– For mistakes, cross out with a single line and initial
Case Notes
• Case Notes Dos (cont’d)
– Be sure to substantiate conclusions and
inferences
– Be sure to link case notes to services related to
the beneficiary's employment or work incentive
activities
– Describe observations and behaviors relevant to
the beneficiary’s goal and work incentive plan
– Be detailed enough to convey necessary
information
Case Notes
• Case Notes Don’ts
– Don’t make value judgments, assumptions, or
guesses
– No blank spaces, white out, or scribbles
– No one else can write your case notes for you!
– Avoid stereotypes, opinions, and diagnoses
Case Notes – Respectful Language
• Poor: Mr. Jones is a 33 year old handicapped male. He is
looking for work, but only has one arm. He says he lost
it in a motorcycle accident 10 years ago. He has a false
arm that he uses when he works.
• Sometimes we think using Mr. or Mrs. will make all the
difference in what we write. Rather, it is the language
we choose that is important.
• How might you change the above paragraph, using
respectful language?
Case Notes – Respectful Language
• Good: Dennis is a dislocated worker who requests
assistance in finding work. He stated that he has five
years experience as a shipping and receiving clerk. He
would like to continue the same type of work and
needs a minor accommodation in order to operate a
computer.
• How does this version differ from the previous one?
Case Notes – Non-judgmental Language
• Poor: Jane looks and smells as though she has not
bathed in days. She just sat there when I asked
questions about her work history. She could be
slow or just lazy.
• How might you change this paragraph to make it
more appropriate and non-judgmental?
Case Notes – Non-judgmental Language
• Good: Jane appears to have poor hygiene.
Additionally, she did not make eye contact, nor
would she respond to questions.
• How does this statement differ from the previous
one?
Case Notes – Clear Description
• Poor: Andrea seemed to be distracted and
obviously nervous.
• Watch for the use of non-specific and misleading
words. Give a description. Show, instead of tell.
Use the word “appear” instead of “seems”.
• How would you change the above statement to
make it clearer?
Case Notes – Clear Description
• Good: Joan was shifting in her seat and chipped at
her nail polish during the meeting.
• How does this statement differ from the previous
one?
Appropriate Language
Words to avoid
Acceptable alternatives
Abnormal, subnormal
Specify the disability
Afflicted with
Birth defect, congenital
defect, deformity
Individual has
Individual with a disability
since birth, individual with a
congenital disability
The blind, the visually
impaired
Individual who is blind,
individual with a vision
impairment
Confined to a wheelchair
Uses a wheelchair
Appropriate Language
Words to Avoid
Acceptable alternatives
Cripple, crippled
Has a physical disability, has
a mobile disability
Hearing Impaired
Individual is deaf, the Deaf
Defective, deformed
Specify the disability
Dwarf
Individual of short-stature
Epileptic
Individual with epilepsy
Attack, spell, fit
Seizure
Insane, manic, lunatic
Individual with a psychiatric
disability
Appropriate Language (cont’d)
Words to Avoid
Mentally retarded
Acceptable alternatives
Suffers from
Victim
Individual with an
intellectual disability
Individual with a disability
Has a disability
Able-bodied
Despite disability
Challenged
Non-disabled
Because of ability
Don’t Use
Final Comments
• Case File Management is a key component of any
quality assurance process!
• Project Managers should use a case file checklist to
complete the case file reviews
Questions?