	Adult Guardianship

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

AG 5: Guardianship Planning, Monitoring, and Accountability

Individuals participate in the development and ongoing review of an assessment-based guardianship plan that:

is the basis for delivery of guardianship services; and
provides a method for regularly reviewing the quality and effectiveness of guardianship services.

Update: Revised Research Note - 06/01/10

AG 5 Original Research Note:

Research suggests that a guardianship plan is critical to effectively providing guardianship services. The guardianship plan is based on the intake assessment, outlines steps to meet identified needs, and documents progress towards achieving desired outcomes. As such, the guardianship plan provides a method for evaluating the quality and effectiveness of guardianship services. Additionally, the guardianship plan provides documentation of baseline capacity so improved functioning is recognized, and guardianship is adjusted or terminated as needed.

Many states do not have systems in place to actively monitor the quality of guardianship services. Instead, they rely on a reactionary system that only responds to petitions or accusations against the guardian. However, unless state law prohibits the organization from creating guardianship plans, the organization should use them as a basis for delivering individualized guardianship services and a method for monitoring service quality and effectiveness.

Interpretation: The term guardianship plan refers to a plan developed by the organization that documents the individual’s service needs and desired outcomes, a plan to meet those needs and desired outcomes, and work done on behalf of the client. Organizations may also refer to this document as the service plan, care plan, or client plan.

Research Note: Research suggests that a guardianship plan is critical to effectively providing guardianship services. The guardianship plan is based on the intake assessment, outlines steps to meet identified needs, and documents progress towards achieving desired outcomes. As such, the guardianship plan provides a method for evaluating the quality and effectiveness of guardianship services. Additionally, the guardianship plan provides documentation of baseline capacity so improved functioning is recognized, and guardianship is adjusted or terminated as needed. Whether or not state law or practice requires the preparation or filing of guardianship plans, the organization should require their use as a basis for delivering individualized guardianship services and as a method for monitoring service quality and effectiveness.

AG 5.01

The individual is involved in the development and ongoing review of the guardianship plan to the greatest extent possible given his or her cognitive and developmental abilities.

Interpretation: The guardianship plan is developed in such a way that the individual retains as much personal responsibility and self-determination as possible.

AG 5.02

Family members, as appropriate, are included in guardianship planning and informed of ongoing progress.

Research Note: Adult guardianship literature suggests that involving family members and close friends in service planning helps ensure that service decisions reflect the desires of the individual, and can increase the likelihood that guardianship responsibilities could eventually be transferred to someone with a personal relationship to the individual. However, while involving friends or family in planning and decision-making can be extremely beneficial, the guardian should carefully assess the appropriateness of including them. In some situations, guardianship is assigned to an organization due to past abuse or exploitation by a friend or family member and including them would be inappropriate.

AG 5.03

The guardianship plan is based on the assessment and includes:

the individual’s identified needs;
the least-restrictive services or conditions that will effectively meet identified needs;
financial and/or service goals, desired outcomes, and timeframes for achieving them; and
opportunities to enhance the individual’s well-being and improve his or her capacity.

Interpretation: Service and support needs include residential placement or housing, rehabilitation, physical or mental health care, aide services or other home supports, education, recreation, transportation, financial services, vocational rehabilitation, and applying for public benefits such as Social Security benefits, food stamps, Veteran’s benefits, or Medicaid.

AG 5.04

Logs or other records are maintained to track implementation of the guardianship plan, and include:

time spent with the individual and advocating on his or her behalf with service providers;
documentation of the individual’s participation in decision-making;
documentation of decisions made;
initiation or termination of direct services;
reports provided to the court or other regulatory bodies as required by law; and
progress towards achievement of desired service goals and outcomes.

AG 5.05

Event-based re-assessments are conducted as needed, and updates are made to the guardianship plan when appropriate.

Interpretation: The organization should conduct a re-assessment when major events occur that could impact the individual’s service needs such as discharge from a hospital, major changes in medical condition or mental health status, or when there is a change to the individual’s living situation.

AG 5.06

The guardianship worker and a supervisor, or a clinical, service, or peer team, review the case at least quarterly to assess:

guardianship plan implementation;
participation of the individual;
the individual’s progress toward achieving service goals and desired outcomes;
timeliness of court reporting;
frequency of contact; and
the continuing appropriateness of the court order and service goals.

Interpretation: Timeframes for the review should be adjusted depending upon issues and needs of the service population.

Research Note: The research shows that a system for actively monitoring open cases is more cost effective for the organization in the long run and ensures a higher quality of services are being provided to individuals receiving services. Active monitoring allows organizations to identify and respond to concerns in a timely fashion, prior to costly litigation, and should be conducted at regular intervals.

AG 5.07

The guardianship plan is provided to the court, or other regulatory bodies, upon request to ensure the care being provided meets the established plan and the individual’s long-term needs.

Update: Revised Standard, Revised Interpretation - 06/01/10

AG 5.07 Original Standard and Interpretation:

The service plan is provided to the court, or other regulatory bodies, upon request to ensure the care being provided meets the established plan and the individual’s long-term needs.

Interpretation: In some jurisdictions, the court may not request the service plan and it may be appropriate for the organization to develop internal procedures for routinely providing the court with the service plan, provided the court will accept the document and the confidentiality of the individual will be protected.

Interpretation: In jurisdictions where guardianship plans are not required to be filed with the court, it may be appropriate for the organization to develop internal procedures to make the guardianship plan available to the court, provided the confidentiality of the individual will be protected.

AG 5.08

The organization has a standardized system for tracking due dates that ensures timely reporting to the court or other government entities as required by law.

Interpretation: Other government entities that may require regular reporting include the Social Security Administration or the Department of Veterans Affairs.

Research Note: Many states have adopted the Uniform Veterans Guardianship Act, which among other things, establishes mandatory accounting and reporting requirements.

AG 5.09

As permitted by law or court order, the guardianship worker makes funeral and burial arrangements that:

respect the individual's expressed desires, culture, heritage, and belief system; and
involve the family to the greatest extent possible and appropriate.

Update: Added Standard - 06/01/10

AG 5.09 replaces AG 9.08

AG 9.08 Original Standard:

As permitted by law or court order, pre-paid burial arrangements are made that:

respect the individual’s expressed desires, culture, heritage, and belief system; and
involve the family to the greatest extent possible and appropriate.

Interpretation: Involvement of the family should include investigating the existence of family plots.

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	PURPOSE: Individuals who receive guardianship services maintain a level of independence and self-determination appropriate to their functional capacity, and are at minimized risk of abuse, neglect, or exploitation.

RELATED FILES


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	QUALITY In this context, the extent to which contemporary and generally recognized standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a "treatment plan".


	RESEARCH For purposes of COA accreditation, all forms of internal or external research involving persons served except internal program evaluation and outcomes research, or educational projects performed by students and interns that are part of their professional training.


	INTAKE The client's entry point for services at which eligibility is assessed against established criteria and a preliminary evaluation of the presenting problem occurs.


	PRACTICE Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.


	MONITORING An evaluation involving a periodic review of consumer services, organizational activities, or conduct. Specifically, monitoring is an activity of case coordination, whereas more broadly, monitoring is an evaluation technique used in overall quality assurance.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	CLIENT See service recipient.


	APPROPRIATENESS The degree to which a particular service, placement, treatment, intervention, or activity is: best suited to an individual's needs; not excessive, unduly intrusive, or restrictive; anticipated to be effective in achieving the desired and specified outcomes; and adequate or sufficient in quantity to address the problem.


	SERVICE GOALS Broad, issue-oriented statements that reflect the realistic achievements to be accomplished in the short or long term. Goals are achieved through the accomplishment of specific quantifiable objectives.


	TERMINATION See CASE CLOSING


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	SERVICE POPULATION A group or target population that the organization's services are designed to serve in accord with its mission, and which includes the organization's service recipients. An organization's service population may be defined by geographic location, specific problems or needs, religion, ethnicity, culture, or other factors.


	ADMINISTRATION The personnel responsible for management functions of the organization, including fiscal management, human resources, and service delivery. Such personnel determine organizational goals, acquire and allocate resources to carry out a program, coordinate activities toward goal achievement, and monitor, evaluate, and make needed changes in processes and procedures to improve the likelihood of goal achievement. The term is synonymously used with MANAGEMENT.