1



## RSA **- 911 Comments and Analysis**  **Comments received from Publication**  **of the Notice of Proposed Information Collection for the Case Service Report (RSA**  **- 911)**  **in the**  **Federal Register on**  **Monday ,**  **July 2, 2012**

**, P**  **age 39224**  A total of 26 commenters responded to the Notice of Proposed Information Collection for the Case Service Record Report (Form RSA

- 911), published in the Federal Register on July 2, 2012, including the Council of State Administrators for Vocational Rehabilitation (CSAVR), the membership organizatio n for all 80 vocational rehabilitation (VR ) agencies. These commenters provided a total of 254 comments , 56 of which addressed the burden computations in terms of estimated hours and costs to the respondents associated with the submission of the revised form. The remaining 198 comments addressed the data element s contained in the revised RSA
- 911 and described in the accompanying Instruction Manual

. 

### 1. **Burden and Cost Comments** Comment(s): All commenters suggested that RSA's estimates of burden to the resp onding VR agencies in terms of the hours of staff time and costs associated with the revised RSA

- 911 were not adequate and incomplete. Nineteen c omments specificall y stated that the burden estimates did not address the need to train counselor and other ag ency staff on inputting the new disability codes (ICD and DSM) and the other new data elements. The burden estimates did not include the hours and costs for sy stem testing, and deplo yment of modified case processing software , and modifying agency reports
. Discussion: RSA agrees that the burden estimates did not account for all areas of activity that VR agencies will engage in as a result of the introduction of the proposed revisions to the RSA
911 , including the training of counselor and other staff, the updating of existing case records, the completion of new case records and the repro gramming of c ase management and other record

k eeping s ys tems. RSA agrees with the commenters that the staff time and costs related to these necessary activities may

be s ignificant. However, as instructed b y the Office of Management and Budget, the computations of estimated burden prepared in response to Item 12 of the Supporting Statement and included in the Paperwork Reduction Statement found on the RSA

911 are to account onl y for the hours and costs to the respondents for the retrieval of data from their records and s ys tems needed for completion of the form and its submission to RSA

. These computations are not to include one

- time costs associated with the provision of training to staff regarding the revisions to the form and instructions and the updating of existing case records with the revised data elements; nor should the computations take into consideration the ongoing costs related to the development and maintenanc e of case records, as such activities are deemed to be customary

business practices. Nonetheless, RSA did include in its ori ginal computations the time required b y staff to obtain the data pertaining to the new or revised data elements, such as that relat ed to primary/secondary disabilities, increasing the burden to each VR agency from 45 hours to 81.25. In addition, based on the comments received, RSA has reconsidered its original estimate associated with the reprogramming of VR agency case management s y stems necessitated b y the revisions to the RSA

- 911 , in creasing the estimate to a total of $900,00 0 for all VR agencies (see Supporting Statement, Item 13).2

Change(s): RSA made no changes to the estimate of burden to the responding VR agencies related to the collection of data and the submission of the RSA

- 911 (Supporting Statement, Item 12); however, it revised the estimated burden associated with the reprogramming of VR agency case management s ys tems in light of the comments received (Supporting Statement, Item 13). 

### 2. **General Comments (those that**  **apply to more than one data element of the**  **RSA -**  **911) 2.1**  **Use of Decimals** Comm e nt ( s ) : E leven comments addressed the use of decimals in the proposed RSA

- 911 , recommending that RSA not require the use of decimals wherever possible

. Discussion: RSA agrees with the comment er s that decimals are not needed for the purpose of reporting data elements on the RSA

- 911
. Although more accurate hourly wage information is indicated by the use of decimal data types for “Weekly Earnings at Closure” and “Hours Worked in a Week at Closure,” it is less burdensome to the agencies to use the integer data type consistently throughout the RSA

- 911. Change(s): All data elements specified as decimal data types for the reporting of dollar amounts and the number of hours were changed to whole integer data types. **2.2 Inconsistencies in the use of blanks, asterisks, or “0”**  Comment(s): Seventeen comments identified inconsistencies in the use of blanks , asterisks, or “0” for the purpose of repo rting unknown data or that which does not pertain to the individual

. One comment suggested that asterisks be used to show that an agency did not have the data for a particular field. Discussion: RSA agrees that there were inconsistencies in the treatment of unknown data or data that is not applicable to the individual

. Change(s): RSA identified the inconsistenc i es and is requiring that the data element s specified be left blank if data is unknown or not applicable , and is revising the instructions to so indicate. For certain data elements, the code “0” continues to be necessary in instances where it indicates a valid coding option

. Additionally , the proposed RSA
- 911 will not allow for the use of asterisk s . **2.3 Avoid reordering codes within data elements**  Comment(s): Eleven comments requested that RSA add new coding options at the end of data element s or justify

when new coding options were added in the middle of a current data element

. E xamples of data elements with new coding op tion s affected b y the change include Source of Referral , Level of Education Obtained at Application and Closure , Significant Disability , and Reason for Closure . Three comments requested that RSA arrange the codes to match the flow of the VR process.3

Discussion: RSA agrees with the comment er s regarding the programming difficulties caused b y reordering coding op tions

. Change(s): RSA re order ed the coding options so that any new coding options follow the order contained in the previous RSA

- 911 , except for the data elements “ Educat ion at Application and Closure ,” where coding options 0 through 4 and 7 have not changed

. Coding option 2 (Extended Employ ment) was eliminated from Emplo ym ent Status at Closure. In the Reason for Closure data element, code option 3 (Refused services or f urther services) and code option 7 (Failure to cooperate) were eliminated and combined into code option 15 (No longer interested in receiving services or further services); code option 5 (Individual in institution) was eliminated and broken out into code o ption 16 (Individual is incarcerated in a prison or jail) and code option 17 (Individual in institution other than a prison or jail). **2.4 Allow use of asterisks for new data elements and codes prior to the implementation of**  **the revised RSA -**  **911** Comment(s): E leven comments requested that an asterisk or a blank be allowed for proposed data elem e nt codes for those cases opened prior to the implementation of the revised RSA
- 911 because of the counselor time needed to retriev e required information and completion o f the current RSA
- 911. Discussion: While RSA agrees that there is an extra burden placed on the agencies in collecting new/revised data on proposed and existing data elements, it is necessary that RSA have the most up - to - date and consistent information to manage the VR program, including the conduct of its monitoring activities

. Change(s): In an effort to ease some of the burden , RSA has identified certain data elements that will not require updating for cases open prior to the implementation of th e revised RSA

- 911 , but only for new cases: Source of Referral, Significance of Disability, and Monthly Publi c Support Amount at Application. **2.5 Use of primary, secondary, and tertiary**  **indicators is confusing**  Comment(s): Nine comment s referred to the use of Primary , Secondary , and Tertiary indicators as confusing and unclear, specificall y in data elements 18, 19, and 20

– “Involvement with Other Agencies and Services at Application” and in data element codes for “Services Provided and Costs for Purchased Services

– (5

- 7 ) Services Provided as Comparable Services and Benefits.” Discussion : RSA agrees that the use of primary , secondary , and tertiary indicators is unnecessarily

complicated and that there is no significant benefit in i dentifying the order of importance for these data element. Change(s): RSA will combine data elements 18, 19, and 20

– “Involvement with Other Agencies and Services at Application” into one data element. Likewise, RSA will combine “Services Provided and Costs for Purchased Ser vices

– (5

- 7) Services Provided as Comparable4

Services and Benefits , ” providing the opportunity to identify as man y as three agencies from which the individual was activel y receiving services or funds at application, or to identify as many as three compara

ble benefit service providers without attaching an order of importance or economic significance. **2.6 Services**  **- General**  Comment(s): One commenter suggested that an y examples included in the RSA

- 911 instructions to provide guidance to VR agencies be removed if the examples are not in the Rehabilitation Act of 1973, as amended (the Act) or its implementing regulations. Discussion : The services or products listed or referenced in the Act and its implementing regulations are not intended to be all

- inclusive of al l services or products that can be provided to individuals. Specifically , 34 CFR 361.48(t) includes the provision of, “other goods and services determined necessary

for the individual with a disability to achieve an employ

ment outcome.” The RSA

- 911 instr

uctions include examples to provide clarification to VR agencies for the purposes of coding services and goods under the appropriate category for consistency . Most of the examples of services and goods included in the RSA

- 911 instructions have been taken directly from the f

ederal regulations, including the definitions of “maintenance,” transportation,” and other services found at 34 CFR 361.5(b). Changes : None 

### 3. **S pecific**  **Data Element**  **Comments 3.1**  **Race** Comment(s): Three comments requested that a race cate gory be added for someone of Middle Eastern or North African de s cent, noting that these races are increasing in some states and that without the ability

to identify

the population, needs cannot be identified and a ss essed properl y. Discussion: RSA is using the OMB

- required coding used for race and ethnicity as published in the Federal Register October 30, 1997, also known as Statistical Policy Directive No. 15, Race and Ethnic Standards for Federal Statistics and Administrative Reporting. Change(s): None **3.2 Veteran Status**  Comment(s): Two commenters felt that the proposed RSA
- 911 instructions required counselors to document veteran status and that the added language attempting to define “active service” was confusing and unnecessarily complicated

. Discuss ion: RSA agrees that the language used in the proposed instructions for this data element was confusing and could lead to misinterpretation of the reporting requirement.5

Change(s): RSA remove the last sentence of the data element description contained in the instructions for the revised RSA

- 911; consequently , the language contained in the current RSA
911 instructions remains unchanged

. **3.3 Involvement with Other Agencies and Services at Application**  Comment(s): Four c omments specificall y found the langua ge “associated with” to indicate consumer Involvement with Othe r Agencies and Services at Application in the proposed RSA
911 instructions vague and unclear

. One commenter stated that an interpretation of the meaning of “association with” can vary widel y. Discussion : RSA agrees that the term “associated with” is vague and needs to be clarified. The information requested for the data element will be used to identify partner programs that provide services to consumers. Faith

- based organizations were omi tted and should be included in the list. Change(s): RSA added language to the instructions to indicate that the intention of the data element is to identify

service providers and funding sources with which individuals have active cases or from which they are receiving funds at application. **3.4 Level of Education Attained at Application**  Comment(s): Seven comments noted that a distinction should be made between “Special Education Certificate of Completion/Diploma or in Attendance” and “High School Diploma / GED” so that the status can be reported separately , rather than merged together. Discussion: RSA agrees with the comment er s that a code for the attainment of a special education certificate , as it appears in the current RSA

- 911 , should be included in the revised version

. Change(s): RSA reinstated the coding option for “ Special Education certificate of completion/diploma or in attendance

. ” **3.5 Living Arrangement at Application**  Comment(s): One commenter mentioned the possible difficulties in breaking out “ Halfway House” into three different coding options (Halfway House

– corrections,

- mental health,

- substance abuse) . The commenter explained that , from the individual ’s perspective , it may be difficult to distinguish between the three different coding options . Additionally , the commenter mentioned the distinction between the three could prove problematic in situations where an organization is serving individuals from all three ty pes of halfway

houses

. Discussion: RSA agrees with the comment er that a dding additional coding options for Halfway House may

be confusing and problematic.6

Change(s): RSA combined the three Halfway House coding options into one as is used in the current RSA
- 911. **3.6 Comm**  **ents on Primary and Secondary Disabilities (** Primary Disabi lity

– Phy sical Impairment, Primary

Disability

– Mental Impairment, Secondary Disability

– Phy sical Impairment, and Secondary Disability

– Mental Impairment) Comment(s): Fifteen comments expressed concern that VR counselors are not qualified to make a di agnosis , assign an International Classification of Disease ( ICD ) or Diagnostic and Statistical Manual of Mental Disorders ( DSM ) code, or that special licensure or certification would be required to assign ICD or DSM codes. Fourteen comments also expressed a related concern that the use of disability

codes based on the ICD and DSM formats would require purchase of medical consulting services for the purpose of assigning disability codes. Discussion: Assignment of an ICD or DSM code is not sy nonymous wi th the diagnosi s of a condition. The a ssignment of IC D codes is normally performed by

medical coders who have varying degrees of training and certification that are ty picall y not equivalent to the education and qualifications required b y the comprehensive sy stems of personnel development established by VR agencies pursuant to Section 101(a)(7) of the Rehabilitation Act and its implementing regulations at 34 CFR 361.18. The assignment of codes is based on the review of the phy sician’s diagnostic narrative and diagnostic conclusion in the medical record and is a coding, rather than the diagnostic process. Payers (insurance companies, Medicaid and Medicare, etc.) currentl y require ICD
- 9 and DSM
- IVTR codes for billing purposes. Payers will be converting to ICD
- 10 and DSM
- V soon. These codes are (or will soon be) commonly available in records from medical and psychological sources. The state VR agency should specificall y request the diagnostic codes as part of the medical records request sent to the medical provider(s). However, in circumstances where current I CD
- 10 or DSM
- V codes are not available, due to either the age of the medical records or the failure of the medical provider to include them, the VR counselors can review the diagnostic narrative and a ssign an I CD or DSM code for data collection purposes. VR counselors currentl y review the diagnostic narrative in the medical record and assign an appropriate RSA disability code based on their professional judgment and training in medical aspects of di sability . Under the new ICD/DSM based coding structure, the counselor will utilize the same level of professional judgment and training to review the diagnostic narrative in the medical record and assign suitable I CD and/or DSM codes for data collection and reporting, rather than diagnostic purposes

. **When ICD -**  **10 and DSM -**  **V codes become commonly available, the VR counselor will be able to copy the code into the 911 without having to make a judgement about the code.**  **This may make selecting the diagnostic code easier in many cases, and increase the**  **reliability of this data element. NOTE: In those instances where the medical record does not include a specific diagnosis**  **or diagnostic conclusion in the medical records, the state VR agency must obtain a**7

**diag nosis or diagnostic conclusion from a qualified provider. VR counselors are not**  **qualified to make diagnostic conclusions regarding medical o r psychiatric conditions. This**  **doe s no**  **t constitute a**  **change from current practice. If the medical records contain a**  **diagnosis by an appropriate qualified individual, the VR counselor can then use**  **professional judgement to select the appropriate code.** Change(s): None Comment(s): Nine comments expressed concern that the large number of potential IC D and DSM codes w ould require extensive coding and would require additional time for the determination of eligibility

. Discussion: Unlike the current RSA disability code list, the I CD and DSM codes utilize a classification s ys tem that makes assignment of a code much more objective and sy stematic. The structure of these two classification sy stems also allow for fast and efficient identification of a suitable code with fewer error s . The use of IC D and DSM codes also will eliminate the need for the counselor to make decis ions as to how to aggregate specific disabilities to fit within a much smaller number of available RSA codes. The I CD and DSM codes will create no additional delay in eligibility

compared to the current sy stem. In both cases, disability codes cannot be assigned absent adequate medical documentation of the presence of a disability . The attainment and review of adequate medical documentation for the purpose of determining eligibility is distinct from the process of assigning codes for the purpose of repor ting data on the RSA
- 911
. See also the first set of comments in this section. Change(s): None Comment(s): Seven comments expressed concern that the assignment of ICD/DSM codes would delay presumptive eligibility , explaining that currently presumptive eligibility can be determined based on a pay

ment stub, SSA letter, ticket to work or similar non

- medical documentation , and that I CD/DSM

- based disability coding would require additional medical records. Discussion: Currently , VR counselors may proceed with presumptive eligibility in the absence of medical records. However when this occurs, it is imperative that the medical records be obtained in a timely

manner from either the Social Security Administration or from the individual’s medical provider(s) . This information is vital to the counselor ’s understanding of an individual’s disability , limitations and capabilities and to ensure the timel y and effective development of the i ndividual ized p lan for e mploy ment (IPE) . This activity is separate from as signment of a disability code ; however , the same records required for the determination of eligibility and/or the development of the IPE can then be used for assignment of a disability code. In addition, the assignment of a disability code under the curre nt sy stem requires access to the individual’s medical records to ensure accurate code assignment. The change from RSA disability codes to ICD and DSM codes does not change the need to obtain and review medical records or the general process of assigning a code **,** nor the process of determining presumptive eligibility followed b y m edical record acquisition **.**8

Change(s): None Comment(s): Five commenters expressed concern that the use of ICD and DSM

- based disability codes reflects an older medical model of re habilitation that has since transformed into the current model , which takes into account the individual’s functional capacity , rather than limitation s, and emphasizes efficient service delivery to enable the individual to achieve employ ment
. One commenter also stated that requiring VR staff to assign an I CD code to all cases would remove the requirement to document the very information required to perform the counselor function of determining the impairment. A commenter also opined that VR counselors have been trained to be experts in determining impairment, and expressed the concern that changing these critical elements of reporting appears to circumvent the role of the counselor as set forth in the Rehabilitation Act

. Discussion: The regulations found at 34 CFR 361.42(a)(1)(i

- iii) specify that qualified personnel must make the determination that a phy sical or mental impairment is present and the impairment(s) constitute an impediment to employment. The qualified VR counselor must then determine whether the individual has significant work limitations as a result of those impairments and whether the individual requires VR services to prepare for, secure, retain or regain emplo ym ent consistent with the applicant ’s unique strengths, resources, priorities, c oncerns, abilities, capabilities, interests and informed choice. The change from RSA’s current disability codes to ICD and DSM

- based disability codes does not alter the current regulations or impact sound case practices in eligibility determination or ser

vice delivery. Change(s): None Comment(s): One commenter suggested that the use of ICD and DSM codes could be time

consuming and possibl y confusing when more than one diagnosis is present in the case file. The ultimate selection by

the counselor wil l often be a judgment call and may not capture the intent of the information being sought. Discussion: RSA acknowledges the potential for multiple diagnoses that may each present one or more impediments to employ ment to appear in the medical record of an individual served by the VR program. In these cases, qualified VR counselors should rel y on their professional training, experience and judgment to determine which of the potentially many diagnoses should be coded as primary

and secondary , in terms of the resulting work limitations and barriers to employ ment
. While the current disability codes can result in an aggregation of multiple diagnoses that reduces the need for the counselor to make such decisions, the change from the current disability

codes to IC D and DSM codes does not substantially change this role of the qualified VR counselor. Change(s): None Comment(s): T hree commenters expressed concern that the requirement to use I CD and DSM

based disability

codes is not consistent w ith the regulati ons at 34 CFR 361.5(b)(6)(ii)(B)(1 )

.9

Discussion: The regulations found at 34 CFR 361.5(b)(6)(ii)(B)(1 ) require the use of “existing information obtained for the purposes of determining the eligibility of the individual and assigning priority for an orde r of selection” , to the maximum extent possible, when conducting assessment for eligibility and rehabilitation needs. As discussed with prior comments in this section, the VR counselor must obtain sufficient medical and ps ychological information to estab lish a diagnosis made by a qualified individual. T he use of ICD and DSM

- based disability codes will not require additional medical records beyond what is already required for the determination of eligibility and the identification of service needs to be a ddressed in the IPE. Change(s): None Comment(s): Four commenters expressed concern that I CD and DSM codes are not alway s readil y available in the medical record. T en comments also expressed concern that re

- creating and collecting this data would int errupt the rehabilitation process for individuals who already have been determined eligible, would be cost prohibitive and that conversion of existing RSA disability codes to the new I CD and DSM format would be time consuming and problematic. These commenters suggested that if the disability code changes are adopted, collection of these data elements should be required onl y for cases that are opened after implementation of the proposed RSA

- 911 form

. Discussion: RSA agrees that I CD, and to a much lesse r extent DSM codes, may not be present in the medical records obtained by the VR agency . Inaddition, with the upcoming change to the ICD
- 10 and DSM

- V, agencies will , as a consequence , receive records over the next few years that may have current diagnost ic information that is coded in the older ICD

- 9 and DSM

- IV
- TR formats. Consequently , if the older codes are present, the counselor will have to determine a current ICD
- 10 or DSM
- V code. C onsistent with prior discussion of coding requirements, RSA does no t consider the assignment of IC D
- 10 or DSM
- V codes to be beyond the scope or ability of a qualified VR counselor

. Furthermore, the identification of I CD/DSM codes associated with case records open prior to the implementation of the revised RSA

- 911, or the conversion of ICD

9 and DSM

- IV
- TR codes to I CD
- 10 and DSM

- V codes, may be accomplished at any point prior to case closure, thus spreading out the burden of identifying current I CD/DSM codes over time as each open case approaches closure. Change(s): None Comment(s): T hree commenter s expressed concern that counselors selecting a code that is an approximation of the diagnosis could create an ethical dilemma and expose the agency to liability for inclusion of incorrect codes in the case service record. Di scussion : Counselors must currently collect medical and ps ychological information that includes a diagnosis or diagnostic conclusion made by appropriate qualified individuals, and then select a code from the very restrictive list of current RSA disability codes. The current process requires aggregation of the disability code which must be mapped to the far smaller list of current RSA disability

codes. The resulting presence of an aggregated disability code in the service record is more likely to convey

m isinformation to the reader of the case service record , than would an ICD or DSM code that is only partially correct. In addition, I CD codes have been10

required for billing purposes since 1996, are in common use and have the benefit of commonl y understood definitions and inclusion criteria. The use of m ore precise disability codes sharing commonality

with ICD and DSM coding s ys tems will result in more accurate identification and tracking of disability

data. Change(s): None Comment(s): Seven comments e xpressed concern that the I CD and DSM code sy stems could be updated causing additional agency expense. Discussion: The I CD
- 9 is currentl y in the process of being replaced b y the ICD

- 10 and is scheduled to occur in October 2013. Similarly , the DSM

- IV
- TR will be replaced b y the DSM

- V in May 2013. The evolution of major changes has historically been very

slow in both these coding s ys tems
. The IC D
- 9 has been in place since 1979 and the DSM

- IVwas last revised in 2000. Consequently , RSA does not envision that major changes resulting in additional agency expense will occur for the next several ye ars . M aking disability code changes at this time will allow states to make onl y a single change in the RSA

- 911 coding structure

. Inaddition, the I CD
10 is designe d to allow for future expansion without invalidating prior codes, and without disrupting the overall I CD
- 10 structure layout and alphanumeric position. Change(s): None Comment(s): Three commenters recommended expansion of the current RSA disability co des , rather than using ICD and DSM

- based disability codes. Discussion: Expanding the disability codes currently

in the RSA

- 911 would not better enable RSA to develop, maintain and share comparative data with other partner programs and agencies regarding the nature and scope of persons with disabilities served by the VR program. Change(s): None Comment(s): One commenter expressed concern regarding the granting of access to these coding s ys tems , stating that licensing information from the ICD web site indicates users must obtain written permission from the World Health Organization (WHO) to use the coding s ys tem within an application. Discussion: IC D and DSM codes are frequentl y present in the medical record obtained b y VR agencies and, if not, can be requested from the provider making the diagnosis. This may be necessary for cases already

in existence at the time of implementation of the revised RSA

- 911 , but can be accomplished at any point prior to case closure as stated in response to comments above

. However , RSA anticipates that some state agencies may desire to include the I CD
- 10 and DSM code look up sy stems within their case management s ys tems, which may be costly to develop and maintain. In the absence of a resident code look up s ys tem in the case management sy stem, ICD
- 10 code books are available at low cost and a web search will reveal free on

- line ICD
- 10 code look up s ys tems currentl y available that can be used to find a code based on the narrative diagnosis found in the medical record.11

Change(s): None Comment(s): Seven comments suggested that the time it would take counselors to use the ICD and/or DSM is very

time consuming and codes are hard to find, with the result that counselors will be spending significant time trying to find disability codes. Ten comments suggested that extensive training will be required for counselors to identify suitable ICD and DSM codes. Discussion: RSA agrees that some training to update knowledge and skills may be necessary

to implement the use of these codes. RSA does not, however, believe that the training will be any more extensive than training in medical or ps yc hological aspects of disability or in training offerings that could be made available through continuing education resources. In addition, there will likely

be online and continuing education classes available for many groups of personnel who work with these codes, as these codes are implemented in 2013. VR Counselors have had exposure to versions of the DSM, and moved from one version to the next with a reasonable amount of additional training. The IC D
- 10 uses an index format and will require minimal training for a qualified counselor to achieve the initial ability to find a suitable code

. P roficiency will rapidly

increase with regular use . Change(s): None Comment(s): One commenter stated the IC D codes do not relate to the differences between nor the potential counseling, service, and emplo ym ent needs of Deaf, Deaf

- Blind, Hard of Hearing, and Late

- Deafened populations. IC D codin g would negate identification of individual consumers as Deaf or Deaf

- Blind or Hard of Hearing or Late

- Deafened. Itwould not allow for identifying which of these sub

- populations are served, underserved, or correctly assigned to counselors with appropriat e communication skills. Discussion: RSA concurs with this observation. The I CD
- 10 contains a great deal of specificity on deafness, hearing loss, blindness and vision loss, but is not as specific regarding age of onset or Deaf

- Blind conditions , such as ushers s yndrome. Change(s): RSA added data element s for Sensory /Communicative Impairment Ty pes with the same one - digit code as in the current RSA

- 911. Comment(s): Three comments were received from agencies concerned about the conversion from one set of disability codes to the other and the need for crosswalks between old and new disability codes. One commenter pointed out the problematic nature of creating a crosswalk disaggregating the current small number of disability codes to the much larger numb er of ICD and DSM

- based disability codes. A commenter noted that it could be extremely time consuming for the end user to correct old disability codes until all current files are converted to the required ICD and DSM coding structure.12

Ten commenters sug gested that the new disability codes be used for new cases only, and one of the commenters suggested that if existing cases must be conformed to the new coding structure, RSA will need to create a crosswalk to convert old cases. The alternative is for each state to interpret the old coding structure into the new coding structure , result ing in inconsistent coding across the agencies. Discussion: RSA does not believe it is possible or practical to create a crosswalk from the current codes used in the RSA

- 911 to the I CD/DSM

- based codes, as the process would invalidate the disability

code data for both old and new cases for a period of years until the vast majority of existing cases were closed. RSA agrees that time would be required to refer to the case re cord and the medical information contained within it in order to recode the case with current ICD/DSM

- based codes. However , this recoding can be accomplished at any point prior to case closure. RSA acknowledges that there would be some burden involved in this process, but that the impact on counselor and other staff over the life of each case would be minimal. In the absence of this approach, agencies would be required to work with two separate concurrent coding s ys tems until all existing cases were clos ed, potentially creating greater expense than converting the codes in existing cases as the counselors work with or close each case. Change(s): None Following is the web address for the IC D codes: http://www.icd10data.com/I CD10CM/Index **3.7 Significant Disa**  **bility** Comment(s): Two comment s requested that RSA clearl y define “most significantly disabled , ” stating that VR agencies vary in their definitions and the data subsequentl y would not be accurate without a uniform definition used by all VR agencies. Discussion: RSA agrees with the comment s that the data obtained for “ most significantl y disabled ” will vary as a result of the differing definitions used by agencies. However, pursuant to Section 101 (a)(5) of the Rehabilitation Act and regulations at 34 CFR 361.36, VR agencies, not RSA , must establish the criteria b y which individuals are considered to be most significantl y disabled and these criteria must be based on a refinement of the elements use d in the definition of an “individual with a significant disability” found at Section 7( 21) of the Rehabilitation Act and 34 CFR 361.5(b)(31). Currently , RSA is unable to determine how many consumers in the hi ghest category

of priority

for service are ser

ved by State agencies. T he code will capture those individuals agencies classify as most significantl y disabled , while recognizing that differences exist among the individuals classified in this category

. Change(s): RSA added language to the instruction s for this data element clarifying that the code designation is based on the agency ’s definition of “most significantl y disabled.” The language now reads “Enter a one

- digit code to indicate whether the individual was considered a person with a significant disability or a most significant disability (as defined by

agency criteria) at any time during his/her VR program.”13

**3.8 Monthly Public Support Amount at Application**  Comment(s): One commenter requested clarification on the definition within the data element “ Monthly Public Support Amount at Application. ” The commenter stated that there was confusion if Social Security retirement benefits w ere included in Social Security Income (SSI) for the Aged, Blind or Disabled, or was included in Social Security Disab ility

Insurance (SSDI), and stated that it should be separated from these two. T h is comment also pertained to the coding of an individual’s primary source of support at the time of case closure. The commenter suggested removing these two categories of in dividuals from data element 38, justifying that the retirement benefits the individual receive s do not affect his or her VR program . Discussion: RSA agree s that confusion could occur if retirement benefits from the Social Security Administration (SSA) we re included as a part of monthly public support amount at application and has revised the instruction to the RSA

- 911 as shown below. Change(s): RSA deleted reference to the reporting of retirement and survivor benefits from the instructions for the RSA

- 911 and has made a similar change to the in s tructions for the reporting of “Monthly

Public Support at Closure.” **3.9 Medical Insurance at Application**  Comment(s): Eight comments requested clarification on the data elements “ Medical Insurance Coverage at Appli cation and at Closure. ” Four comments specified confusion about how to report this information for individuals who are young adults or youth receiving insurance through parents. Additionally , two comments reflected confusion over how to code individuals receiving services who are covered under a spouse. Discussion: RSA agrees that the language should be clarified to b etter explain how to code individuals covered by

their parent’s or spouse ’ s health insurance. Change(s): RSA added language in the instr uctions to the RSA

- 911 under the code 45 “Private Insurance through Other Means” to indicate that “individuals receiving benefits through their parent/famil y member’s insurance plan should use this code.” **3.10 Dates of Extended Evaluation**  **/ Trial Work Experience**  Comment(s): Five comments requested clarification on the instructions relating to the start and end dates of “Dates of Extended Evaluation. ” The instructions refer to both “Trial Work Experience” and “Extended Evaluation” within the description o f this data element. However, commenters indicated confusion in the case where an individual engaged in both Trial work experience and Extended evaluation , asking which start and end dates should be used for this field.14

One c ommenter pointed out that if an individual participated in both trial work experiences and extended evaluation sequentially , it would not be possible to capture the dates for each service since both statuses are listed together. Another c ommenter asked if reporting the end date for exten ded evaluation would be necessary since the eligibility

date, wait list date and closure date for an individual is currentl y reported on the RSA

- 911, thus making this element redundant. One commenter requested the definition for trial work experience an d extended evaluation be provided to ensure continuity across all agencies. Discussion : RSA appreciates the commenter s ’ concerns that an individual participating in a trial work experience may

require an extended evaluation. RSA will make the necessary changes to allow for the reporting of each status separately to address this concern. Pursuant to 34 CFR 361.43, a VR agency can make a determination that an individual receiving services under an IP E is ineligible for VR services. Prior to the determi nation that an individual with a disability

is incapable of benefiting from VR services in terms of an employ ment outcome due to the severity of the individual’s disability , the VR agency must conduct a trial work experience, or in limited circumstances, i f the individual cannot take advantage of a trial work experience, he or she should participate in an extended evaluation (34 CFR 361.42(e)(1) and 361.42(f)(1)). As a result of these requirements and that to obtain clear and convincing evidence prior to d etermining that an individual i s too significant ly disabled to benefit from the provision of VR services, trial work experiences can take place at any time in the rehabilitation process. Therefore, it is necessary to capture the start and end dates of both trial work experiences and extended evaluation s . T he RSA

- 911 instructions are not intended to provide the statutory or regulatory definitions of VR term s . In stead, they de fine the fields and data that must be reported. All users should reference the Act and its implementing regulations for further clarification on trial work experience and extended evaluation. Change(s): RSA modified the RSA
- 911 instructions to include trial work experiences in addition to extended evaluation. An additional report ing element was added to this section to allow VR agencies to report the start and end date for trial work experience , along with those for extended evaluation, so each element can be reported independentl y. **3.11 Supported Employment Goal**  Comment(s): One c ommenter indicated that the following language “For individuals who se employ ment goal was supported employ ment in their IPE at some point in the VR process ” was not correct because determining eligibility is part of the VR process yet supported employ ment as an emplo ym ent outcome is not necessaril y determined until the development of an IPE. Discussion : RSA agrees with the commenter that the language should be changed.15

Change(s): RSA changed the language in the instructions for the RSA

- 911 to: “For indi viduals who had an emplo ym ent goal of supported employ ment in their IPE at some point during their rehabilitation and received supported employ ment services under the plan, indicate when the supported employ

ment goal was included in the IPE.” **3.12 S**  **ervices Pro vided and Costs for Purchased Services**  Comment(s): Ten c omments expressed confusion over the language in the RSA

- 911 instructions describing the data element “Services P rovided and Costs for Purchased Services”. One commenter stated it was unclear if th e funds for purchased services included VR grant Title I only , other sources of match, or if the funds also included program income. Additionally , three comments stated that the RSA
- 911 instructions did not appear to provide for services that were purchas ed b y the state VR agencies and paid for by both the state VR agencies and a comparable benefit. One commenter requested clarification regarding the reason for tracking the use of supported employ

ment funds provided under Title VI
- B of the Rehabilitation Act separatel y. Discussion: RSA agrees that the language used under the seven categories (codes) for “ Services Provided and Costs for Purchased Servic es” was confusing. Sources of Title I funds would include state and other recipient matching funds as well as VR program income used for VR program purposes . RSA has determined to capture the use of funds provided under Title VI

- B separately to better evaluate the uses of the se supplemental funds for the provi sion of VR services to individuals with the m ost signifi cant disab ilities

. Change(s): RSA clarified the language contained in the instructions to the RSA

- 911 under “Services Provided” an d “ Costs for Purchased Services ” by deleti ng, expanding, and generally re - crafting the language used. **3.13 Services**  **Provided as Comparable Services and Benefits**

**– Primary and Secondary**  Comment(s): One commenter expressed concern that the identification of comparable benefits at the time an IPE is developed would be challenging, making reporting inaccurate. Two commenters stated if an authorization is not developed for a particular service or no pay ment is necessary , the data would not be captured thus making reporting difficult. One commenter reported if counselors calculated this data at the time of closure, it woul d be time consuming and create an unnecessary

burden for the counselors and the VR agency . Finally , a commenter stated the regulations do not define ranked levels of comparable benefits , resulting in the collection of inaccurate data. Fifteen comments express ed concern regarding the additional burden associated with the identif ication of services not funded by the VR agency , but instead through a comparable benefit or service provider

. Discussion : Section 101(a)(8) of the Rehabilitation Act and regulati ons at 34 CFR 361.53 require the utilization of comparable services and benefits prior to the provision of VR services with VR program funds, with the exceptions noted at 34 CFR 361.53(b)

. VR agencies must determine if an y comparable services or benefits e xist and are available prior to the provision of16

services, unless such determination would interrupt or delay the progress of the individual, an immediate job placement or if the individual is determined to be at extreme medical risk (361.53(a)(1)

- (3)). When developing an IPE, VR agencies are required to identify the terms and conditions needed to achieve an employ ment outcome including the responsibilities of other entities as the result of arrangements made pursuant to the comparable services or benefits (Section 10 2(b) of the Rehab ilitation Act; 34 CFR 361.46(a)(6)). An y service necessary to achieve an emplo ym ent outcome, regardless if the service is funded by the VR agency , the consumer, or one or more providers of comparable service s or benefit s , must be included on the individual’s IPE along with the source of its funding ( 34 CFR 361.46(a)(2)). Currently , all VR services identified as necessary in the individual’s IPE to achieve an employ ment outcome sh ould be reported on the RSA

- 911. The revision s to the RSA

- 911 instructions do not result in any additional burden to the VR agencies, but rather clarify the data RSA collects through the existing form. Change(s): None **3.14 Graduate College or University Training**  **and Four**  **- Year College or University**  **Tra ining**  Comment(s): Two commenter s indicated the proposed definition of Graduate College or University

Training overlaps with other definitions within the training such as Four

- Year College or University Training. The commenters stated that both training services may result in the completion of “...a certificate or other recognized educational credential.” The commenters stated that for clarification purposes RSA needs to stipulate which certificates or programs could be included under the particular traini ng service

. D iscussion: RSA agrees with the comment regarding overlap of Graduate College or University Training with a four

- Year College or University Training. Change(s): RSA revised the language describing these data elements in RSA

- 911 instructions to clarify the distinction between Graduate College or University Training and Four

- Year College or University Training, as follows: “ Full

- time or part

- time training leading to a degree recognized as being beyond a baccalaureate degree, generally recogniz ed as Master of Science, Arts (M

. S
. or M
. A
. ) , Educational Specialist (Ed.S.) or Doctor of Philosophy (Ph

. D
. ) or Doctor of Jurisprudence (J

. D
. ). Insome cases, this may be post

- graduate or post

- doctoral residencies or specialty training required to become proficient in a specialty in addition to the acquisition of a graduate degree. Such training would be provided by a college or university

. ” **3.15 On**  **- the**  **-**

**job Supports and On**  **- the**  **- job supports**  **- SE**  Comment(s): One commenter requested replacing the acronymSE wi th s upported employ ment and to change the phrase “ time

- limited ” with “ short

- term ”. Discussion: RSA agrees with the requested changes.17

Change(s): The changes were made in the RSA
- 911 instructions. **3.16 Rehabilitation Technology**  Comment(s): One commenter e xpressed concern that the current description of the term “rehabilitation technology” included in the RSA

- 911 instructions exceeds the definition found at 34 CFR 361.5(b). Specifically , the commenter believes the regulations do not consider hearing aids o r wheelchairs to be rehabilitation technology and such items may be more closel y aligned with the definition of “phy sical and mental restoration ” found at 34 CFR 361.5(b)(40)(vii). The commenter further stated it was the understanding of the agency that s uch products could be defined, at times as rehabilitation technology under the certain circumstances, but not in every case. The commenter believes listing these specific examples would lead staff to conclude the device defines rehabilitation technology , as opposed to the need to address the barriers for individuals with disabilities, and should be defined by the agency

depending upon the circumstances. Discussion : The definition included in the RSA

- 911 instructions was developed from Section 7(30) of the Act, the definition found at 34 CFR 361.5(b)(45), and the language found at 34 CFR 361.48(q). The definition of “rehabilitation t echnology” at 34 CFR 361.5(b)(45) includes the terms rehabilitation engineering, assistive technology devices and assistiv e technology services. The definitions for these terms have been incorporated into the definition for rehabilitation t echnology

found within the instructions for the RSA

- 911. RSA specifically

included the examples of hearing aids, low vision aids and wh eelchairs within the instructions to provide VR agencies clarification and consistency on this subject. As the commenter pointed out, the manner in which VR agencies report the provisions of these devices varies not only

from agency

to agency , but has bee n reported differentl y within the same agency depending upon the circumstances. RSA believes it necessary to include these particular examples to ensure agencies are reporting the provision of rehabilitation technology consistently

. RSA determined devi ces such as wheelchairs and hearing aids, although not specificall y defined under the Rehabilitation Act or its implementing regulations, are consistent with the definition for assistive technology

devices at 361.5(b)(7). A ssistive t echnology d evices are defined as an y equipment that is used to increase, maintain or improve the functional capacity of an individual with a disability . Furthermore, rehabilitation technology is defined at 361.48(q) as any technology

aid and device, including sensory devices that are used to address the barriers confronted b y individuals with disabilities. RSA believes devices such as wheelchairs and hearing aids full y meet the intent and definition of rehabilitation t echnology when examining the purpose and use of each of the se devices. Changes : None **3.17 Customized Employment Services**  Comment(s): Nine commenters requested clarification o n the new service “ c ustomized e mploy ment s ervices

. ” One commenter felt the agency ’s ability to verify the key component of18

employer negoti ation would be difficult to verify and track within its case management s ys tem. In addition, the commenter made the statement that based on the description of this service contained in the instructions to the RSA

- 911, any contact a counselor made with an employer that included “negotiation” c ould be classified as customized employ ment. Two commenters asked why an individual eligible to receive services is required to be significantl y disabled, as required b y the description in the instructions , and does this mean individuals with disabilities who are eligible for services , but not significantly disable d, cannot participate in this service. One commenter felt the definition of customized employ ment is open to interpretation and may not be consistently reported by the VR agencies

. This and another commenter stated that agencies may

find it difficult to report the provision of this service appropriately because it is similar to and appears to overlap with other services, such as “Job Placement Assistance , ” “On
the

- Job Supports , ”, “”

job placement ” and “ supported employ me nt. ” One commenter stated “ c ustomized e mploy ment ” is not a service defined in the Rehabilitation Act, or discussed in the f

ederal regulations , and, therefore , VR agencies should not be required to report the provision of this service through the RSA

- 911. Four commenters requested clarification on the difference between customized employ ment and supported employ

ment. One commenter asked if both customized employ ment and supported employ m ent services can be provided to the same individual , and if so, could supported employ ment funds be used. Discussion: Customized employ ment is a service that is currentl y provided by VR agencies and other Federal and State programs. Although component s of customized employ ment can include job placement assistance and on

- the

- job training, the service is a distinct, separate service distinguished by

negotiations with an employer to create a position for an individual with a disability that would otherwis e not be available. Negotiations with an employer, as described in the RSA

- 911 instructions, can include developing current unidentified and unmet needs of the employer and the needs of the employee; developing a set of job duties or tasks; developing a w ork schedule , including determining the hours to be worked; determining a job location; developing a job arrangement , such as job carving, job sharing, or a split schedule; or determining the specifics of supervision. These negotiations are designed to me et the needs of both the individual and the employer , resulting in a successful outcome that otherwise may not be achieved

. Since negotiation for a particular position is essential for customize employ ment, this activity must be documented , though not n ecessarily performed, by the counselor. This activity may be provided b y a community provider, another state or federal agency, or even the eligible individual. The identification of the services required b y an individual to achieve his or her emplo ym e nt goal is based on that individual’s specific disability

- related and vocational needs (Section 103(a) of the Rehabilitation Act and 34 CFR 361.48)

. In light of the comments, RSA recognizes that19

some individuals with non

- significant disabilities might req uire customized employ

ment services to address their disability and vocational needs

. Consequently , the reference to individuals with significant disabilities has been removed from the description of this service category in the instructions to the RSA

- 911 . However , in most instances, those individuals who require the specific services that comprise the category of customized employ

ment will be persons with significant disabilities. RSA disagrees with the commenter’s statement that customized employ ment is the same or similar to supported employ ment. Although supported employ ment funds, or Title VI

- b funds, may be used for this service if the individual has been determined eligible and has a supported employ ment goal identified on their IPE, supported employ ment services require ongoing support services and the identification of long

- term supports, ty picall y through a provider, to maintain employ

ment. In addition, supported employ ment services are to be provided to individuals with the most significant disabilit ies . It is possible that an individual can receive customized employ

ment and supported employ ment services, assuming the individual meets the requirements for supported employ ment pursuant to Section 7(35) of the Act and 34 CFR 361.5(b)(53). RSA recognizes that the term “ customized employment ” is not specificall y referenced in the Rehabilitation Act or its implementing regulations

. However, the Act does not specify all VR service s that can be provided to eligible individuals and permits VR agenci es to deliver other services determined necessary for the individual to achieve employ ment (Section 103(a) of the Rehabilitation Act ; 34 CFR 361.48(t)). Changes : The reference to “ individuals with significant disabilit ies ” has been removed from the de scription of the data element “customized employ ment services” contained in the RSA

- 911 Instruction Manual. **3.18 Elements summarized as Jobs, earnings, and hours at closure**  **(Number of Job/Occupations at Closure, Weekly Earnings at Closure, Hours Worked in a W**  **eek at Closure)**  Comment(s): Five comment er s expressed concern regarding the inability of VR agencies to report data on multiple jobs obtained by the individual, if he or she achieves an employ ment outcome with more than one employer at the time of case c losure , as proposed in the revised RSA
- 911 and its instructions. These commenters stated that individuals with disabilities may find it necessary

to obtain more than one employment outcome, particularly in a poor econom y . In addition, two commenters were concerned that the inability to report multiple employ ment outcomes for the same individual, along with the wages earned and hours worked in connection with them, could affect the performance of the VR agencies on standards and indicators, including Indic ator 1.5 , which measures the average hourl y wage at closure for individuals with disabilities who achieved an employ ment outcome compared to the average s tate hourly wage. Discussion: The information collected through the RSA

- 911 regarding the individual ’s employ ment outcome has been designed to be consistent with the Rehabilitation Act and its implementing regulations. VR agencies must develop an IPE designed to achieve a specific20

employ ment outcome consistent with the individual’s unique strengths, res ources, priorities, concerns, abilities, capabilities, interests, and informed choice (34 CFR 361.45(b)(2)). Prior to closing the case record for an individual who has achieved an employ ment outcome, the employ ment secured must be consistent with the goal identified on the individual’s IPE (34 CFR 361.56(a)). RSA recognizes that an individual may find it necessary

to secure emplo yment outside of the rehabilitation process for living expenses not covered b y the VR program . In addition, an individual who secures employ ment at an entry

level consistent with his or her rehabilitation goal may earn a wage not sufficient to support him or herself and may find it necessary

to accept other part - time work . As a result, the individual may be employed in a second ary job unrelated to the employ

ment goal specified on the IP E for the purpose of supplementing his or her income

. In either case, if the job is not related to the individual’s employ ment goal, as defined on the IP E, this employ

ment , along with the wages e arned and the hours worked, should not be reported. However, RSA also recognizes that the individual can obtain more than one job that is consistent with the employ

ment goal specified on the IPE and agrees that under such circumstances the VR agency shoul d report the multiple outcomes , along with the wages and hours associated with them. RSA believes an y effect the revised instructions may have on the performance of VR agencies, including that on s tandards and i ndicators, is outweighed b y ensuring that, c onsistent with VR program regulations, they report onl y emplo ym ent outcomes, including the wages earned and hours worked , that resulted from the VR services provided to assist the individual to achieve the employ ment identified on the IPE
. Change(s): R SA has modified the instructions pertaining to the reporting of employ ment outcomes, wages earned and hours worked to permit VR agencies to report data for more than one employ

ment outcome , if each is consistent with the individual’s vocational goal as doc umented on the IPE.