CFD 4: Service Planning and Monitoring
Families and providers work together to develop and review service plans
that are the basis for delivery of appropriate services and support.
Generally children age six or over are to be included in service planning
, unless there are clinical
justifications for not doing so.
NA The organization provides only parent education groups.
A family-centered service plan is developed within an appropriate timeframe with the full participation of family members, and expedited service planning is available when crisis or urgent need is identified.
Service planning is to be conducted so that family members retain as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices can receive help with making or learning to make decisions.
The service plan is based on the assessment, and includes:
- agreed-upon goals, desired outcomes, and timeframes for achieving them;
- services and supports to be provided, and by whom; and
- a parent’s or legal guardian’s signature.
The service plan is tailored to meet the family’s unique needs, and:
- builds on family strengths;
- addresses family risks; and
- reflects the family’s description of its resources, concerns, and priorities.
A family’s unique background, experiences, skills, race, culture
, language, religion, and socioeconomic status are to be taken into consideration when developing a service plan. Providers should be fully informed about issues and preferences that may impact service delivery with various groups in the service population
During service planning the organization explains:
- available options;
- how the organization can support the achievement of desired outcomes; and
- the benefits, alternatives, and risks or consequences of planned services.
Extended family members and significant others, as appropriate and with the consent of the family, are advised of ongoing progress and invited to participate in case
The organization can facilitate the participation of extended family and significant others by, for example, helping arrange transportation or including them in scheduling decisions.
The provider and family regularly review progress toward achievement of agreed upon goals and sign revisions to service goals
The provider and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:
- service plan implementation;
- the family’s progress toward achieving goals and desired outcomes; and
- the continuing appropriateness of the family’s goals.
Interpretation: Experienced providers may conduct reviews of their own cases. In such cases, the provider’s supervisor reviews a sample of the provider’s evaluations as per the requirements of the standard.
Timeframes for service plan review should be adjusted depending upon issues and needs of persons receiving services, and the frequency and intensity of services provided.