Comprehensive Review on Medical Separations and Direct Threat Assessments for Health Staff

 
Medical Separations and
Direct Threat Assessments
 
An in-depth review for Health staff  (Exhibit 5-6)
including contractors
 
0
1
 
Medical Separations
 
0
2
 
Medical Separations with
Reinstatement Rights
 
0
3
 
Direct Threat Assessments
 
AGENDA
 
Disability Accommodation as a part of Medical
Separations and Direct Threat Assessments will be
discussed in each applicable section.
 
2
 
P
u
r
p
o
s
e
 
This training provides an 
in-depth review
geared specifically to Job Corps Health and
Wellness staff and subcontractors.
Participants 
will receive a deep dive 
into
the new policies, practices, and associated
forms.
Special focus 
will be given to the revisions
of Form 2-04 Individualized Assessment of
Possible Direct Threat.
 
3
 
M
e
d
i
c
a
l
S
e
p
a
r
a
t
i
o
n
s
 
PRH Chapter 6, Section 6.2 R5
 
4
 
M
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d
i
c
a
l
 
S
e
p
a
r
a
t
i
o
n
O
v
e
r
v
i
e
w
 
When Do Medical Separations Occur?
A medical separation occurs when a student
is 
no longer able to participate 
in Job Corps
due to 
medical conditions
(including pregnancy-related conditions
,
dental conditions, substance use conditions,
or mental health conditions).
 
5
 
M
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d
i
c
a
l
 
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n
O
v
e
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w
 
(
c
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t
.
)
 
What Type of Separation Occurs First?
At the time of medical separation, the
student 
is always first separated 
as a
Medical Separation with Reinstatement
Rights (MSWR).
They may be 
reinstated
 into the Job Corps 
within
180 days
.
A 
regular medical separation 
is given only if
reinstatement following the MSWR 
does not
occur
.
 
6
 
M
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s
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a
 
L
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t
 
R
e
s
o
r
t
!
 
Medical separations must only be used
as 
a last resort
, after
 
Administrative Leave
with Pay
Personal Leave with
Pay
Other types of leave
and/or
 
Other methods of
addressing the relevant
medical concerns have
been 
tried or considered
in each individual case
and determined to be
insufficient
 
7
 
M
e
d
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c
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S
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p
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i
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n
 
Q
u
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l
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f
i
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d
 
P
r
o
v
i
d
e
r
s
 
Qualified licensed/certified health
providers 
include:
Center Physicians/Nurse
Practitioners/Physician Assistants
Center Mental Health Consultants (CMHCs)
Center Dentists
Trainee Employee Assistance Program (TEAP)
Specialists
Student’s treating provider or outside
specialist
 
8
 
Medical Separation
Considerations
 
A medical separation 
may be
considered 
when the appropriate
qualified health professional has
determined the student to have a
preexisting or acquired health
condition 
that 
requires
 treatment
beyond the basic health services
provided by Job Corps; 
AND
 
The necessary treatment is 
unavailable
or will be 
unusually costly
 to Job Corps;
AND
 
Administrative Leave with Pay, Personal
Leave with Pay, other types of leave, and
other methods of addressing relevant
medical concerns without resorting to
separation 
have been tried or
considered in each individual case 
and
determined to be insufficient
.
 
9
 
M
e
d
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c
a
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p
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t
i
o
n
C
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s
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s
 
(
c
o
n
t
.
)
 
Medical separations 
must not be used 
in lieu of 
providing
disability accommodations (i.e., reasonable accommodation,
reasonable modification in policies, practices, or procedures,
and auxiliary aids and services) including equally effective
communications for individuals with disabilities.
Disability accommodations 
must be tried or considered 
with
the goal of allowing the student to participate in the Job
Corps program 
to the maximum extent possible.
Medical separations 
must not be based on stereotypes
regarding certain disabilities or speculation regarding their
management or associated expense.
 
10
 
Medical
Separations
for Direct
Threat
 
The Health and Wellness Director 
will complete the
Center Applicant/Student File Review Form 
(which is
found in Form 2-04 Direct Threat Assessment) if the
Center’s HWD has a
reasonable belief, based on objective evidence
, that
the student has a medical condition or disability that
may pose a significant risk of substantial harm to
the health or safety of others.
Then the HWD will 
refer the student 
to a qualified health
professional who has 
current, documented expertise in
the medical condition or disability 
involved.
The 
Direct Threat Assessment 
(Form 2-04) 
must be
completed
 
in order to determine whether a medical
separation is appropriate.
 
11
 
Medical
Separations
for Health
Care Needs
 
The HWD will 
refer the student 
to a qualified health
professional who has 
current, documented expertise in
the medical condition or disability 
involved if the
Center’s HWD has a
reasonable belief, based on objective evidence
, that
the student has a medical, mental health, oral
health, and/or substance abuse treatment/
monitoring need 
that presents a significant barrier
to continued participation 
that 
cannot be
addressed 
through reasonable accommodation,
reasonable modification in policies, practices or
procedures, and auxiliary aids and services.
 
Detailed Health Care Needs Assessment training will be provided at a later date.
 
12
 
M
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d
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c
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S
e
p
a
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i
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n
 
R
e
q
u
i
r
e
m
e
n
t
s
 
Health and social service written
referrals 
must be 
provided
to medically separated students.
 
Health staff 
must approve 
all
transportation plans and if an escort
is needed.
 
Students 
must be 
followed up
monthly
 by the Health and Wellness
Director while separated.
 
Documentation 
of
 
monthly 
follow
up must be in the student health
record.
 
13
 
M
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S
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p
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D
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c
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t
a
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i
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Documentation for a medical separation in the student health
record 
must include at a minimum
:
The clinical assessment for separation, including current
symptoms/behaviors and functional impairments and a diagnostic code;
Individualized treatment instructions;
Student consent;
Referral source(s);
Transportation details, including whether an escort is needed;
Dates of separation and anticipated return to center;
Individualized student medical expectations to return; and
If the 
student is an individual with a disability
, a copy of any
accommodation plan and CIS Accommodation Plan Notes tab
documentation.
 
14
 
Sample MSWR Form
 
15
 
 Medical Separation Extensions
 
The request should be accompanied by
supporting documentation 
from the
student’s health-care provider 
verifying
that extension of leave is medically
necessary.
 
Center staff 
must submit 
a request to
the Regional Office to extend a MSWR
beyond 180 days 
for 
extenuating
circumstances
 and/or if there is a
request for disability accommodation
related to a change in the date 
of the
student’s return.
 
Documentation
 
Request Extension
 
Individualized
 
Requests will be reviewed on a 
case-by-
case 
basis.
 
16
 
D
i
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t
 
T
h
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t
A
s
s
e
s
s
m
e
n
t
s
 
PRH Chapter 2, Form 2-04
 
17
 
Legislative updates
 
to direct threat
language
 occurred in 2017 and
required modification of existing
PRH policies to ensure compliance
with Section 188 of the Workforce
Innovation and Opportunity Act,
Section 504 of the Rehabilitation Act
of 1973, and related implementing
regulations.
Direct threat to self or others is now
direct threat to 
others
.
 
Threat to
“Others”
 
18
 
D
i
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e
c
t
 
T
h
r
e
a
t
D
e
f
i
n
e
d
 
Federal disability nondiscrimination laws
define a “direct threat” as a 
significant risk
of substantial harm
 to the 
health or safety
of 
others
 that 
cannot be eliminated 
or
reduced
 by reasonable accommodation,
reasonable modification in policies,
practices, or procedures, and auxiliary aids
and services.
 
19
 
Significant Risk Qualification
 
20
 
Applicants + Students
 
Form 2-04 
was previously
for 
applicants only
.
Now the form 
has been
expanded 
to include 
both
applicants
 and 
enrolled
students
.
Applicants?
Applicants?
Enrolled
Students?
 
OR
 
21
 
D
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T
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C
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Direct threat may be considered if there is 
reasonable
belief, based on objective evidence
, that the
individual has a medical condition or disability that
may pose a significant risk of substantial harm to the
health or safety of 
others
.
Threat to self 
is no longer
 
part of the definition of
direct threat.
Direct Threat Assessments, 
Policy and Requirement
Handbook Form 2-04, 
may be considered for
applicants 
as part of the 
Applicant File Review
process and for 
students
 as part of the 
medical
separation 
process.
 
22
 
Q
u
a
l
i
f
y
i
n
g
S
t
a
n
d
a
r
d
 
Job Corps requires, as a
qualification standard,
that an applicant or
student 
not pose a
direct threat to the
health or safety of
others
, including
students and staff.
 
Like any qualification
standard, this
requirement 
must
apply to all applicants
and students, not just
to those with
disabilities
.
 
23
 
Applicant File Review Process
Records Manager 
receives
 applicant file
in CIS and 
logs
 
on AFR Tracking Log.​
The Health and Wellness Director
(HWD)
 
is the File Review Coordinator
for the center and 
completes
 
a general
review of medical and disability-related
documentation
 
and the 
“Job Corps
Health Questionnaire (ETA 653).”
 
Applicant
 and Student Processes
 
24
 
Documenting Initial Reviews
The initial review of applicant files must
be documented on the new Center
Applicant File Review Form in PRH Form
1-06 for Health Care Needs or the
Center Applicant/Student File Review
Form for Direct Threat which is included
with Form 2-04 Direct Threat
Assessment.
 
Applicant and 
Student
 Processes
 
Student Medical Separation Process
Initiated
 by Center Physician, Center Mental Health Consultant, or other appropriate
qualified health professionals (including the student’s individual treating provider).
Student has a preexisting/acquired health condition that 
requires treatment beyond
the basic health services
 provided by Job Corps and:
Treatment is 
unavailable 
or will be unusually costly to Job Corps; and
ALL leave and other methods 
have been tried or considered in each individual case and
determined to be insufficient.
If the student is an individual with a disability, the center with the student, via an interactive
disability accommodation process, has considered whether 
any disability accommodations
would address or mitigate any concerns, to allow the student to participate in the Job Corps
program to the maximum extent possible.
 
25
 
Reasonable
Belief
 
A DTA should be conducted if the
HWD has a 
reasonable belief
,
based on 
objective evidence
, that
an individual applicant or student
has a medical condition or
disability 
that may pose a
significant risk 
of substantial harm
to the health or safety of 
others
.
 
26
 
The fact that an individual has been
referred
 
for a direct threat assessment
does not necessarily indicate 
that they will
be determined to be a direct threat.
 
27
 
C
l
i
n
i
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a
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A
s
s
e
s
s
m
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n
t
 
The clinical assessment of
direct threat 
must only be
determined
 
by 
qualified
health professionals 
who
have 
current, documented
expertise 
in the 
medical
condition(s) or disability
or disabilities
 involved in a
particular case.
 
General medical
expertise
, without
expertise in the specific
medical condition(s) or
disabilities at issue in a
given case, 
is
insufficient
.
 
A center 
may need to
consult
 
with the 
individual’s
treating provider
 or may
need to retain an 
outside
provider
 with the 
necessary
current expertise 
in the
particular medical
condition or disability 
and
its effects, to conduct a
direct threat assessment in
a given case.
 
28
APPLICANTS AND STUDENTS
 
Form 2-04
Direct Threat Assessment
 
The qualified licensed health
professional begins the
completion of the direct threat
assessment.
 
29
 
Effective Communication
 
Appendix 201
Communicating with
Individuals with
Disabilities
 
Obligation is separate from
reasonable accommodation or
modification.
 
Must be documented on the
assessment.
 
Required if needed to participate
in the clinical interview or
disability accommodation process.
 
30
 
D
e
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o
f
D
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T
h
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a
t
 
As part of the
determination of direct
threat, the qualified health
professional 
must 
consider:
01
 
What 
factors
triggered the
review of the
individual’s file for
possible direct
threat to others?
Include responses from
ETA 653 (applicants),
information from applicant file/student
health record, clinical interview and/or
health 
providers (applicants/students)
 
31
 
D
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D
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T
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02
 
What are the 
specific
symptoms and behaviors
related to the medical
condition or disability
considered to potentially
pose a direct threat to
others?
 
32
Do not rely on diagnoses alone.
Describe the specific symptoms
and behaviors in detail.
03
 
What is the 
nature and
severity
 
of the potential
harm to others (e.g.,
death, incapacitation,
serious injury, minor
injury/emotional distress)?
Nature is what kind of harm to others?
Severity is related to the frequency and
seriousness of harm?
Include information from the CCMPs, applicant
file/student health record, 
education records,
clinical interview and/or other health providers
or staff if applicable
.
04
 
What is the 
duration of
the risk
 (i.e., how long
will the risk last)?
 
33
Are the symptoms and behaviors that pose a
risk to others acute/short, chronic/on-going,
etc.?
 Include information from the CCMPs, applicant
file/student health record, education records, clinical
interview and/or other providers or staff if
applicable.
05
 
What is the 
imminence
of the potential harm (i.e.,
how soon is the harm
likely to occur)?
The harm to others must be serious and likely
to occur, not remote and speculative. Give your
best clinical judgment on how soon the harm to
others may occur.
 Include information from the CCMPs, applicant
file/student health record, education records, clinical
interview and/or other providers or staff if applicable
.
 
D
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34
 
Where to Start?
 
Center clinicians check the ETA 653
Job Corps Health Questionnaire 
to
see which items were endorsed,
any additional comments regarding
items endorsed, and if there is any
supporting documentation for each
item. (May need to request
records).
ETA 653
 
Check to see if there are Chronic
Care Management Plans (CCMPs)
and if the provider(s)
recommended applicant for Job
Corps.
The center clinicians must contact
provider(s) if there are conflicting
recommendations.
CCMPs
 
35
 
FIRST WEEK OF
APPLICANT FILE REVIEW
SCHEDULE APPLICANT
INTERVIEW:
If unable to reach applicant after 2
attempts (try all numbers on the
data sheet), contact 
Outreach
and 
Admissions for assistance.
OBTAIN NEEDED RECORDS:
Fax authorization(s). If no
records after 2 attempts
(faxes, phone calls), continue
assessment with available info.
CALL CCMP PROVIDER(S)
:
If unable to reach provider(s)
after 2 attempts, continue
assessment with available
info.
Document all activities & attempts to reach applicant, provider
and Outreach and Admissions.
REVIEW ALL RECORDS
Make notes of disclosed conditions on ETA 653, in
 health
 records
,
 
and in
school disability documents in case applicant interview is needed.
 
36
 
Applicant Interview is Key!
 
Single most
important part of
the clinical
assessment
particularly if there
are no records and
no CCMP.
 
Should be conducted with
applicant alone (in whole or in
part)
.
For minors, parents/guardians
should be invited to participate.
Even then, you should request
for some part of the interview
to be with the applicant alone.
 
Interactive
 and 1:1
 
37
 
In person, Telephone or
Videoconference
 
Only specific questions
may be asked regarding
any conditions,
symptoms or behaviors
that have been disclosed
or documented
anywhere in the
applicant file.
 
A
 
See new 
Sample
Interview Questions 
--
specifically designed to
ask about current
behaviors/ symptoms
and functional
limitations.
 
B
 
Specific behavioral or
clinical observations
from interview should
be documented.
 
C
 
38
 
Mental Status Exam
(MSE)
 
Specific behaviors and clinical
observations
 made during the
clinician’s time with the
applicant are documented.
Yellow highlighting 
indicates which
areas can be “
assessed
” during a
telephone interview.
In 
Sample Applicant Interview
.
 
39
 
Direct Threat to Others?
06
 
40
 
41
 
Where to Start?
 
Check relevant information in
the SHR which may include:
ETA 653
CCMPs
Mental Health Notes
Any psychiatric or psychological
evaluations
SF-600 Chronological Record
Review
Documentation
in SHR
 
Check to see if there are case
notes that may describe
behaviors on center and
interactions with staff and other
students.
 
42
 
Check to see if an incident
on center prompted the
concern about danger to
others.
SIR and/or
Incident Report
CIS Case Notes
 
Student Interview
 
Student may or may not be
available for interview if danger to
others behavior resulted in
immediate removal from center.
 
Should be conducted with student
as soon as possible on center or via
telephone/telehealth options if off
center.
 
Documentation of efforts to
schedule and complete student
interview.
 
43
 
There must be an
interactive student
interview!
 
44
 
Direct Threat to Others?
06
 
45
 
When to
Consider
Disability
Accommodation?
 
46
 
D
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If, it is determined that an individual poses a direct threat
as a result of a medical condition or disability, the
qualified health professional conducting the assessment
must determine 
whether a disability accommodation
would either eliminate 
the risk 
or 
reduce
 it to 
an
acceptable level
.
 
Every
 effort should be made to
 identify appropriate
disability accommodations
 that 
may eliminate 
or 
reduce
the risk in a given case.
 
47
 
Post Direct Threat Assessment
Person with a Disability?
 
The 
qualified health
professional
, 
in collaboration
with the DC
, 
must
 consider
reasonable accommodations
that may eliminate or reduce
the risk sufficiently to allow
for enrollment.
 
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48
 
Disability Accommodation
 
The qualified health professional
completing the assessment, in
collaboration with the Disability
Coordinator 
identifies 
disability
accommodations that are 
likely
to 
reduce the level of risk
including considerations of
requested accommodations from
either the applicant/student or
others on their behalf.
 
49
 
Applicant/Student Responses
Accepts
 – The applicant/student
accepts the accommodation.
Declines
 – The applicant/student
declines or refuses the
accommodation.
 
50
 
Examples
Angry outbursts in groups
Physical Impulsiveness
Grabbing other’s property
Pushing when waiting
Assaultive Behavior
Allow frequent breaks through the day
Schedule adjustment to attend therapy
sessions off center
Allow pass to designated cool down areas
Reduce mandatory participation in large groups
Provide doodle pad or stress ball
Positive behavioral supports (self-
monitoring, check-in/check-out)
 
51
 
Unable to ID Reasonable Accommodations
 
Command hallucinations to harm others
D
isorganized/incoherent speech
V
erbalizations of harming others
I
mpaired realty testing (delusional)
V
erbal or physical aggressive behavior
 
52
 
Disability Accommodation Summary
 
The Disability Accommodation (DA)
summary area 
is not for clinical
summaries
.
Summarize any special
considerations or findings 
related to
DA here
 
including documenting the
applicant’s/student’s input
.
For example
, the DC explained the
interactive DA process to the
applicant who stated that they did
not need or wish to discuss
accommodations.
 
53
 
Sample Summary
 
55
 
Attestation of Experience
 
There is a new signatory section on
the 
Form for Individualized
Assessment of Possible Direct
Threat.
 
The qualified health professional
attests
 to the necessary licensure,
training, and clinical experience to
complete the assessment.
 
56
 
R
e
s
o
u
r
c
e
s
 
57
 
Job Corps Disability Website
https://supportservices.jobcorps.gov/disability/Pages/default.aspx
 
58
 
Job Corps Health & Wellness Website
https://supportservices.jobcorps.gov/Health/Pages/default.aspx
 
59
 
Please contact your Regional
Disability Coordinator and/or
your Regional Health
Specialist if assistance is
needed.
 
60
Slide Note

Welcome to an in-depth review of medical separations and direct threat assessments for all Health and Wellness staff, including contracted staff such as Center Physicians, Center Mental Health Consultants, Dentists, and TEAP specialists.   

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This resource provides an extensive overview of medical separations and direct threat assessments relevant to Job Corps health and wellness staff and subcontractors. It covers topics such as the process of medical separations, reinstatement rights, disability accommodation, and when medical separations should be considered as a last resort. The focus is on equipping health personnel with updated policies, practices, and forms for effective decision-making in handling medical conditions impacting Job Corps participation.


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  1. Medical Separations and Direct Threat Assessments An in-depth review for Health staff (Exhibit 5-6) including contractors

  2. 01 01 Medical Separations 02 02 Medical Separations with Reinstatement Rights AGENDA 03 03 Direct Threat Assessments Disability Accommodation as a part of Medical Separations and Direct Threat Assessments will be discussed in each applicable section. 2

  3. Purpose Purpose This training provides an in-depth review geared specifically to Job Corps Health and Wellness staff and subcontractors. Participants will receive a deep dive into the new policies, practices, and associated forms. Special focus will be given to the revisions of Form 2-04 Individualized Assessment of Possible Direct Threat. 3

  4. Medical Medical Separations Separations PRH Chapter 6, Section 6.2 R5 4

  5. Medical Separation Medical Separation Overview Overview When Do Medical Separations Occur? A medical separation occurs when a student is no longer able to participate in Job Corps due to medical conditions (including pregnancy-related conditions, dental conditions, substance use conditions, or mental health conditions). 5

  6. Medical Separation Medical Separation Overview Overview (cont.) (cont.) What Type of Separation Occurs First? At the time of medical separation, the student is always first separated as a Medical Separation with Reinstatement Rights (MSWR). They may be reinstated into the Job Corps within 180 days. A regular medical separation is given only if reinstatement following the MSWR does not occur. 6

  7. Medical Separations Medical Separations are a are a Last Resort! Last Resort! Medical separations must only be used as a last resort, after Other methods of addressing the relevant medical concerns have been tried or considered in each individual case and determined to be insufficient Administrative Leave with Pay Personal Leave with Pay and/or Other types of leave 7

  8. Medical Separation Medical Separation Qualified Providers Qualified Providers Qualified licensed/certified health providers include: Medical separations must be documented in the student health record by a qualified licensed/certified health provider. Medical separations must be initiated by health services staff. Center Physicians/Nurse Practitioners/Physician Assistants Center Mental Health Consultants (CMHCs) Center Dentists Trainee Employee Assistance Program (TEAP) Specialists Student s treating provider or outside specialist 8

  9. Medical Separation Considerations A medical separation may be considered when the appropriate qualified health professional has determined the student to have a preexisting or acquired health condition that requires treatment beyond the basic health services provided by Job Corps; AND The necessary treatment is unavailable or will be unusually costly to Job Corps; AND Administrative Leave with Pay, Personal Leave with Pay, other types of leave, and other methods of addressing relevant medical concerns without resorting to separation have been tried or considered in each individual case and determined to be insufficient. 9

  10. Medical Separation Medical Separation Considerations Considerations (cont.) (cont.) Medical separations must not be used in lieu of providing disability accommodations (i.e., reasonable accommodation, reasonable modification in policies, practices, or procedures, and auxiliary aids and services) including equally effective communications for individuals with disabilities. Disability accommodations must be tried or considered with the goal of allowing the student to participate in the Job Corps program to the maximum extent possible. Medical separations must not be based on stereotypes regarding certain disabilities or speculation regarding their management or associated expense. 10

  11. The Health and Wellness Director will complete the Center Applicant/Student File Review Form (which is found in Form 2-04 Direct Threat Assessment) if the Center s HWD has a Medical Separations for Direct Threat reasonable belief, based on objective evidence, that the student has a medical condition or disability that may pose a significant risk of substantial harm to the health or safety of others. Then the HWD will refer the student to a qualified health professional who has current, documented expertise in the medical condition or disability involved. The Direct Threat Assessment (Form 2-04) must be completed in order to determine whether a medical separation is appropriate. 11

  12. The HWD will refer the student to a qualified health professional who has current, documented expertise in the medical condition or disability involved if the Center s HWD has a Medical Separations for Health Care Needs reasonable belief, based on objective evidence, that the student has a medical, mental health, oral health, and/or substance abuse treatment/ monitoring need that presents a significant barrier to continued participation that cannot be addressed through reasonable accommodation, reasonable modification in policies, practices or procedures, and auxiliary aids and services. Detailed Health Care Needs Assessment training will be provided at a later date. 12

  13. Medical Separation Requirements Medical Separation Requirements Health staff must approve all transportation plans and if an escort is needed. Health and social service written referrals must be provided to medically separated students. Students must be followed up monthly by the Health and Wellness Director while separated. Documentation of monthly follow up must be in the student health record. 13

  14. Medical Separation Medical Separation Documentation Documentation Documentation for a medical separation in the student health record must include at a minimum: The clinical assessment for separation, including current symptoms/behaviors and functional impairments and a diagnostic code; Individualized treatment instructions; Student consent; Referral source(s); Transportation details, including whether an escort is needed; Dates of separation and anticipated return to center; Individualized student medical expectations to return; and If the student is an individual with a disability, a copy of any accommodation plan and CIS Accommodation Plan Notes tab documentation. 14

  15. Sample MSWR Form 15

  16. Medical Separation Extensions Documentation The request should be accompanied by supporting documentation from the student s health-care provider verifying that extension of leave is medically necessary. Request Extension Center staff must submit a request to the Regional Office to extend a MSWR beyond 180 days for extenuating circumstances and/or if there is a request for disability accommodation related to a change in the date of the student s return. Individualized Requests will be reviewed on a case-by- case basis. 16

  17. Direct Threat Direct Threat Assessments Assessments PRH Chapter 2, Form 2-04 17

  18. Threat to Others Legislative updates to direct threat language occurred in 2017 and required modification of existing PRH policies to ensure compliance with Section 188 of the Workforce Innovation and Opportunity Act, Section 504 of the Rehabilitation Act of 1973, and related implementing regulations. Direct threat to self or others is now direct threat to others. 18

  19. Direct Threat Direct Threat Defined Defined Federal disability nondiscrimination laws define a direct threat as a significant risk of substantial harm to the health or safety of others that cannot be eliminated or reduced by reasonable accommodation, reasonable modification in policies, practices, or procedures, and auxiliary aids and services. 19

  20. Significant Risk Qualification A significant risk means a high, not a slight, probability of risk; A speculative or remote risk is insufficient. 20

  21. Applicants + Students Enrolled Students? Applicants? Applicants? OR Now the form has been expanded to include both applicants and enrolled students. Form 2-04 was previously for applicants only. 21

  22. Direct Threat Direct Threat Considerations Considerations Direct threat may be considered if there is reasonable belief, based on objective evidence, that the individual has a medical condition or disability that may pose a significant risk of substantial harm to the health or safety of others. Threat to self is no longer part of the definition of direct threat. Direct Threat Assessments, Policy and Requirement Handbook Form 2-04, may be considered for applicants as part of the Applicant File Review process and for students as part of the medical separation process. 22

  23. Qualifying Qualifying Standard Standard Job Corps requires, as a qualification standard, that an applicant or student not pose a direct threat to the health or safety of others, including students and staff. Like any qualification standard, this requirement must apply to all applicants and students, not just to those with disabilities. 23

  24. Applicant and Student Processes Applicant File Review Process Documenting Initial Reviews Records Manager receives applicant file in CIS and logs on AFR Tracking Log. The initial review of applicant files must be documented on the new Center Applicant File Review Form in PRH Form 1-06 for Health Care Needs or the Center Applicant/Student File Review Form for Direct Threat which is included with Form 2-04 Direct Threat Assessment. The Health and Wellness Director (HWD) is the File Review Coordinator for the center and completes a general review of medical and disability-related documentation and the Job Corps Health Questionnaire (ETA 653). 24

  25. Applicant and Student Processes Student Medical Separation Process Initiated by Center Physician, Center Mental Health Consultant, or other appropriate qualified health professionals (including the student s individual treating provider). Student has a preexisting/acquired health condition that requires treatment beyond the basic health services provided by Job Corps and: Treatment is unavailable or will be unusually costly to Job Corps; and ALL leave and other methods have been tried or considered in each individual case and determined to be insufficient. If the student is an individual with a disability, the center with the student, via an interactive disability accommodation process, has considered whether any disability accommodations would address or mitigate any concerns, to allow the student to participate in the Job Corps program to the maximum extent possible. 25

  26. Reasonable Belief A DTA should be conducted if the HWD has a reasonable belief, based on objective evidence, that an individual applicant or student has a medical condition or disability that may pose a significant risk of substantial harm to the health or safety of others. 26

  27. The fact that an individual has been referred for a direct threat assessment does not necessarily indicate that they will be determined to be a direct threat. 27

  28. Clinical Clinical Assessment Assessment APPLICANTS AND STUDENTS A center may need to consult with the individual s treating provider or may need to retain an outside provider with the necessary current expertise in the particular medical condition or disability and its effects, to conduct a direct threat assessment in a given case. General medical expertise, without expertise in the specific medical condition(s) or disabilities at issue in a given case, is insufficient. The clinical assessment of direct threat must only be determined by qualified health professionals who have current, documented expertise in the medical condition(s) or disability or disabilities involved in a particular case. 28

  29. Form 2-04 Direct Threat Assessment The qualified licensed health professional begins the completion of the direct threat assessment. 29

  30. Effective Communication Appendix 201 Communicating with Individuals with Disabilities Obligation is separate from reasonable accommodation or modification. Required if needed to participate in the clinical interview or disability accommodation process. Must be documented on the assessment. 30

  31. What factors triggered the review of the individual s file for possible direct threat to others? 01 Determination of Determination of Direct Threat Direct Threat As part of the determination of direct threat, the qualified health professional must consider: Include responses from ETA 653 (applicants), information from applicant file/student health record, clinical interview and/or health providers (applicants/students) 31

  32. Determination of Direct Threat Determination of Direct Threat What are the specific symptoms and behaviors related to the medical condition or disability considered to potentially pose a direct threat to others? What is the nature and severity of the potential harm to others (e.g., death, incapacitation, serious injury, minor injury/emotional distress)? 02 03 Nature is what kind of harm to others? Severity is related to the frequency and seriousness of harm? Include information from the CCMPs, applicant file/student health record, education records, clinical interview and/or other health providers or staff if applicable. Do not rely on diagnoses alone. Describe the specific symptoms and behaviors in detail. 32

  33. Determination of Direct Threat Determination of Direct Threat 04 05 What is the imminence of the potential harm (i.e., how soon is the harm likely to occur)? What is the duration of the risk (i.e., how long will the risk last)? The harm to others must be serious and likely to occur, not remote and speculative. Give your best clinical judgment on how soon the harm to others may occur. Are the symptoms and behaviors that pose a risk to others acute/short, chronic/on-going, etc.? Include information from the CCMPs, applicant file/student health record, education records, clinical interview and/or other providers or staff if applicable. Include information from the CCMPs, applicant file/student health record, education records, clinical interview and/or other providers or staff if applicable. 33

  34. Applicant File Review Process 34

  35. Where to Start? CCMPs ETA 653 Center clinicians check the ETA 653 Job Corps Health Questionnaire to see which items were endorsed, any additional comments regarding items endorsed, and if there is any supporting documentation for each item. (May need to request records). Check to see if there are Chronic Care Management Plans (CCMPs) and if the provider(s) recommended applicant for Job Corps. The center clinicians must contact provider(s) if there are conflicting recommendations. 35

  36. FIRST WEEK OF APPLICANT FILE REVIEW REVIEW ALL RECORDS Make notes of disclosed conditions on ETA 653, in health records, and in school disability documents in case applicant interview is needed. SCHEDULE APPLICANT INTERVIEW: If unable to reach applicant after 2 attempts (try all numbers on the data sheet), contact Outreach and Admissions for assistance. OBTAIN NEEDED RECORDS: Fax authorization(s). If no records after 2 attempts (faxes, phone calls), continue assessment with available info. CALL CCMP PROVIDER(S): If unable to reach provider(s) after 2 attempts, continue assessment with available info. Document all activities & attempts to reach applicant, provider and Outreach and Admissions. 36

  37. Applicant Interview is Key! Interactive and 1:1 Single most important part of the clinical assessment particularly if there are no records and no CCMP. Should be conducted with applicant alone (in whole or in part). For minors, parents/guardians should be invited to participate. Even then, you should request for some part of the interview to be with the applicant alone. 37

  38. In person, Telephone or Videoconference A B C Only specific questions may be asked regarding any conditions, symptoms or behaviors that have been disclosed or documented anywhere in the applicant file. See new Sample Interview Questions -- specifically designed to ask about current behaviors/ symptoms and functional limitations. Specific behavioral or clinical observations from interview should be documented. 38

  39. Mental Status Exam (MSE) Specific behaviors and clinical observations made during the clinician s time with the applicant are documented. Yellow highlighting indicates which areas can be assessed during a telephone interview. In Sample Applicant Interview. 39

  40. Direct Threat to Others? 06 40

  41. Student Medical Separation Process 41

  42. Where to Start? Review SIR and/or Incident Report CIS Case Notes Documentation in SHR Check relevant information in the SHR which may include: Check to see if an incident on center prompted the concern about danger to others. Check to see if there are case notes that may describe behaviors on center and interactions with staff and other students. ETA 653 CCMPs Mental Health Notes Any psychiatric or psychological evaluations SF-600 Chronological Record 42

  43. Student Interview Student may or may not be available for interview if danger to others behavior resulted in immediate removal from center. Should be conducted with student as soon as possible on center or via telephone/telehealth options if off center. There must be an interactive student interview! Documentation of efforts to schedule and complete student interview. 43

  44. Same Interview Guidelines for Applicants and Students Only specific questions may be asked regarding any conditions, symptoms or behaviors that have been observed, demonstrated, disclosed, or documented anywhere in the student health record. Focus on current behaviors/ symptoms and functional limitations. Specific behavioral or clinical observations from interview should be documented. Completion of Mental Status Exam. 44

  45. Direct Threat to Others? 06 45

  46. Direct Threat? No Enroll When to Consider Disability Accommodation? YES Submit Person with a disability? recommendation of denial to the Regional Office. No YES Consider disability accommodation. 46

  47. Disability Disability Accommodation Accommodation Considerations Considerations If, it is determined that an individual poses a direct threat as a result of a medical condition or disability, the qualified health professional conducting the assessment must determine whether a disability accommodation would either eliminate the risk or reduce it to an acceptable level. Every effort should be made to identify appropriate disability accommodations that may eliminate or reduce the risk in a given case. 47

  48. Post Direct Threat Assessment 07 Person with a Disability? Lorem ipsum dolor Lorem ipsum dolor The qualified health professional, in collaboration with the DC, must consider reasonable accommodations that may eliminate or reduce the risk sufficiently to allow for enrollment. 48

  49. Disability Accommodation The qualified health professional completing the assessment, in collaboration with the Disability Coordinator identifies disability accommodations that are likely to reduce the level of risk including considerations of requested accommodations from either the applicant/student or others on their behalf. 49

  50. Applicant/Student Responses Accepts The applicant/student accepts the accommodation. Declines The applicant/student declines or refuses the accommodation. 50

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