Client Books and Intake Procedures

The client book(s) contains important information relating to the individual in services. It fulfills
DHS/DSPD/DCFS contract requirements of program supports as well as pertinent information to
obtain interagency services, i.e., medical, food stamps, housing, employment, and social security
benefits. Client books are created and maintained for each individual in NES services regardless
of the services code and/or provider contracting the services. The client book is specific to the
type of service NES is providing. These include Residential books for both RHS and Supported
Living (SL) hourly as well as other living skills supports and Day Services books for all day
program contracted services, typically DSG, SED, or SEI.
Residential Habilitation Support is a residential service designed to assist a Person to gain
and/or maintain skills to live as independently as possible and fully participate in a community
setting of their choosing based and to avoid isolation in their homes or communities.
Supported Living provides one-to-one support, supervision, training and assistance for Persons
to live as independently as possible. This service is available to those who live alone in their own
homes, with roommates, or a spouse or for adults who live with their parents or other related
caregivers.
Day Supports provides daily and quarter hour support, supervision and training. DS provides a
safe, non-residential, community habilitation program in a structured programmatic setting, other
naturally occurring environment, or community setting where people can gather in groups during
the day to avoid becoming isolated and participate in and contribute to their community. DS also
maintains or improves a Persons job-readiness skills, work abilities, dexterity, stamina, and
other skills.
Supported Employment for an Individual provides ongoing one-to-one quarter hour and daily
supports to Persons in the Person's efforts to obtain, maintain, and advance in competitive
employment in integrated work settings.
__________________________________________________________________

DHS/DSPD Contract Requirements

The Contractor shall maintain separate records for each Person served, updated at least annually
or sooner upon a material change in the Person's circumstances.
All records are the property of DHS/DSPD and the State of Utah and shall be furnished to
DHS/DSPD within 24 hours of request. These records shall be maintained for five years from the
date of discharge.
A Persons records shall include the following information as applicable:
The Person's name, address, phone number, birth date, identification number (PID) and
Medicaid number;

name and address of sponsor or owner of facility providing services;

Support Coordinators name, address and phone number;
A photograph of the Person,
The name, address, and phone number of the Person's representative or guardian, if any;
The contact information for the Person's emergency contacts and instructions on how to
contact them;
The name and phone number of the Persons primary care physician or health care
professional, medical specialist, and medical insurance information, if any;
A copy of the Persons social history;
Documentation of behavioral or other incidents involving property damage, together with
a report by the Person's team authorizing any charges or expenses placed against the
Persons funds for reimbursement to the Contractor for property damages for which the
Person is held responsible;
The Persons current Person-Centered Support Plan (PCSP) with the Contractor's support
strategies and records documenting the implementation of those strategies (e.g., monthly
summaries, attendance records, and service records identifying the service provided, the
name of the Person providing the service, the location where services were provided and
the date and number of hours provided);
The Persons admission and termination dates and the Person's payment source
(DHS/DSPD or private);
Human Rights Committee and Behavior Peer-review Committee documentation,
guardianship/legal representation appointments, and other pertinent legal documents;
A record of all incidents and protective service investigations documented in accordance
with DHS and DHS/DSPD requirements;
A written agreement signed and dated by the Person or the Persons representative prior
to the delivery of services that identifies:
o All of the costs and fees that shall be charged by the Contractor for care and services,
including any extra costs such as personal items that may be incurred;
o The Persons obligations regarding the payment of such charges; and
o The Contractors refund policy
A statement signed by the Person and/or the Persons representative verifying that the
Contractor both explained to the Person and provided him/her with a copy of its
grievance policy and procedures.

In addition to the above information, the follow items are also required of the Contractor:
The Contractor shall maintain the Persons health information including the following:
Authorization for any emergency medical treatment needed
A record of all incidents requiring first aid and/or a referral to medical personnel or a
health care facility,
A record of all accidents or injuries.
The following is required when the PCSP provides for medical assistance:
A record of all medical and /or dental examinations performed, including assessments,
treatments, and prescribed medication(s),

A record of all surgeries, immunizations, illnesses, chronic complaints, and significant

changes in health,
A record of all medication(s) taken by the Person,
A record of all medication errors

The following is required when the PCSP provides for nutritional support:
The Contractor shall assist the Person in planning meals to meet basic nutritional
standards, special diets, food preferences, customs, and appetites.
The Contractor providing Medicaid reimbursed home and community-based waiver services
shall document all direct services provided as identified below:
The name of the Person served;
The name of the Contractor and the Contractor's staff member, who delivered the service;
The specific service provided;
The date and time the service was provided;
The amount of time spent delivering the service; and Progress notes describing the
Persons response to the service (e.g., progress or the lack of progress as documented in
the monthly summaries and/or progress notes).

DHS/DCFS Contract
Client Information Provided for Placement
Within five business days of placement, or as soon as available to the Division, the Case
Manager shall provide the Contractor with copies of essential records from the Clients
permanent file including:
Client information.
o Copy of Social Security card and birth certificate;
o DHS/DCFS Foster Placement Verification and Medical Authorization Letter;
o Current assessment information; and
o Clients criminal history if applicable.
Summary of the Clients behavior and individual treatment needs, as identified through
the Divisions assessment process.
Most recent available education records such as name and address of school most
recently attended, transcripts, and Individualized Education Program (IEP), if applicable.
Summary of prior placements/services.
Most recent available health records such as name and address of Clients health
providers, medical, dental, and vision reports, immunization records, and medications.
Most recent available mental health evaluations, psychiatric evaluations, and
psychological evaluations.
Insurance/Medicaid card.
Consent form from the Division authorizing Contractor to obtain medical/dental care for
the Client.
List of people approved to contact/visit the Client.
Upcoming scheduled appointments such as court or medical.

If the Contractor does not receive this information within five business days, the Contractor shall
contact the Case Manager. If this does not resolve the problem, the Contractor shall contact the
Case Managers supervisor for resolution.
NES shall be responsible to maintain client records, coordinate medical, school, and mental
health care with the Case Manager and parent/guardian, and facilitate family contact and
visitation with Case Manager approval and document the family visit.
__________________________________________________________________

NES Responsibility to Create, Update, and Maintain Client Books

NES Program Specialists at each NES location are primarily responsible to create, update, and
maintain client books. This responsibility may be divided between a residential program
specialist and a day services program specialist depending on the scale of services and number of
clients at the local office.
Listed below are the list of contents for both residential books and day books:

Residential Book - Consumer File Index

1. Face Sheet
2. Table of Contents Sections
3. Index
Section A - Access to Record
A-1. Log of Inspection
A-2. Consumer File Inventory Audit
Section B Personal Information
B-1. Vital Statistics
B-2.Birth Certificate
B-3. Social Security Card
B-4. Utah ID Card
B-5. Personal Inventory / Deletion of Belongings (if rep payee, place in finance book)
Section C Intake Information
C-1. Application for Services
C-2. Intake Assessment
C-3. Intake Review of NES Policies, Procedures, and Authorizations
C-4. Previous Program Discharge Information (if available)
C-5. Intake Checklist
Section D Assessments
D-1. Individuals Assessment for Supports
D-2. Independence Levels

D-3. Consumer Satisfaction Survey

D-4. Other Assessments
Section E Psychological / Professional Evaluations
Section F - DSPD/DHS/DCFS / History
F-1. DSPD Social History / Social Summary
F-2. SIS Supports Intensity Scale
F-3. ICAP Inventory for Consumer & Agency Planning
F-4. DHS/DSPD Eligibility for Services (if available)
F-5. Individuals History to be filled out only if not DSPD Funded/Private Pay
Section G - Court Documents
G-1. Guardianship Court Documents
G-2. Legal Court Documents
Section H Lease Agreement / Home Certifications
H-1. Lease Agreement
H-2. Professional Parent Certificate
Section I Social Security Correspondence
Section J Medicaid / Workforce Services Correspondence (and other community services,
i.e., Food Stamps
Section K Medicaid Cards
Section L Medicare Correspondence
Section M Person Centered Support Plan
M-1. PCSP Meeting Signature Page
M-2. Annual Review of NES Policies and Procedures
M-3. NES Support Strategies
M-4. NES Goal Data Documentation Collection (applicable form)
M-5. DSPD Service Plan / Action Plan (PCSP/ISP)
M-6. Other Interagency Information (i.e., Behavior Plan)
Section N Monthly Progress Reports PCSP
N-1. Monthly Progress Report
N-2. Charted Goal Data Documentation Collected
N-3. Daily Reports
N-4. Planned Activity Calendar
N-5. Planned Weekly Menus
N-6. Evacuation Drills
N-7. Street Safety Drills
N-8 Miscellaneous Supports

Section O Behavior Plan / Supports / Progress

O-1. Behavior Support Plan and data collection tools
O-2. Functional Assessment
O-3. Behavior Observations
O-4. Behavior Plan Peer Review
O-5. Fidelity Checklist
O-6. Behavior Plan Monthly Progress Report (MPR) file collected data with applicable month.
Section P Incident Reports - Behaviors
Section Q NES Team Clinical Reviews
Section R - Medical History
R-1. Medical Information and History
R-2. Immunization Record
R-3. Miscellaneous Medical Reports/History
Section S - Annual Medical Exams
Section T - Medical Appointments
T-1. Medical Appointments (divided by condition or doctor)
Section U Incident Reports Illness/Injury/Seizure Reports
Section V - Nurses Notes / Monthly Reports
Section W - Medication Tracking
W-1. Medication Administration Report Sheets (MARS)
W-1a. Incident Reports for Medication Errors filed behind applicable month.
W-2. Current medications side effects
Section X Lab Reports
Section Y Miscellaneous Supports / Correspondence
Y-1. Human Rights See Human Rights book for reviews, restrictions, and rights infringements
Y-2. Burial Fund Plan and/or Life Insurance Policy (if applicable)
Y-4. Miscellaneous Correspondence
Section Z Miscellaneous Financial / Employment

Day Services Book - Consumer File Index

I.
II.
III.
IV.

Face Sheet
Consumer File Index
Consumer File Audit
Log of Inspection

1. Personal Information
1.1 Vital Statistics
1.2 Birth Certificate or UTAH ID
1.3 Social Security Card
1.4 Guardians Court Documents (if applicable)
1.5 Correspondence and Other Related Information
2. Intake Information
2.1 Application for Services
2.2 Intake Assessment
2.3 Intake Review of NES Policies, Procedures, and Authorizations with signatures
2.4 Individuals Assessment for Support
2.5 Eligibility for Services (if available)
2.6 Previous Program Information (If available)
2.7 Intake Checklist
3. Incident Reports
4. Medical Information
4.1 Medical Information and History
4.2 MARS
4.3 Current Medication Side Effects (for at least medications taken during day program)
4.4 Medical Information From Other Providers
5. Assessments
5.1 Social History
5.2 Psychological Evaluation
5.3 Supports Intensity Scale-SIS
5.4 Other Assessments
5.5 Consumer Satisfaction
5.6 Program Review
6. PCSP Information
6.1 NES PCSP Meeting Signature Page
6.2 Annual Review of NES Policies
6.3 NES Support Strategies
6.4 NES Goal Data Collection Documentation Tool(s)
6.5 Service Support Plan and Action Plan
6.6 Residential Information (i.e., BSP)

7. PCSP Goal Support

7.1 Monthly Progress Report
7.2 Charted Data Collection Documentation Notes

Client Intake Process

Procedures to initiate NES required contract reviews and obtain signatures at the time an
individual enters services are the same whether an individual qualifies for residential services,
day services, or both.
The Program Specialist will print out the applicable forms, assist as needed to complete the
forms, collect all intake documents and prepare the appropriate clients book(s) for the services
the individual will be receiving from NES.
All generated NES forms may be found on the company website, www.nestraining.com.
Click on the folder titled Client Intake Packet. From this folder you may print each form
with information NES is required to complete at the time services begin.
The Application for Services and Intake Review of NES Policies must be completed when a
person enters services as the contract requires some of the information given on these forms is to
be reviewed before services begin.
The Program Specialist will review each point listed on the Application for Services and
details of NES policy given on the Intake Review of NES Policies with the individual
entering services.
The Program Specialist with then sign the forms on each applicable page and have the
client sign each blank where their signature is required.
If these forms are not completed within 30 days of initial request for NES to provide services,
NES is not in contract compliance.
Every effort must be made to obtain the clients signatures on these two forms in a timely
manner.
If the person coming into NES services indicates they have a guardian, a copy of the
guardianship court records must be obtained and placed into the client book.
If an individual coming into NES services has a guardian, it is most important to review
the Application for Services and Intake Review of NES Policies with the guardian and
obtain their signatures.
If a parent says they are their childs guardian, ask if they have been to court to obtain
guardianship for the individual. If they say they have not and the individual is 18 years
of age, the individual is considered an un-adjudicated adult. The individuals signature is
required on all NES forms. If the person claiming to be guardian provides a copy of
guardianship from the court, their signature is the most important signature on NES
documents.
If the parents have not obtained legal guardianship be respectful and even let them sign
the paperwork if its important to them. As a representative of NES you want to develop
a good relationship with the parents of the individuals we serve. Just keep in mind when
there is not a legal guardian the individuals signature must be on the NES forms.
B-5 Personal Belongings is a residential form and only used for residential services. The
Program Specialist will complete this form by listing the individuals personal property and
possessions when they enter services.

This is especially important for DCFS clients or when NES is the individuals rep payee.
As new purchases are made or items disposed of, the individuals staff or house manager
typically updates the information on this form.
This form is reviewed and both the client and NES staff reviewing the form draw a line
and sign indicating the list is correct and current at the time of the annual PCSP meeting.

The Individual Assessment can be completed by the Program Specialist from information
obtained from the last provider, support coordinator, or parents, someone who knows the
individuals need for support.
It is a general guide of the individuals abilities and desire for independence and what
type of support NES staff can expect to help him/her with.
For example, the person loves to communicate with others. This would be written in the
strengths column. However, the person needs support to not be bossy towards others or
become frustrated if others dont response as the person expected. Comments to this
effect would be written in the second column under concerns/need for support.
The Intake Assessment contains information about the individual coming into services,
important contact information, medical conditions, current medications, and other background
information that will be helpful to NES staff providing supports.
If a parent is present at the intake meeting ask them to fill out this form to enable staff to
provide needed supports.
This form may be completed by the Program Specialist from information gathered at the
intake meeting or from other information provided by the support coordinator.
Fill the applicable information into each space as completely as possible
The Intake Checklist is a list of information and forms to be collected at the time an individual
enters services with NES.
It provides a record of information obtained and information needed to help the Program
Specialist prepare the new clients book(s).
The Medical Information form is completed by a parent whenever possible. Encourage the
parent to complete the information to the best of their ability, not only to provide NES with
contract required information but to provide medical information when NES assists with medical
support or in the event of an emergency for individuals in NES services who are not supported
with their medical needs.
If a parent is not available to complete this form, or refuses to complete a medical history,
the Program Specialist may complete the form to the best of his/her ability from
information given at the intake and/or provided by the support coordinator.
One of the best reference sources to complete this form may be found in the social
snapshot or social history, required by the DHS/DSPD contract.
It must contain at minimum, the individuals primary physician and contact information,
current medical information, and as much history as you are able to gather from the
support team.
If the individual will be in residential services with NES providing medical support, you
may list the names and contact information of physicians and dentists typically used by

the NES house where the individual will be living.

The NES Social History form is completed when the individual is not funded through
DHS/DSPD/DCFS.
This form is used to comply with DHS contract requirements and is completed for private
pay individuals like those attending day services from an ICFMR.
The form is completed by the Program Specialist from information given at the intake or
information gathered from the support team.

The Vital Statistics form is completed by the Program Specialist from information obtained
during the intake process and or from the support coordinator.
This form contains personal information about the individual, when they came into
services, the type of services they are receiving, and contact information for both
emergency and non-emergency situations.
It also contains information under the Transfers within the Company section where
items like job or housing transfers could be listed that may be helpful for future planning
and supports.
Other Forms and information will be collected from either parents or the support coordinator
like a birth certificate, Utah ID, social security card, social history, psychological evaluations and
other information used to obtain services for the individual at the time of intake or within the
first 30 days of service.
If NES does not receive these items, the program specialist should contact the support
coordinator.
Although not specifically listed in the DHS/DSPD contact as a document NES is to
maintain in the file, the birth certificate and social security card are necessary for NES to
request benefits or apply to be the individuals rep payee. A copy of the social security
card and either birth certificate or Utah ID also fulfill USA requirements for individuals
who work and receive a pay check.
o Often, the day services and supported living services have a harder time obtaining
these documents. As these are not specified in the DHS/DSPD contract they are not
core items in NES books. However, its important to request these documents and
list in the clients books the efforts made to obtain copies of these records.
In addition to the above named forms, there are two other forms used for both residential and day
services books. These forms are completed as client books are created; the Face Sheet and the
Log of Inspection.
The Face Sheet contains much of the important to know information about the individual. Much
of the information listed on the face sheet fulfills DHS/DSPD contract requirements as noted at
the beginning of this section on client book expectations. The face sheet is completed from
information collected at the time of intake and the 30 day review of goals for PCSP planning
purposes.

Much of the information on the face sheet can be found on the Intake Assessment and the
PCSP.
Take a picture of the new client for the face sheet. This could be done at the intake
meeting. If you use your cell phone camera be sure to delete the clients picture from
your phone once uploaded for the face sheet to protect their privacy.

The Log of Inspection is placed in the clients book to record the names and titles of staff or
other individuals who had access to the clients information. The program specialist should enter
his/her name on the first line to begin this record as having created the file.

The Client Book(s)

The residential book uses the tabbed alphabet to index the sections of this book. Generally plan
on a three inch 3-ring binder to begin the client book however, this may be adjusted as you add
information or if the individual receives SLN where we do not provide many of the support
items.
The day program book uses the big tab dividers to index the day book. This book varies by
office, some use a 3-ring binder others use hanging files.
Follow the pattern established in the local office. Typically you need a 1-1/2 to two inch
3-ring binder if binders are used and 3-tab manila folders with handing folders and prong
fasteners if that system is used.
Go to the website, www.nestraining.com, and click on the Day Program Book or Residential
Book folder as appropriate to gather additional NES forms to create the client book.
Additional forms for the Residential Book would be the Table of Contents for section
titles, the Index, D-2 Independence Levels, D-4 Non-Verbal Communication (if
applicable), and Medication History if NES is providing medical support.
Additional forms for the Day Book would be the Index.
The Consumer Inventory and Audit forms are for use by the Program Specialist to track
what forms, if any, need to be followed up and placed into the book. It save the specialist
the time of continually going through the book to see what is missing. This form is
ideally completed when the book is updated following the annual meeting.
Collect the materials and forms needed to create the clients book then make the book.
NOTE: If a client receives both residential and day services a book shall be created for
each program area and maintained with documentation records generated within the
program.
The Program Specialist will file each of the NES intake forms, signature pages, and supporting
information obtained from DSPD, DCFS, or parents in the appropriate sections of the book as
he/she creates the client book(s).

Each NES generated form has a number in the upper right hand corner indicating where it is to
be filed in the client book. For other documents received from parents, support coordinators, and
team members, the specialist will have to refer to the index for placement into the client book.

Once the Program Specialist has completed the steps to this point the client book is created
and now ready for maintenance and updates to the file.

Update the Client Books Annually

Each individual in NES services has an annual planning meeting where successes are celebrated,
goals are discussed and any changes in the type of services provided as well as contact
information and supports is recorded.
If the individual resides in an ICFMR these are referred to as ISPs.
If the individual is DSCF the annual plan is developed with educators and is the SEP.
Following this meeting the client books are updated with any changes. Only two NES forms
must be updated and dated to the same date as the PCSP:
A new Face Sheet and Vital Statistics are printed and placed into the clients book(s).
The new PCSP report is obtained from the support coordinator after they finish completing the
report following the meeting. The Program Specialist uses the PCSP to write NES support
strategies and from the support strategies data collection sheets are created and monthly progress
reports are changed to reflect the new goals and plan dates.
Details are given in the section titled PCSP of this book to provide the Program Specialist
with the information needed to prepare for the PCSP meeting, then write NES support
strategies and other forms following the PCSP meeting.

Maintain the Client Books

The Program Specialist is responsible to collect records and maintain the client office books.
However, the local NES office may assign a Filing Specialist to assist the Program Specialist
with filing the many reports and information that comes into the office each month into the client
books.
As you review the following steps it may be personnel assigned other than the Program
Specialist but the ultimate responsibility still falls to the Program Specialist to maintain the client
books with the quality standards NES has established.
The Program Specialist shares forms and information with the house manager to maintain and
update the clients house book as well as the office books.
The Program Specialist will check the data notes and monthly progress reports each month when
ready to be filled into the books to ensure forms and reports are from the current year PCSP. If
the Program Specialist finds staff is using old forms from a previous year and NES has received

the new PCSP and new strategies have been written, the Program Specialist will communicate
with the appropriate house manager or program manager to ensure the correct goal forms are
used.
Data is collected and reports are generated each month to document services provided, progress
or non-progress on goals, and the health and safety of each individual in services. These records
are typically turned into the Program Specialist by house managers and/or program managers.
Each NES office uniquely identifies personnel work assignments and duties to be
reported to DSPD/DCFS. The monthly progress reports may be written by house
managers and turned into the Program Specialist to print report and forward to the
support coordinators or case workers. The reports may be written by the Program
Specialist and reviewed and signed off by the Director before being sent to the support
coordinator or case worker. Other staff may be assigned to write the reports that are then
reviewed and signed off by the program manager. Whatever the office personnel
assignments are the monthly progress reports together with the collected data notes are
turned into the Program Specialist for filing into the clients office book(s) when
completed.
The Specialist will file the collected reports that have been reviewed and placed into the
filing folder including monthly progress reports, data collection notes, daily reports,
menus, activity calendar, street safety and evacuation drills into section M in the
residential book. Day program reports include monthly progress reports, data collection
notes, and other employment information are filed into section 7 of the day program
book.
Other data collected reports are also turned into the Program Specialist to be filed into the
clients book(s). These records include but are not limited to medication or MARS, medical
appointments, Social Security and Medicaid/Medicare letters and information.
When the Program Specialist receives a MARS report he/she will check each medication to see
staff have initialed the appropriate boxes. If the Program Specialist finds any boxes not initialed
the MARS is returned to the house manager or program manager to research and either have the
box initialed or turn in a missed med report. See NES policy on initialing MARS reports and
what to do if a med error occurs.
If the Program Specialist files a MARS into the client box and the MARS has an uninitialed box, it is counted as a missed med and a med error. Do not let this go into the
book un-noticed.
When NES provides medication assistance, the pharmacy sends medication facts for each
prescription drug the client uses. These are filed into the residential client books in
section W behind the MARS.
If a day program client has a noon med, a copy of the drug facts need to be maintained in
section 4 Medical Information of the clients book.
If the client uses over the counter drugs you may find the drug side effects detailed online
at www.drugs.com. It will take a little effort to collect these reports but knowing side
effects and what to watch for helps staff provide a safe environment for each client.
o You may include the prescription drugs for day program clients in section 4, for the
same reason, to note possible drug reactions and side effects.

Medical Appointments are filed in the clients office book in sections S and T as applicable.
Section T is divided into symptoms or doctors to facilitate ease in finding reports.
The Program Specialist will note any follow up appointments and if the visit is not turned
in will check with the house manager to obtain a copy of the visit to maintain complete
medical records.
Correspondence, Court documents, or new assessments are filed into the appropriate sections,
residential books are sections D-L, day program books are sections 1 and 5.
Each year the program specialist will back file the previous years client records, except medical,
into clearly marked banker boxes listing the year, type of files, residential or day program, to be
stored for a year at the local NES office. At the same time, the banker boxes of files from the
prior year will be taken to a storage unit and maintained for five years.
__________________________________________________________________________
The Program Specialist plays a key role in the quality documentation supporting services
rendered by NES staff for each client. The Program Specialist works closely with Directors and
Managers to provide the quality NES expects. The Program Specialist may also be invited to
attend state audits or reviews to answer questions and provide state workers with any details on
the clients we serve.